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ORIGINAL ARTICLE

The Effects of Splenic Artery Embolization on Nonoperative


Management of Blunt Splenic Injury: A 16-Year Experience
Ashraf A. Sabe, BA, Jeffrey A. Claridge, MD, David I. Rosenblum, DO, Kevin Lie, MD,
and Mark A. Malangoni, MD

Introduction: Nonoperative management (NOM) of blunt splenic injury has


become the preferred treatment for hemodynamically stable patients. The
O ver the last decade, nonoperative management (NOM)
has become the preferred treatment for hemodynami-
cally stable patients with blunt splenic injury. Early reports
application of splenic artery embolization (SAE) in NOM has been contro-
versial. We hypothesized that incorporation of initial use of SAE into a practice established the use of bed rest, frequent monitoring of red
protocol for patients at high risk for NOM failure (contrast extravasation or blood cell count, and serial abdominal exams as standard
pseudoaneurysm on computed tomography, grade 3 injury with large hemoperi- principles of NOM.1–3 Computed tomography (CT) has evolved
toneum, grade 4 injuries) would improve patient outcomes. as the preferred method to identify which patients are appropri-
Methods: A retrospective analysis of three continuums of practice was ate for NOM and to select when patients should undergo further
performed: group I (January 1991–June 1998), SAE not part of routine investigation. Advancements in CT technology have improved
NOM; group II (July 1998 –December 2001), introduction and discretionary our ability to define the degree of splenic injury and more
use of SAE; and group III (January 2002–June 2007), standardized use of accurately to identify patients who are more likely to fail
initial SAE for patients considered at high risk of nonoperative failure. The NOM.4 –12 Splenic artery embolization (SAE) has been dem-
primary outcome measure was the success of NOM. Failure of NOM was onstrated to effectively stop bleeding in selected patients,
defined as the need for abdominal operation. Secondary outcomes were thus avoiding the need for operation.10 –13
mortality, length of stay, and splenic salvage. Splenic injury grades ⬎3, derived from The American
Results: Over 16 years, 815 patients with blunt splenic injury were treated Association for the Surgery of Trauma Splenic Injury Scale
at our level 1 trauma center. There were 222 patients in group I, 195 in group (SIS), have been associated with a greater likelihood for
II, and 398 in group III. There was an increase in the use of SAE over time failure of NOM.5,9,11,14,15 This grading system alone has not
with a significant improvement in the utilization of NOM (61% in group I;
been sufficient to define which patients with splenic injury
82% in group II; 88% in group III; p ⬍ 0.05). This was associated with an
can be safely managed nonoperatively. Other findings on CT,
increase in successful NOM (77%, group I; 94%, group II; 97%, group III;
including active extravasation, traumatic pseudoaneurysm, or
p ⬍ 0.0001 group I vs. group II and III). Mortality, length of stay, and splenic
salvage were similar in groups II and III but significantly improved when
a large hemoperitoneum have been associated with the need for
compared with group I.
operation.10,11,13 The incorporation of these parameters along
Conclusions: The increased use of initial SAE in high-risk patients expanded with the grade of injury has improved the ability to predict which
the successful use of NOM but was not associated with other incremental patients are likely to have successful NOM.8,9,11,13,16
improvements. In a previous study,13 we compared a cohort of patients
Key Words: Splenic artery embolization, Blunt spleen injury. from 1991 to 1998 who had standard NOM to a later group
in which SAE was selectively used to improve the success of
(J Trauma. 2009;67: 565–572) NOM. That analysis demonstrated that the increased use of
SAE correlated with increased success of NOM and was
associated with decreased mortality.13
We hypothesized that a practice protocol, which incor-
Submitted for publication December 4, 2008. porated the initial use of SAE for patients identified to be at
Accepted for publication June 4, 2009. high risk for NOM failure (contrast extravasation or pseudo-
Copyright © 2009 by Lippincott Williams & Wilkins aneurysm on CT, grade 3 injury with large hemoperitoneum,
From the Departments of Surgery (A.A.S., J.A.C., M.A.M.), and Radiology
(D.I.R., K.L.), Case Western Reserve University School of Medicine, Metro- grade 4 injury), would further improve the success of NOM
Health Medical Center, Cleveland, Ohio. for appropriate patients with blunt splenic injury.
Supported by National Center for Research Resources (NCRR), a component of
the National Institutes of Health (NIH) and NIH Roadmap for Medical
Research, grant 1KL2RR024990 (to J.A.C.). PATIENTS AND METHODS
The contents of this manuscript are solely the responsibility of the authors and do Patients for this retrospective analysis were derived
not necessarily represent the official view of NCRR or NIH.
Presented at the 67th Annual Meeting of the American Association for the Surgery
from our hospital trauma registry between the years 1991 and
of Trauma, September 24 –27, 2008, Maui, Hawaii. 2007 and consisted of all patients older than 16 years with
Address for reprints: Jeffrey A. Claridge, MD, MS, FACS, MetroHealth Medical blunt splenic injury admitted to MetroHealth Medical Center,
Center, Room H939, Hamann Bldg, 2500 MetroHealth Drive, Cleveland, OH an American College of Surgeons verified Level I trauma center.
44109-1998; email: jclaridge@metrohealth.org.
The following data were collected from patient records: demo-
DOI: 10.1097/TA.0b013e3181b17010 graphics, initial vital signs, hematocrit, and Injury Severity Score

