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Original Research |
1 Department of Radiology, Bicêtre Hospital, 78 rue du
Général Leclerc, Le Kremlin-Bicêtre 94270, France.
2 Department of Interventional Radiology, Centre Hospitalier Universitaire
Vaudois, Lausanne, Switzerland.
3 Department of Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne,
Switzerland.
4 Present address: Division of Diagnostic Imaging, Section of Interventional
Radiology, University of Texas M. D. Anderson Cancer Center, Houston,
TX.
Received November 19, 2004;
accepted after revision February 1, 2005.
Address correspondence to B. Bessoud.
Abstract
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MATERIALS AND METHODS. The records of patients with traumatic splenic injuries admitted during a 52-month period were retrospectively reviewed for patient age and sex, mechanism of injury, injury severity score (ISS), RBC transfusion requirements, AAST splenic injury CT grade, presence of active contrast extravasation or blush on CT examination, and amount of hemoperitoneum on CT examination. Demographics, CT findings, transfusion requirements, and outcome were compared using the Student's t test or chi-square test in patients undergoing standard nonoperative management and nonoperative management TPSAE—that is, TPSAE followed by nonoperative management.
RESULTS. Of the 79 identified patients with splenic trauma, 67 were managed nonoperatively. Thirty-seven patients (28 men, nine women; mean age, 40 years; mean ISS, 28.8) underwent nonoperative management TPSAE and 30 patients (27 men, three women; mean age, 37 years; mean ISS, 25.1) underwent nonoperative management. Age, sex, and ISS were not significantly different between the two groups. TPSAE was always technically feasible. Splenic injuries were significantly more severe in the nonoperative management TPSAE group than in the nonoperative management group with respect to the mean splenic injury AAST CT grade (3.7 vs 2, respectively; p < 0.0001), active contrast extravasation or blush (38% [14/37] vs 3% [1/30], respectively; p = 0.0005), and hemoperitoneum grade (1.6 vs 0.8, respectively; p = 0.0006). Secondary splenectomy rate was lower in the nonoperative management TPSAE group (2.7% [1/37] vs 10% [3/30]). No procedure-related complications were encountered during early and delayed clinical follow-up.
CONCLUSION. TPSAE is a feasible and safe adjunct to observation in the nonoperative management of severe traumatic splenic injuries. The secondary splenectomy rate using nonoperative management TPSAE (2.7%) is among the lowest reported despite a selection of severe injuries.
Keywords: abdomen • embolization • interventional radiology • spleen • trauma
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Categorization
Patients were first categorized by hemodynamic status (i.e., stable or
unstable) and then by CT findings. Hemodynamic instability was defined by a
systolic blood pressure of less than 90 mm Hg refractory to resuscitation
maneuvers. All patients who were hemodynamically unstable with evidence of
free abdominal fluid on a multiple-view FAST (focused abdominal sonography for
trauma) [20] examination went
directly to the operating room. Hemodynamically stable patients or unstable
patients with a negative FAST result immediately went to the CT suite.
Imaging, Interpretation, and Patient Management
All trauma patients underwent a standardized CT examination performed in
our institution using an 8- or 16-MDCT scanner (LightSpeed, GE Healthcare).
After an unenhanced CT examination of the head was performed to exclude
intracranial hemorrhage, a bolus test was performed with 20 mL of contrast
medium and a single 10-mm-thick slice through the initial ascending aorta to
determine the time to peak enhancement. A craniocaudal thoracoabdominal
examination was then performed in a single session after a two-step protocol
for administration of IV contrast material (iopentol or iohexol, 300 mg I/mL):
70 mL of contrast medium (injection rate, 1 mL/sec) was administered and was
followed by 50 mL of contrast medium (5 mL/sec) pulsed with 50 mL of saline
(injection rate, 5 mL/sec). The scan acquisition delay was always determined
as 70 sec plus the time to peak enhancement in the ascending aorta. The
scanning parameters were a collimation of 1.25 mm, a table speed of 35 mm, and
a pitch of 1.75. Axial slices were reconstructed with a slice width of 2.5 mm
and slice interval of 2.5 mm.
