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Role of Arterial Embolization in Non-Operative Management of Splenic Injuries
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ADVANCING SCIENCE, ENHANCING LIFE
Role of Arterial Embolization in Non-Operative Management of
Splenic Injuries
Jamaica Hospital Trauma ConferenceJuly 21st, 2014
Greg Eckenrode
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Management of Traumatic Spleen Injuries
• Historically, nearly all splenic injuries were managed operatively
• Non-operative management developed in the pediatic population in the late 1960s
• Increasing prevalence in adult population since the 1980s – Currently 50-70% of splenic injuries
Stein DM, Scalea TM J Intensive Care Med. 2006;21(5):296.
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Operative Management
• Hemodynamically unstable patients with evidence of abdominal bleeding– Positive FAST or DPA/DPL
• Patients requiring abdominal exploration for other injuries– Intraperitoneal free air– Signs of peritonitis
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Operative Management
• Hemodynamically stable patients– CT findings of contrast extravasation or vascular
blush– High grade injuries (generally IV-V)– Age > 55– Unable to safely observe patient
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Conventional Non-Operative Management
• Admit to monitored care setting
• Bed rest, NPO
• Serial Hgb/Hct every 6 hours for 24 hours
• Frequent vital signs, serial abdominal exams
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Splenic Angiography and Embolization
• First applied to traumatic splenic injuries in 1995
• Multiple techniques– Distal selective– Proximal– Both
• Intended to improve success of non-operative management
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Clinical Questions
• Does splenic artery angiography and embolization improve non-operative management outcomes?
• Which patients should undergo angiography and embolization?
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Western Trauma Association
• 4 L1 trauma centers in the United States• 155 patients who underwent angiography and
embolization for pseudoaneurysm, active bleeding on CT, significant hemopertoneum, and high grade injuries
• Compared against the results of the Eastern Trauma Association study, which used conventional observation
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Comparison Results
Haan, et al; J Trauma. 2004 Mar;56(3):542-7.
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Ullevaal University Hospital: 2006
• In 2002, implemented policy that all patients with splenic injury Grades III-V or ongoing bleeding underwent arterial embolization
• Compared to all splenic injuries from 2000-2002, when arterial embolization was no performed at the hospital
Gaardner, C, et al; J Trauma. 2006 Jul;61(1):192-8
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Study Outcomes
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Complications
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Multicenter Variation: 2010
• Compared 4 L1 trauma centers with variation in rates of splenic artery embolization in non-operative management
• Rates ranged from 19% to 1%• Compared rates of splenic salvage and non-
operative failure
Bannerjee, et al; J Trauma Acute Care Surg. 2013 Jul;75(1):69-74
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Population Comparison
Bannerjee, et al; J Trauma Acute Care Surg. 2013 Jul;75(1):69-74
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Management Comparison
Bannerjee, et al; J Trauma Acute Care Surg. 2013 Jul;75(1):69-74
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Splenic Salvage Rate
Bannerjee, et al; J Trauma Acute Care Surg. 2013 Jul;75(1):69-74
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Wake Forest - 2014
• Single site L1 Trauma Center• Prior to 2010, angiography and embolization
performed for CT contrast blush• Starting in 2010, prospectively performed
angiography and embolization on all Grade III-IV splenic injuries
• Compared non-operative failure rates against recent historical controls from 2007-2009 period
Miller, et al; J Am Coll Surg. 2014 Apr;218(4):644-8
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Study Group Comparison
Miller, et al; J Am Coll Surg. 2014 Apr;218(4):644-8
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Study Results
• 2010-2012: Non-operative failure rate of 5%– Failure rate of 25% in 16 protocol deviations
(p=0.02)
• 2007-2009: Non-operative failure rate of 15% (p=0.04)
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Conclusions
• In historical comparisons, patients with splenic injuries who are candidates for non-operative management have better outcomes when SAE is utilized
• Centers which perform a higher rate of SAE have higher rates of spelic salvage and lower rates of non-operative management failure
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Conclusions
• Centers which implement a standard protocol mandating SAE for non-operative splenic injuries experience decreased rates of of non-operative failure and increased rates of splenic salvage
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Future Directions
• No prospective, head-to-head randomized clinical trial of SAE in non-operative splenic injuries
• Limited data with respect to cost effectiveness
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Splenic Injury Grading
• Grade I:– Hematoma: Subcapsular, < 10% of surface area– Laceration: Capsular tear < 1 cm depth
• Grade II– Hematoma: Subcapsular, 10 - 50 % of surface area– Laceration: Capsular tear 1 - 3 cm depth not
involving trebecular vessel
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Splenic Injury Grading
• Grade III– Hematoma• Subcapsular, > 50% of surface area• Subcapsular, expanding• Ruptured subcapsular or parenchymal• Intraparenchymal > 5cm
– Laceration• > 3cm depth• Involving trabecular vessel
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Splenic Injury Grading
• Grade IV– Laceration: segmental or hilar vessels with > 25%
devascularization
• Grade V– Hematoma: shattered spleen– Laceration: total devascularization