The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 67, Number 3, September 2009 565
Sabe et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 67, Number 3, September 2009

(ISS). Abdominal CT scans were concurrently reviewed by The aforementioned groups were compared based on
radiologists and attending surgeons, and splenic injuries were initial treatment, ultimate treatment, and outcomes. The pri-
graded according to the SIS of the American Association for mary outcome variable was successful NOM, which was
the Surgery of Trauma.5 Relevant operative notes and pathol- defined as the percent of patients not requiring abdominal
ogy reports were reviewed to confirm the SIS grade. For surgery. Secondary outcome variables included mortality,
patients who underwent SAE, angiographic procedure notes length of stay (LOS), and overall splenic salvage (any out-
were evaluated for documentation of contrast extravasation come other than splenectomy). Failure of NOM is defined as
and the presence of a pseudoaneurysm. Technical failure of patients who initially managed without operation and subse-
SAE was defined as the inability to successfully cannulate quently required an operation for hemorrhage.
and embolize the splenic artery. A SAE failure was defined as Statistical analysis was performed using SPSS software
a patient who needed subsequent operation after SAE. (SPSS Inc, Chicago, IL). Student’s t tests were used to
Patients were divided into three continuums of practice: compare continuous data, which are expressed as mean ⫾
group I (January 1991–June 1998), SAE not part of routine SEM. GraphPad software (GraphPad Software, Inc, San Di-
NOM; group II (July 1998 –December 2001), introduction ego, CA) was used for ANOVA of multiple groups with
and discretionary use of SAE; and group III (January 2002– Tukey post hoc testing while categorical data were compared
June 2007), standardized use of initial SAE for patients by Fisher’s exact test or Pearson ␹2 analysis as appropriate.
determined to be at high risk of failure. The following When categorical data among the three groups were com-
protocol was followed on arrival of patients to the emergency pared, further subgroup comparisons were made only if the p
department with suspected intra-abdominal injury: if hemo- value was ⬍0.05. This study was approved by the Metro-
dynamically unstable, patients had immediate exploratory Health System Institutional Review Board.
laparotomy; those who were hemodynamically stable under-
went abdominal CT with intravenous contrast unless transferred
from another hospital with an adequate CT scan for assessment RESULTS
of injury. Prospectively defined indications for initial SAE in A total of 815 adults with blunt splenic injury were
group III included contrast extravasation or pseudoaneurysm identified. There were 222 patients in group I, 195 in group II,
on CT; grade 3 injuries with a large hemoperitoneum; or and 398 in group III. Characteristics, treatments, and out-
grade 4 injuries. The protocol also suggested that all patients comes of all patients are presented in Table 1. Patients were
with grade 5 injury should have an immediate operation. predominantly men. ISS was significantly greater in group I
Those who did not fulfill these criteria underwent standard (27.2 ⫾ 0.9) compared with groups II and III (22.9 ⫾ 0.9 and
NOM without SAE. Initial SAE was performed within 12 21.2 ⫾ 0.6, respectively, p ⬍ 0.0001). The mean SIS scores
hours of presentation and involved occlusion of the proximal and the percentage of each grade of splenic injury were
splenic artery with coils in 99% of patients. similar among the groups.