All splenic injuries were graded by the attending radiologist according to the AAST Organ Injury Scale (Table 1). Ten radiologists with 2–20 years' experience with abdominal CT were involved during the study period.
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When the splenic injury was grade III or higher or when active contrast extravasation or blush within the splenic parenchyma was visualized, splenic angiography with proximal splenic embolization was proposed to the attending surgeon. The final decision between standard nonoperative management (i.e., bed rest and observation) or nonoperative management TPSAE (i.e., TPSAE followed by standard nonoperative management) was at the attending surgeon's discretion. Six surgeons with 5–15 years' experience with trauma surgery were involved in the selection of patients.
TPSAE was performed in the angiography suite by the attending interventional radiologist. The time from the admission CT examination to TPSAE was evaluated using semiquantitative data: less than 1 hr, from 1 to 2 hr, or more than 2 hr. Four interventional radiologists with 3–20 years' experience with interventional radiology were involved during the study period. TPSAE was performed using a standardized technique (Figs. 1A, 1B, 1C, and 1D). After anteroposterior celiac and splenic arteriograms were obtained, the main splenic artery was selectively cannulated with the tip of the catheter at least beyond the origin of the dorsal pancreatic artery. The catheterization was performed with 5-French catheters (Cobra or Simmon Glidecath, Terumo) and whenever necessary (i.e., in case of arcuate ligament compression of the celiac trunk or splenic artery tortuosity) a coaxial 3-French microcatheter (SP, Terumo) (n = 6). The embolization was performed using 0.035-inch coils or 0.018-inch microcoils (Tornado, Cook) in the proximal (i.e., main) splenic artery. The embolization end point was the complete absence of opacification of the splenic artery distal to the coils, requiring one to six coils or microcoils (mean, 3.2). The procedure was then followed by bed rest and observation.
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Complications
Early follow-up (i.e., during hospital stay)—Patients
underwent daily physical examination, vital signs monitoring, and monitoring
of hemoglobin and hematocrit levels. Only in cases of symptoms suggesting
splenic embolization complication (mainly symptomatic splenic infarction or
abscess) or bleeding was a CT examination performed. Rebleeding was not
considered as a complication of the treatment, but rather as treatment
failure.
Delayed follow-up—In the nonoperative management of the TPSAE group, outpatient records were reviewed for delayed complications. At the end of the retrospective collection of data, all the nonoperative management TPSAE patients were contacted by telephone and asked to come for a consultation with an interventional radiologist. Infectious events, left flank pain, or any symptoms that could suggest delayed splenic bleeding or abscess were checked.
Statistical Analysis
Statistical analysis was performed by our institution statistician using
standard software. Age, sex, ISS, AAST CT grade, the presence of contrast
extravasation or blush, the amount and grade of hemoperitoneum on CT
examination, and RBC transfusion requirements were compared using the
Student's t test or chi-square test in patients undergoing standard
nonoperative management or nonoperative management TPSAE. A p value
of 0.05 or less was considered significant.
The end point of the statistical analysis was the comparison of the secondary splenectomy rate in the two groups of patients. Secondary splenectomy was defined as a splenectomy performed after an initial decision of nonoperative management had been made.
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Thirty-seven patients (55%) underwent nonoperative management TPSAE: 28 men and nine women. The mean age was 40 ± 17 years (range, 20–89 years). The mean ISS was 28.8 ± 2.9 (range, 4–66). Three patients had coagulation disorders (anticoagulation therapy [n = 2], von Willebrand's factor deficit [n = 1]), and one had a pathologic spleen due to lymphocytic leukemia. The mean splenic injury CT grade was 3.7 ± 0.7 (range, III–V), active contrast extravasation or blush was depicted by CT in 14 patients (38%), and hemoperitoneum was graded as 1.6 ± 0.8 (mean ± SD). The mean transfusion requirement was 1 ± 1.9 units. None of the patients who were successfully treated with nonoperative management TPSAE required further transfusion after the embolization. However, nonoperative management TPSAE failed in one patient (2.7%), requiring postprocedure transfusion (4 units) and surgery with secondary splenectomy.
