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Monday, December 28, 2020

Distal Embolization in Grade V Splenic Injury

Clinical Results of Distal Embolization in Grade V Splenic Injury: Four-Year Experience from a Single Regional Trauma Center


Clinical question

In patients with grade-V blunt splenic injury (BSI) according to the American Association for the Surgery of Trauma (AAST), does distal splenic artery embolization (SAE) confer non-operative clinical success and splenic salvage?

Take-away point
Distal SAE is safe for patients with grade-V BSI and effective for splenic salvage

Reference
Lee, Rang, Chang Ho Jeon, Chang Won Kim, Hoon Kwon, Jae Hun Kim, Hohyun Kim, Sung Jin Park, Gil Hwan Kim, and Chan Yong Park. “Clinical Results of Distal Embolization in Grade V Splenic Injury: Four-Year Experience from a Single Regional Trauma Center.” Journal of Vascular and Interventional Radiology 31, no. 10 (October 1, 2020): 1570-1577.e2.

Click here for abstract

Study design
Single-institution, retrospective cohort study consisting of 42 patients who underwent SAE for grade V BSI

Funding source
Biomedical Research Institute Grant 2017B010

Setting
Pusan National University Hospital, Busan, Republic of Korea.




Figure. Visual Synopsis of results

Summary


Blunt splenic injury (BSI) is a common and potentially life-threatening sequelae of abdominal trauma. Timely evaluation and severity grading using an organ injury scale published in 2008 (revised 2018) by the American Association for the Surgery of Trauma (AAST) is widely used to guide management options consisting of observation, splenic arterial embolization (SAE), or surgical resection. Based on computed tomography (CT) scan or intraoperative exploratory findings, patients are categorized as low-grade (I-III) or high-grade (IV-V). Guidelines for management of BSI vary per institution. Operative management is generally reserved for patients who have high-grade BSI or hemodynamic instability while the use of SAE for either cohort remains controversial. Thus, the authors conducted a retrospective cohort of 42 patients with grade-V BSI who underwent distal SAE to evaluate technical and clinical success, splenic salvage rates, and complications.

Pre-procedure CT scans of 88 patients who underwent distal SAE at a single trauma center were reviewed and 42 patients were categorized as grade-V using the revised guidelines by the AAST. Patients were further stratified based on hemodynamic stability with hemodynamically unstable patients defined as systolic blood pressure < 90 mmHg or systolic blood pressure > 90 mmHg requiring vasopressors and/or who had base excess >-5 mmol/L at admission and/or shock index >1 and/or transfusion of at least 4–6 units of packed red blood cells in the first 24 hours. 23 subjects were hemodynamically unstable and 19 patients were hemodynamically stable. Male to female ratio was 35 to 7 and average age was 47 years.

Technical success was defined as cession of bleeding while performing splenic angiography and clinical success was defined as successful SAE without rebleeding or splenectomy. If a second SAE was required for rebleeding then secondary clinical success was determined by need for splenectomy after second SAE. Splenic salvage was defined as viable splenic tissue on follow-up CT. Follow-up CT was performed retrospectively at 3, 7, and 30 days post-SAE. Major complications as determined by the Society of Interventional radiology included any complication that required extended hospitalization or advanced care leading to permanent adverse effects or death.

Technical success of distal embolization was achieved in all patients. Clinical success was achieved in 80.9% of patients (n=34). Secondary clinical success was achieved at 88.1% (n=37) as 3 patients required a second embolization. 4 patients required post-SAE splenectomy and 2 patients suffered from major adverse complications. One of these patients died of acute respiratory distress syndrome and the other patient developed a splenic abscess at 22 days post-SAE. Splenic salvage was achieved at 85.7% (n=36). There was no significant difference seen in primary clinical success (p = .709) or splenic salvage rates (p = .197) between hemodynamically stable and unstable patients.

The authors concluded that distal SAE is safe for patients with grade-V BSI who are hemodynamically stable or unstable. However, for unstable patients, they discuss that distal SAE may be better suited for patients who respond to general resuscitation efforts prior to intervention. A previous consensus study had concluded that time to intervention for nonoperative management of BSI should be < 60 minutes. The authors propose that the high success rates in the current study may be attributed to its short time to intervention (mean = 91 minutes) which was shorter than similar previous studies with less successful clinical outcomes (mean = 171 minutes).

Commentary


This study consisted a small sample size (n=42) at a single institution over a 5-year period. Extending the study period to an earlier date may increase sample size and improve study power. This study had a median follow-up period of 247 days and additional longitudinal follow-up is necessary to determine NOM failure rates requiring splenectomy. Also, this study only evaluated splenic salvage via CT scan as a secondary outcome. In addition to splenic salvage, previous retrospective studies have included secondary endpoints such as splenic function determined by immunoglobulin and/or T-cell subset levels. Including more characteristics of splenic function may provide more convincing evidence that SAE has advantages over operative management in BSI.

Post Authors:

Daniel Yoakum, RMC Class of 2022
@DanYoakum 

David M. Tabriz, Assistant Prof VIR RUMC
@DrDaveTabriz

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