TABLE 1. Characteristics, Treatments, and Outcomes of Patients With Blunt Spleen Injuries
Group I (n ⴝ 222) Group II (n ⴝ 195) Group III (n ⴝ 398) p
Characteristics
Age (yr) 35.0 ⫾ 1.2 37.9 ⫾ 1.4 37.4 ⫾ 0.9 NS
Male (%) 142 (64) 122 (62.6) 251 (63.1) NS
Injury severity score 27.2 ⫾ 0.9† 22.9 ⫾ 0.9 21.2 ⫾ 0.6 ⬍0.0001
Splenic injury score 2.8 ⫾ 0.1 2.7 ⫾ 0.1 2.6 ⫾ 0.1 NS
Initial systolic blood pressure (mm Hg) 130.2 ⫾ 2.1 128.3 ⫾ 1.9 126.3 ⫾ 1.3 NS
Initial pulse (beats/min) 100.9 ⫾ 1.7 100.0 ⫾ 1.5 99.4 ⫾ 1.2 NS
Hematocrit (%) 34.3 ⫾ 0.5 34.8 ⫾ 0.6 35.5 ⫾ 0.4 NS
Treatments
Initial operation (%) 86 (38.7)† 35 (17.9)† 47 (11.8)† ⬍0.05
Initial nonoperative management (%) 136 (61.3)† 160 (82.1)† 351 (88.2)† ⬍0.05
Initial splenic artery embolization (%) 0† 17 (8.7)† 92 (23.1)† ⬍0.0001
Overall splenic artery embolization (%) 6 (2.7)† 34 (17.4)† 118 (29.6)† ⬍0.01
Outcomes
Successful nonoperative management (% of 105 (77.2)† 151 (94.4) 340 (96.9) ⬍0.0001
initial nonoperative management)
Mortality (%) 26 (11.7)† 12 (6.2)† 20 (5.0)† ⬍0.05
Length of stay (d) 14.7 ⫾ 1† 10.3 ⫾ 0.8 9.8 ⫾ 0.5 ⬍0.0001
Splenic salvage (%) 125 (56.3)† 166 (85.1) 351 (88.2) ⬍0.0001
Data presented as mean ⫾ standard error of the mean.
* Significant compared with group I.
† Significant compared with all other groups.
NS, not significant.

566 © 2009 Lippincott Williams & Wilkins


The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 67, Number 3, September 2009 A 16-Year Experience With Splenic Trauma

There was a significant increase in the use of NOM Patients Initially Treated With NOM
(p ⬍ 0.05) and concurrent increase in the success rate of Six hundred forty-seven patients (79.4%) had planned
NOM over time. This was associated with a significant NOM. The characteristics, treatments, and outcomes of these
increase in the initial and overall use of SAE (p ⬍ 0.01). patients are presented in Table 3. The rate of successful NOM
Mortality decreased significantly over time (group I vs. increased over time (p ⬍ 0.0001), as the use of initial SAE
groups II and III; p ⬍ 0.0001), and the LOS was shorter in increased (0%, group I; 10.6%, group II; 26.2%, group III;
groups II and III compared with group I (p ⬍ 0.0001). p ⬍ 0.0001). Both ISS and SIS are significantly greater in
Furthermore, the splenic salvage rate increased in groups II patients managed nonoperatively compared with patients who
and III compared with group I (p ⬍ 0.0001). As reflected in had an operation (p ⬍ 0.0001; Table 4). The mean SIS grade
Figure 1, these findings correlated with an increase in proto- was lower in patients who had successful NOM (p ⬍ 0.001;
col compliance with the use of SAE (protocol described in the Table 5). There was also a significant increase in protocol
methods) across groups (p ⬍ 0.004). compliance in patients who had successful NOM compared
with those who failed NOM (p ⬍ 0.05; Table 5).
Mortality decreased from 5.8% in group I to 1.2% in
Patients Managed With Initial Operation groups II and III combined (p ⬍ 0.01). Splenic salvage
Table 2 demonstrates the characteristics and outcome improved from 81% to 97% over time (p ⬍ 0.0001, group I
parameters of patients who had immediate operation. Six vs. groups II and III). There was no significant difference in
patients had urgent exploratory laparotomy (5 for diaphrag- the LOS between the groups.
matic rupture and 1 for emergent cesarean section), and
minor splenic injuries were discovered incidentally at oper-
ation and did not require treatment. Two of these patients Patients Managed With Initial SAE
subsequently required SAE for delayed splenic rupture. Com- Patients who underwent initial SAE had a higher SIS
pared with the other groups, there was a significant decrease than those who were initially observed in groups II and III
in the incidence of splenorrhaphy (p ⬍ 0.05) in group III. (⬍0.0001). In group I, no patients were managed with initial
There were no statistically significant differences in the SAE. The average SIS in patients who had initial SAE (3.5 ⫾
mortality, LOS, or splenic salvage among these three groups 0.1) was similar those who had initial operation (3.7 ⫾ 0.1)
of patients. in groups II and III. Five of the 109 patients (4.6%) who were