Thirty patients (45%) underwent standard nonoperative management. There were 27 males and three females; the mean age was 37 ± 15 years (range, 17–80 years). The mean ISS was 25.1 ± 3.1 (range, 4–66). The mean splenic injury CT grade was 2 ± 0.8 (range, I–IV), active contrast extravasation or blush was depicted on CT in one patient (3%), and hemoperitoneum was graded as 0.8 ± 0.7 (mean ± SD). The mean transfusion requirement was 1.7 ± 3.4 units. Four patients required transfusion (3–7 units) after the initial decision of standard nonoperative management, and nonoperative management failed in one of these patients who subsequently underwent a splenectomy. Nonoperative management failed in two other patients who had sudden hemodynamic instability that required surgical exploration and splenectomy. Thus, nonoperative management failed in three patients (10%).
The time from the admission CT examination to TPSAE was always less than 1 hr. TPSAE was always feasible without immediate procedure-related complications.
Age, sex, and ISS were not significantly different in the nonoperative management TPSAE and standard nonoperative management groups (Table 2). The overall RBC transfusion requirements were not significantly different despite a trend toward lower requirements in the nonoperative management TPSAE group (1 vs 1.7 units) (Table 2). Moreover, only one nonoperative management TPSAE patient, the one requiring secondary splenectomy, required further transfusion after TPSAE was performed.
There were significant differences in the nonoperative management TPSAE group when compared with the standard nonoperative management group with respect to the mean splenic injury AAST CT grade (3.7 vs 2, respectively; p < 0.0001), active contrast extravasation or blush (38% [14/37] vs 3% [1/30], respectively; p = 0.0005), and hemoperitoneum grade (1.6 vs 0.8, respectively; p = 0.0006). The secondary splenectomy rate was lower in the nonoperative management TPSAE group (2.7% [1/37] vs 10% [3/30], respectively), but no statistical difference was found (p = 0.3179). In the standard nonoperative management group, secondary splenic surgery was needed between the sixth and 48th hr after admission in three patients (10% [3/30]) based on sudden hemodynamic instability (n =2) or abdominal compartment syndrome (n =1). The patients were all men, ages 21, 24, and 35 years, and all were involved in motorcycle crashes (n = 2) or pedestrian injury (n = 1) with ISS values of 66, 27, and 50, and splenic injury CT grades of IV, II, and I, respectively. There was no evidence of active contrast extravasation or blush in these three patients, although hemoperitoneum was visualized and graded 3, 1, and 2, respectively. Exploratory surgery showed persistent active bleeding originating from the spleen with subsequent splenectomy achieved in all three patients.
Thirty-six (97%) of the 37 patients treated with nonoperative management TPSAE were successfully treated without surgery. It should be noted that three patients became hemodynamically unstable with systolic blood pressure under 90 mm Hg and tachycardia just before TPSAE, when the patients were in the angiography suite. After consultation with the attending surgeon, these procedures were still indicated and were successfully performed, which allowed the hemodynamic status to normalize a few minutes after embolization. No further splenic angiography or embolization was necessary. The only secondary splenectomy in this group was performed in a 38-year-old man involved in a car crash. In that patient, the ISS was 41 and the CT scan revealed a grade III splenic injury with active contrast extravasation and grade 2 hemoperitoneum. On day 2 after admission, the patient experienced sudden hemodynamic instability. Exploratory laparotomy showed continued splenic hemorrhage, and splenectomy was achieved.
Complications
Early follow-up—One nonoperative management TPSAE patient
complained of marked left flank pain and mild fever (38.5°C) at day 6.
