Splenic Artery Embolization: Short and Long Term Outcomes

Splenic Artery Embolization:
Short and Long Term Outcomes
How well does it really work?
Jacob Cynamon, MD
Ajay Kohli, MD
Division of Vascular and Interventinal Radiology
Montefiore Medical Center
GEST 2016
Jacob Cynamon, M.D.
• No relevant financial relationship reported
Background
In blunt abdominal trauma, the spleen is the most
commonly injured visceral organ.
American Association for Surgery for Trauma
developed splenic injury grading system.
The injury grade, applied in conjunction with clinical
monitoring, helps guide management of the patient.
NOM with or without Embolization vs Surgery
Grade
Spleen Injury
I
Subscapular Hematoma <10% of surface area
capsular laceration <1 cm depth
II
Subscapular hematoma <10-50% of surface area
Intraparenchymal haematoma <5 cm in diameter
Laceration 1-3 cm depth without trabecular vessels
III
Subscapular Hematoma >50% of surface area or
expanding intra-parenchymal haematoma >5 cm or
expanding laceration >3 cm depth or involving
trabecular vessels
Ruptured subcapsular or parenchymal haematoma
IV
Laceration involving segmental or hilar vessels with
Major devascularisation (>25% of spleen)
V
Shattered spleen
Hilar vascular injury with devascularised spleen
Dr Salvatore
Scalfani
Hemodynamically stable patients with splenic injuries of all grades can often be managed
nonoperatively, especially when the injury is further characterized by arteriography.
Sclafani et. al. Nonoperative salvage of computed tomography-diagnosed splenic injuries: utilization of angiography for triage and embolization for
hemostasis. J Trauma. 1995 Nov;39(5):818-25; discussion 826-7.
Indications for Angiography and Embolization
? All Grade injuries
? All Grade III, IV, V hemodynamically stable
? Only Grade III, IV, V with active blush on CT
?? Unstable Patients
Technique
Proximal
Distal
Both Proximal and Distal
Coils
Plugs
Splenic Injury Algorithm
Moore FA, Davis JW, Moore EE Jr, Cocanour CS, West MA, McIntyre RC Jr. Western Trauma Association (WTA) critical decisions in trauma:
management of adult blunt splenic trauma. J Trauma. 2008;65(5): 1007Y1011.
Non-operative Management
• Peitzman AB (2000): Risk of overwhelming post-splenectomy infection
prompted preservation of the injured spleen. However, with each grade,
the incidence of successful observation declined as the grade increased
(as determined by the quantity of hemoperitoneum).
• Velmahos (2010): Multicenter study of the Research Consortium of New
England Centers for Trauma showed that only a minority of grade IV and
V BSI can be managed without surgery and that the rate of NOM failure is
high.
• Sabe (2009): Incorporating SAE for patients with blunt splenic injury has
expanded the use of NOM with greater success of NOM, a decline in
mortality, an increase in overall splenic salvage as well as a shorter LOS.
Interventions at all splenic grade
Requarth (2011): meta-analysis of 10,157 patients that
presented with NOM for splenic injury
Failure rate for Grade IV was 43.7% without and 17.3% with SAE
Failure rate for Grade V was 83.1% without and 25.0% with SAE
Conclusion: Routine SAE shows decreasing failure rate
of NOM especially in Grade IV and V injuries
Requarth, J.a., R.b. D'agostino, and P.r. Miller. "Nonoperative Management of Adult Blunt Splenic Injury With and Without Splenic Artery
Embolotherapy: A Meta-Analysis." Journal of Vascular Surgery 55.3 (2012): 886. Web.
Miller (2014): Studied a Prospective Protocol Requiring
Angiography and Embolization for all high-grade splenic
injuries undergoing NOM - regardless of contrast blush
Protocol deviation: 31% failure rate of patients that deviated
from protocol versus 5% failure rate of patients that stayed on
protocol
Miller, Preston R., Michael C. Chang, J. Jason Hoth, Nathan T. Mowery, Amy N. Hildreth, R. Shayn Martin, James H. Holmes, J. Wayne Meredith, and
Jay A. Requarth. "Prospective Trial of Angiography and Embolization for All Grade III to V Blunt Splenic Injuries: Nonoperative Management Success
Rate Is Significantly Improved." Journal of the American College of Surgeons 218.4 (2014): 644-48. Web.
Conclusion: Non Operative Management is
Improved with Embolization even if there was no
blush
NOM
Nonoperative Management Success Rate Is Significantly Improved
Early: Angio and Embolization was at Operator Discretion
Late: Prospective Protocol that Required Embolization of all Patients Undergoing NOM.
Miller, Preston R., Michael C. Chang, J. Jason Hoth, Nathan T. Mowery, Amy N. Hildreth, R. Shayn Martin, James H. Holmes, J. Wayne Meredith, and
Jay A. Requarth. "Prospective Trial of Angiography and Embolization for All Grade III to V Blunt Splenic Injuries: Nonoperative Management Success
Rate Is Significantly Improved." Journal of the American College of Surgeons 218.4 (2014): 644-48. Web.