77
*
NOM Success % 94

97

81 *

Splenic Salvage % 97

97

4 Group I

SAE % 18 *** n = 136


Group II
29 n = 160
Group III
n = 351

Protocol Compliance % 76 **

89

0 10 20 30 40 50 60 70 80 90 100
Figure 1. A comparison of patients managed nonoperatively. Protocol compliance is defined in the methods. *p ⬍ 0.05,
group I versus group II and III, **p ⬍ 0.05, group II versus III, and ***p ⬍ 0.05, between all the three groups.

© 2009 Lippincott Williams & Wilkins 567


Sabe et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 67, Number 3, September 2009

TABLE 2. Characteristics, Treatments, and Outcomes of Patients Who Had Initial Operation
Group I (n ⴝ 86) Group II (n ⴝ 35) Group III (n ⴝ 47) p
Characteristics
Age (yr) 36.1 ⫾ 1.9 42.4 ⫾ 4.0 39.6 ⫾ 2.9 NS
Injury severity score 34.1 ⫾ 1.5 32.5 ⫾ 2.1 29.7 ⫾ 2.1 NS
Splenic injury score 3.5 ⫾ 0.1 3.7 ⫾ 0.2 3.6 ⫾ 0.2 NS
Initial systolic blood pressure (mm Hg) 121.8 ⫾ 3.4 118.5 ⫾ 6.12 113.8 ⫾ 5.1 NS
Initial pulse (beats/min) 106.6 ⫾ 2.5 112.2 ⫾ 3.6* 106.9 ⫾ 4.9 ⬍0.0001
Hematocrit (%) 31.5 ⫾ 1.0 27.0 ⫾ 1.0* 31.1 ⫾ 1.1 0.022
Treatments
Splenectomy (%) 69 (80.2) 24 (68.6) 38 (80.9) NS
Splenorrhaphy (%) 17 (19.8) 10 (28.6) 4 (8.5)† 0.017
Operation for other indication (%) 0 1 (2.9) 5 (10.6)* 0.002
Outcomes
Mortality (%) 18 (20.9) 11 (31.4) 15 (31.9) NS
Length of stay (d) 20.0 ⫾ 2.4‡ 14.0 ⫾ 3.2 12 ⫾ 1.7 0.05
Splenic salvage (%) 17 (19.8) 11 (31.4) 9 (19.2) NS
Data presented as mean ⫾ standard error of the mean.
* Significant compared with group I.
† Significant compared with group II.
‡ Significant compared with all the other groups.
NS, not significant.

TABLE 3. Characteristics, Treatments and Outcomes in Patients Initially Managed Nonoperatively


Group I (n ⴝ 136) Group II (n ⴝ 160) Group III (n ⴝ 351) p
Characteristics
Age (yr) 34.3 ⫾ 1.5 36.9 ⫾ 1.5 37.1 ⫾ 0.9 NS
Injury severity score 22.8 ⫾ 1.0 20.5 ⫾ 0.9 19.9 ⫾ 0.6* ⬍0.0001
Splenic injury score 2.4 ⫾ 0.1 2.5 ⫾ 0.1 2.5 ⫾ 0.1 NS
Initial systolic blood pressure (mm Hg) 135 ⫾ 2.6 130.5 ⫾ 1.9 128.0 ⫾ 1.2* ⬍0.0001
Initial pulse (beats/min) 97.6 ⫾ 2.1 97.2 ⫾ 1.5 98.4 ⫾ 1.1 NS
Hematocrit (%) 35.9 ⫾ 0.5 36.5 ⫾ 0.6 36.1 ⫾ 0.4 NS
Treatments
Initial splenic artery embolization (%) 0 (0)† 17 (10.6)† 92 (26.2)† ⬍0.0001
Late splenic artery embolization (%) 6 (4.4) 17 (10.6)* 24 (6.8) 0.036
Outcomes
Successful nonoperative managment (%) 105 (77.2)† 151 (94.4) 340 (96.9) ⬍0.0001
Mortality (%) 8 (5.8)† 1 (0.6) 5 (1.4) ⬍0.01
Length of stay (d) 11.4 ⫾ 0.8 9.5 ⫾ 0.7 9.5 ⫾ 0.6 NS
Splenic salvage (%) 110 (80.9)† 155 (96.9) 342 (97.4) ⬍0.0001
Data presented as ⫾ standard error of the mean.
* Significant compared with group I.
† Significant compared with all the other groups.
NS, not significant.