Abdominal CT examination showed multiple small gas bubbles in a perisplenic
fluid collection. Aspiration was performed under CT guidance: The fluid was
macroscopically typical of hematoma and the culture was negative.
Delayed follow-up—The outpatient records of the 36 nonoperative management TPSAE patients (one underwent splenectomy) did not document any complication related to the splenic embolization.
Among these 36 patients, 26 were contacted by telephone. Twenty-four came to the consultation 6–63 months (mean, 26 months) after the TPSAE, and no procedure-related complications were reported. Two patients refused the consultation but reported no complications during the telephone interview. In addition, no patient has presented with symptoms suggesting delayed bleeding. Ten were lost on follow-up.
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Identifying risk factors of nonoperative management failure is of great interest because they may represent useful criteria with which to select patients for other management options. Indeed, nonoperative management must be applied in selected patients, but only hemodynamic stability on admission or after initial resuscitation has been recognized as a triage tool. Abdominal CT is the most reliable method with which to identify and assess the severity of injury to the spleen, but no consensus exists on whether the CT grade of splenic injury, the presence of active contrast extravasation or parenchymal blush on CT scan, or both are correlated with the risk of failed nonoperative management and may be used to better select patients [7, 14, 21–24]. Because of the high reported rates of failed nonoperative management, the potential implication of the traumatic injury severity in the nonoperative management outcome, and the high spleen salvage rates reported using splenic embolization in severe blunt splenic trauma [17, 18, 25–27], we were prompted to propose TPSAE as a systematic adjunct to bed rest and observation for grade III–V splenic injuries or in cases of active contrast extravasation or blush on CT in patients who do not require emergency surgery.
In the present series, nonoperative management TPSAE was always proposed by the attending radiologist in cases of grade III–V splenic injuries or in any grades associated with active contrast extravasation or blush on CT and the final decision was at the attending surgeon's discretion. That is the reason we have a control group treated with standard nonoperative management with grade I–IV traumatic splenic injuries and injuries associated with contrast extravasation or blush. However, with time, nonoperative management TPSAE became the standard of care proposed by all surgeons at our institution in cases of grade III–V traumatic splenic injury or in cases of active contrast extravasation or blush. Indeed, TPSAE was rapidly performed and always technically feasible without technique-related complications.
Despite significantly more severe splenic injuries in the nonoperative management TPSAE group—that is, those who had a higher injury grade, higher rate of active contrast extravasation or blush on CT, and higher grade of hemoperitoneum on CT—a trend toward a lower failure rate was depicted in the nonoperative management TPSAE group (2.7% [1/37] vs 10% [3/30], respectively). The splenectomy rate achieved with nonoperative management TPSAE was not significantly different (p = 0.3179) from the rate in the standard nonoperative management group. However, this 2.7% (1/37) failure and splenectomy rate is lower than most of the reported failure rates with standard nonoperative management.
Nonoperative management TPSAE was effective even in four patients with high bleeding risk (i.e., coagulation disorders [n = 3] and pathologic spleen [n = 1]). Moreover, we performed TPSAE in three patients who became hemodynamically unstable at arrival in the angiography suite, which allowed dramatic normalization of their hemodynamic status soon after embolization. These cases, if confirmed in larger prospective series, should allow one to use TPSAE even in hemodynamically unstable patients as soon as the spleen has been identified as the only source of hemorrhage on CT examination. Finally, a trend toward lower transfusion requirements was achieved in the nonoperative management TPSAE group (1 vs 1.7 units, respectively), and none of the patients in that group (except the one requiring secondary splenectomy) required further transfusion after TPSAE was performed.