Proximal vs Distal Embolization
Prox. vs Distal Embolization: Major
Complications requiring Splenectomy
Total
206 13(6.3%) 1(0.5%) 4(1.9%) 111
10(9.0%) 3(2.7%) 0(0%)
Schnüriger, Beat, Kenji Inaba, Agathoklis Konstantinidis, Thomas Lustenberger, Linda S. Chan, and Demetrios Demetriades. "Outcomes of Proximal
Versus Distal Splenic Artery Embolization After Trauma: A Systematic Review and Meta-Analysis." The Journal of Trauma: Injury, Infection, and Critical
Care 70.1 (2011): 252-60. Web.
Proximal vs Distal Embolization: Major Complications
● Failure rate did not reach clinical or statistical significance
● Higher rate of infarcts with distal embolization (1.6% to 3.8%)
as opposed to proximal embolization (0.0% to 0.5%):
○ Rate of infarction lower in proximal embolization because it does occlude
flow to the spleen but, in theory, enables clot formation by decreasing
blood flow to parenchyma
● No clinical or statistical significant difference in infectious
complications within analyzed study sets
Long Term Results
• OPSI- Overwhelming Post Splenectomy Infection risk is
540 times that of controls
• After SAE, immune function is preserved. As measured by
an adequate response to vaccination with T-cell
independent antigen PPV-23, splenic function of patients
treated with SAE was preserved.
• No statistically significant immunological difference was
found between proximally and distally embolized patients
Olthof DC, Lammers AJ, van Leeuwen EM, et al. Antibody response to a T-cell-independent antigen is preserved after splenic artery embolization for trauma.
Clin Vaccine Immunol. 2014;21(11):1500–1504. doi: 10.1128/CVI.00536-14
Antibody response is preserved after SAE
Antibody response for patients with splenic artery embolization, splenectomy, and healthy controls.
Olthof DC, Lammers AJ, van Leeuwen EM, et al. Antibody response to a T-cell-independent antigen is preserved after splenic artery embolization for trauma.
Clin Vaccine Immunol. 2014;21(11):1500–1504. doi: 10.1128/CVI.00536-14
30 day Readmission rate following BSI
(34/199)
(8/33)
NOM
no SAE
n=2704
NOM
w SAE
n=257
(7.36%)
(12.84%)
199
33
Surgery for Splenic
Injury on readmission
(30/34)
(3/8)
30/199=15%
3/33=9.1%
30/2704=1.1% 3/257=1.2%
Freitas, Gil, Olubode A. Olufajo, Khaled Hammouda, Elissa Lin, Zara Cooper, Joaquim M. Havens, Reza Askari, and Ali Salim. "Postdischarge
Complications following Nonoperative Management of Blunt Splenic Injury." The American Journal of Surgery 211.4 (2016)
Factors determining readmission after BSI
Clinical Factors:
Charlson Comorbidity Index greater than or equal to 2 (aOR 1.91, 95%
CI 1.11 to 3.28, P = .020)
Age greater than or equal to 45 (aOR 1.83, 95% CI 1.38 to 2.44, P <
.001)
Non Clinical Factors:
Discharge against medical advice (adjusted odds ratio [aOR] 2.85,
95% confidence interval [CI], 1.58 to 5.15, P = .001)
Being on public insurance (aOR 1.51, 95% CI 1.05 to 2.17, P =
.028).
Freitas, Gil, Olubode A. Olufajo, Khaled Hammouda, Elissa Lin, Zara Cooper, Joaquim M. Havens, Reza Askari, and Ali Salim. "Postdischarge
Complications following Nonoperative Management of Blunt Splenic Injury." The American Journal of Surgery 211.4
Failure rate of NOM in Elderly
Siriratsivawong; et al. Nonoperative Management of Blunt Splenic Trauma in the Elderly: Does Age Play a Role? The American Surgeon (June 2007)
585-9
SAE in the context of Liver Cirrhosis
Patients with Liver Cirrhosis (LC) that presented with BSI have a higher rate
of NOM failure, morbidity, and mortality compared with non-LC patients.
Preexisting coagulopathy and Grade 4 to 5 BSI were the highest predictors
of NOM failure.
Bugaev, Nikolay, Janis L. Breeze, Vladimir Daoud, Sandra Strack Arabian, and Reuven Rabinovici. "Management and Outcome of Patients with Blunt
Splenic Injury and Preexisting Liver Cirrhosis." Journal of Trauma and Acute Care Surgery 76.6 (2014): 1354-361. Web.