designated to have initial SAE and one of the 47 patients Compliance improved to 89% when this protocol was prospec-
(2.3%) who had late SAE had a technical failure. Ultimately, tively applied (p ⫽ 0.011). The success of NOM increased
two of these patients required splenectomy, three had splen- between these two groups from 94.4% to 96.9%; however, this
orrhaphy, and one was observed successfully. Seven patients was not statistically significant. The increased use of SAE was
who had initially successful SAE had persistent bleeding. All not associated with a difference in mortality, LOS, or splenic
of these patients required splenectomy. salvage. Outcomes stratified by SIS grade are demonstrated in
Discretionary (Group II) Versus Protocol-Based Table 6. NOM was most successful in patients with lower grade
(Group III) Use of Initial SAE injuries and decreased as SIS increased. Splenic salvage also
As demonstrated in Figure 1, when retrospectively decreased with increasing SIS. Six patients who had NOM in
applying our protocol to group II where the use of initial groups II and III died. None died of persistent bleeding or a
SAE was discretionary, the overall compliance rate was 76%. missed intra-abdominal injury.

568 © 2009 Lippincott Williams & Wilkins


The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 67, Number 3, September 2009 A 16-Year Experience With Splenic Trauma

initially observed (Fig. 2). Patients selected for initial SAE


TABLE 4. Comparison of Patients by Initial Treatment in
Groups II and III had a higher SIS grade of injury than those who did not have
SAE. The mean grade of splenic injury for patients who had
Initial Initial
Variable Operation NOM p
SAE was similar to patients who presented to the trauma
center with hemodynamic instability and had immediate op-
Age (yr) 40.8 ⫾ 2.4 37.0 ⫾ 0.8 NS eration. Other reports have demonstrated a higher grade of
Injury severity score 30.9 ⫾ 1.5 20.1 ⫾ 0.5 ⬍0.0001 splenic injuries among patients requiring SAE.1,12,14,17 This
Splenic injury score 3.7 ⫾ 0.1 2.5 ⫾ 0.1 ⬍0.0001 suggests that the use of SAE, whether done initially or for
Initial systolic blood 115.8 ⫾ 3.9 128.8 ⫾ 1.0 ⬍0.0001 those who are failing NOM, can reduce the need for operation
pressure (mm Hg)
Initial pulse (beats/min) 109.2 ⫾ 3.2 98.0 ⫾ 0.9 ⬍0.0001
and increase the rate of overall splenic salvage, despite the
Hematocrit 29.4 ⫾ 0.8 36.2 ⫾ 0.3 ⬍0.0001
greater need for splenectomy at operation. Patients who failed
Total 82 511 —
NOM were significantly older and had a greater ISS and SIS,
which is consistent with our previous study as well as
Data presented as ⫾ standard error of the mean. observations of others.10,14,18
Our protocol identified patients at high risk for failure
if they had vascular blush or pseudoaneurysm on CT, grade 3
TABLE 5. Comparison of Successful vs. Failed injury with large hemoperitoneum, or grade 4 injury. These
Nonoperative Management (NOM) in Groups II and III parameters have been demonstrated to be associated with an
Successful Failed increased failure of NOM in previous reports.8,10,14 Haan et
Variable NOM NOM p al.19 found a significant association with NOM failure and the
Age (yr) 36.7 ⫾ 0.8 45.3 ⫾ 4.3 ⬍0.05 presence of arteriovenous fistula but did not report increased
Injury severity score (ISS) 19.8 ⫾ 0.5 28.6 ⫾ 3.6 0.001 failure rates with large hemoperitoneum or active contrast
Splenic injury score (SIS) 2.5 ⫾ 0.1 3.4 ⫾ 0.2 ⬍0.001 extravasation. Marmery et al.11 recently proposed a new
Initial systolic blood 129.2 ⫾ 1.0 120.5 ⫾ 7.3 NS CT-based grading system in which active bleeding, arterio-
pressure (mm Hg) venous fistula, pseudoaneurysm, and vascular injury are the
Initial pulse (beats/min) 97.9 ⫾ 0.9 103.5 ⫾ 3.6 NS main parameters used to determine the grade of splenic
Hematocrit 36.3 ⫾ 0.3 34.5 ⫾ 1.9 NS injury. Using criteria similar to theirs in the present protocol,
Mortality (%) 6 (1.2) 0 (0) NS we have demonstrated a 97% success rate among patients
Protocol compliance (%) 409 (83.3) 13 (65) ⬍0.05 selected for NOM and 88% rate of overall splenic salvage.
Total 491 20 — These results equal or surpass previous single institution and
Data presented as ⫾ standard error of the mean. multicenter reports.11,14,19,20
Although SAE adds to the cost of care, the benefits of