Only a few studies have reported the use of splenic embolization in the emergency management of splenic injury. In a King's County Hospital study [17], 172 patients with blunt splenic injury were enrolled and 60 patients needed embolization because of evidence of angiographic arterial extravasation. The authors reported successful outcome in 93% of the patients after embolization (proximal, distal, or both). Haan and colleagues [18] reported their experience with splenic embolization in 40 of 126 patients with angiographic evidence of vascular injury (e.g., arteriovenous fistula, pseudoaneurysm, or contrast extravasation). Successful outcome occurred in 92% of patients, with 5% of them requiring reembolization. These series, and ours, showed that splenic embolization is feasible, safe, and effective even in CT grade injuries of III or higher (65% in [18], 100% in the present series) or in cases of contrast extravasation.
Unlike Haan and colleagues [18], we chose to embolize patients even if the initial angiography examination was negative for contrast material extravasation, arteriovenous fistula, or pseudoaneurysm. Our choice may be supported by our splenectomy rate, which is lower than those in the two series that performed embolization only in cases of angiographic vascular abnormalities. Moreover, findings reported by Haan et al. [18] of 8% continued bleeding requiring laparotomy and 3.5% bleeding requiring secondary splenic embolization among their patients with negative angiography (initially treated expectantly) may support our choice.
As others [17] have shown, we chose proximal splenic artery embolization rather than selective distal embolization. The end point of proximal embolization, as in surgical artery ligation [28], is to reduce the splenic bleeding by decreasing blood flow in the main splenic trunk. Indeed, TPSAE allows reduction in the intrasplenic arterial blood pressure [29], a condition that may help clots to organize and the spleen to heal. Moreover, it is theorized that proximal embolization allows the spleen to remain, at least partially, perfused by collaterals [30], thus limiting the risk of splenic infarction. A series of CT examinations of embolized spleens has shown proximal embolization to be associated with less frequent and smaller infarcts than distal embolization [31]. Consequently, splenic function impairment should be less marked in cases of proximal embolization, but this remains to be shown.
Procedural, early, and delayed complications of TPSAE were rare. Coil migrations and splenic artery dissections have been described in previous series [17, 18], but we did not report any complication at the time of angiography. During the first days and weeks after splenic embolization, splenic abscess and infarcts are the two major concerns. Haan et al. [32] recently reported a 3% splenic abscess rate (4/140) after embolization (proximal, distal, or combined) and that 3% of infarcts suspected of being infected (4/140), due to the presence of air within it, were all aseptic at analysis. As in our patient who was treated by aspiration for a suspected splenic abscess that proved to be a liquefied hematoma containing gas, significant air and gas can be depicted after embolization (proximal or distal) in a splenic or perisplenic collection or infarct in the absence of infection [33]. In their large series, Haan et al. [32] also reported a significant infarction rate (i.e., > 25% of the gland) of 21% that finally had limited short-term clinical implications because the infarcts were associated with minimal symptoms. Besides the rare delayed bleeding due to pseudoaneurysm rupture, the main concern during delayed follow-up is residual splenic function after splenic embolization and the related infectious risk, which has been poorly evaluated in the literature. Our long-term follow-up (mean, 26 months) showed no evidence of infectious complications in the 26 followed patients.
Our series has some limitations. First, it is a retrospective nonrandomized study; thus, the choice between nonoperative management TPSAE and standard nonoperative management was made by several attending surgeons at the time of each patient's admission. Second, we did not separate patients undergoing TPSAE regarding the vascular abnormalities (i.e., patients with active extravasation vs those with contrast blush); indeed, there may be some concern regarding the applicability of proximal embolization alone in the face of active extracapsular contrast extravasation. This is currently in evaluation in a large prospective study. Finally, we did not yet evaluate the effects of TPSAE on splenic function and its potential clinical implications.
Despite these limitations, we believe that TPSAE has a major role to play in the management of severe traumatic splenic injuries. The addition of TPSAE to nonoperative management in patients with grade III–V injury may improve the success and complication rates so that they are equivalent to those of nonoperative management of low-grade injury. Large prospective controlled studies should be performed to further define the roles of standard nonoperative management, TPSAE, and surgical splenic preservation techniques.
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