85 F S/P MVA, Unstable
5 day f/u
5 month f/u
Splenic
Injury
Splenic
Injury
Hemodynamically Stable
Hemodynamically Unstable
Contrast Enhanced CT
Grade I – II
With no blush
Observational
Management
Splenic Injury III, IV or V
or
Blush with any grade
Splenic Artery
Embolization
OR for
splenectomy
Embolization
needs to be
studied further
Conclusions
• Variations in indications and technique remains problematic
when reviewing the literature
• NOM with embolization is best for higher grade splenic
injuries or any grade with a blush or extravasation
• The absence of a blush on CT should probably not preclude
embolization in high grade splenic injuries
• Splenic function usually remains intact after embolization
• Embolization in unstable patients needs to be studied
References
Freitas, Gil, Olubode A. Olufajo, Khaled Hammouda, Elissa Lin, Zara Cooper, Joaquim M. Havens, Reza Askari, and Ali Salim. "Postdischarge Complications following
Nonoperative Management of Blunt Splenic Injury." The American Journal of Surgery 211.4
Requarth, J.a., R.b. D'agostino, and P.r. Miller. "Nonoperative Management of Adult Blunt Splenic Injury With and Without Splenic Artery Embolotherapy: A MetaAnalysis." Journal of Vascular Surgery 55.3 (2012): 886. Web.
Dasgupta, N., Matsumoto, A. H., Arslan, B., Turba, U. C., Sabri, S., & Angle, J. F. (2012). Embolization therapy for traumatic splenic lacerations. Cardiovascular and
interventional radiology, 35(4), 795-806
Harbrecht, B. G., Ko, S. H., Watson, G. A., Forsythe, R. M., Rosengart, M. R., & Peitzman, A. B. (2007). Angiography for blunt splenic trauma does not improve the
success rate of nonoperative management. Journal of Trauma and Acute Care Surgery, 63(1), 44-49.
Siriratsivawong, Kris; Zenati, Mazen; Watson, Gregory A; Harbrecht, Brian G; et al. "Nonoperative Management of Blunt Splenic Trauma in the Elderly: Does Age Play a
Role? . The American Surgeon (Jun 2007): 585-9
Olthof DC, Lammers AJ, van Leeuwen EM, et al. Antibody response to a T-cell-independent antigen is preserved after splenic artery embolization for trauma. Clin
Vaccine Immunol. 2014;21(11):1500–1504. doi: 10.1128/CVI.00536-1
Schnüriger, B., Inaba, K., Konstantinidis, A., Lustenberger, T., Chan, L. S., & Demetriades, D. (2011). Outcomes of proximal versus distal splenic artery embolization after
trauma: a systematic review and meta-analysis. Journal of Trauma and Acute Care Surgery, 70(1), 252-260.
Stassen, N. A., Bhullar, I., Cheng, J. D., Crandall, M. L., Friese, R. S., Guillamondegui, O. D., ... & Schuster, K. M. (2012). Selective nonoperative management of blunt
splenic injury: an Eastern Association for the Surgery of Trauma practice management guideline. Journal of Trauma and Acute Care Surgery, 73(5), S294-S300.
Miller, Preston R., Michael C. Chang, J. Jason Hoth, Nathan T. Jay A. Requarth. et al "Prospective Trial of Angiography and Embolization for All Grade III to V Blunt
Splenic Injuries: Nonoperative Management Success Rate Is Significantly Improved." Journal of the American College of Surgeons 218.4 (2014): 644-48. Web.
Bugaev, Nikolay, Janis L. Breeze, Vladimir Daoud, Sandra Strack Arabian, and Reuven Rabinovici. "Management and Outcome of Patients with Blunt Splenic Injury and
Preexisting Liver Cirrhosis." Journal of Trauma and Acute Care Surgery 76.6 (2014): 1354-361. Web.
Peitzman, Andrew B., Brian Heil, Louis Rivera, Michael B. Federle, Brian G. Harbrecht, Keith D. Clancy, et al.. "Blunt Splenic Injury in Adults: Multi-institutional Study of
the Eastern Association for the Surgery of Trauma." The Journal of Trauma: Injury, Infection, and Critical Care 49.2 (2000): 177-89. Web.
Sabe, Ashraf A., Jeffrey A. Claridge, David I. Rosenblum, Kevin Lie, and Mark A. Malangoni. "The Effects of Splenic Artery Embolization on Nonoperative Management of
Blunt Splenic Injury: A 16-Year Experience." The Journal of Trauma: Injury, Infection, and Critical Care67.3 (2009): 565-72. Web.
Dries, D.j. "Blunt Pancreatoduodenal Injury: A Multicenter Study of the Research Consortium of New England Centers for Trauma (ReCONECT)." Yearbook of Critical
Care Medicine 2011 (2011): 227-28. Web.
Sosada, Krystyn, Maciej Wiewióra, and Jerzy Piecuch. "Literature Review of Non-operative Management of Patients with Blunt Splenic Injury: Impact of Splenic Artery
Embolization." Videosurgery and Other Miniinvasive Techniques Wiitm 3 (2014): 309-14. Web.
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