a reduced LOS and avoidance of operation will most likely
DISCUSSION offset this expense. Although our data does not show a signifi-
This study demonstrates that implementation of a pro- cant improvement in primary and secondary outcome measures,
tocol that incorporates SAE for patients with blunt splenic the initial use of SAE may avoid some of the potential compli-
injury has expanded the use of NOM. The use of SAE was cations of hemodynamic instability that invariably occur if SAE
also associated with greater success of NOM, a decline in is reserved only for those patients who are failing NOM. Addi-
mortality, an increase in overall splenic salvage, and a shorter tionally, the improvement in overall splenic salvage rate that
LOS. However, the prospective application of a structured occurred when SAE was used more frequently may provide a
protocol using defined criteria for initial SAE did not further potential benefit of avoiding the occurrence of overwhelming
improve these outcomes. However, we achieved a 97% postsplenectomy infection. This is an uncommon complication
splenic salvage rate in ⬎350 patients who had NOM with use that has a high mortality rate.21
of this protocol. There are a number of limitations to this study. Fore-
The rate of splenectomy and splenorrhaphy decreased most, this is a retrospective analysis which compares data
while the use of SAE and the success of NOM increased over over the span of 16 years. Thus, differences in outcomes can
time. The criteria for use of SAE may have shifted patients be multifactorial and may in part reflect changes in medical
who previously would have had splenorrhaphy or splenec- practice rather than the effects of SAE. There has been a
tomy to have successful NOM, thus increasing the relative national trend to use NOM more often for the treatment of
rate of splenectomy among operated patients. Although the blunt splenic injuries and its success has improved over time.
grade of splenic injury was similar across all the three groups, This may be due to recognition that patients previously
we did notice a decrease in ISS in more recent years, which thought to need operation are good candidates for NOM, a
may reflect an increase in the overall number of patients with greater threshold of the trauma surgeon to not associate the
splenic injury treated at our trauma center.13 need for a low volume transfusion with NOM failure, and an
The use of initial NOM increased during the 16-year increased application of NOM in patients with serious head
period of this study. Of the 109 patients who had initial SAE, injury and multisystem injuries.2,3,18 A recent report has
90% were successfully managed without operation nearly suggested that improvements in the success of NOM may be
matching the NOM success rate of 93% in patients who were due to the increased number of patients treated at designated

© 2009 Lippincott Williams & Wilkins 569


Sabe et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 67, Number 3, September 2009

TABLE 6. Outcomes by AAST Splenic Injury Score of Patients With Blunt Splenic Injury in Groups II and III
SIS Grade n Initial NOM (%) Splenic Artery Embolization (%) Successful NOM (% of Initial NOM) Splenic Salvage (%)
1 129 123 (95.3) 1 (0.8) 123 (100) 127 (98.4)
2 123 117 (95.1) 9 (7.3) 115 (98.3) 117 (95.1)
3 159 146 (91.8) 60 (37.7) 137 (93.8) 141 (88.7)
4 145 109 (75.2) 77 (53.1) 101 (92.7) 113 (77.9)
5 20 3 (15.0) 3 (15.0) 2 (66.7) 2 (10.0)
Total 576 498 150 478 500

Figure 2. Initial treatment plan and the outcome for all patients. (A) 93% successful NOM and (B) 90% successful NOM. OR:
operating room.

trauma centers in recent years, which has resulted in a coordinated multicenter studies to more clearly define factors
decrease in ISS and more splenic injuries that are less associated with failure of NOM. Additionally, further studies
severe.22 The small number of failures of NOM and SAE and are needed to assess the long-term outcomes of splenic
the low mortality rate affects the statistical power to draw function after SAE.
conclusions regarding specific parameters associated with
failure of NOM and death. Experience of the interventional
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The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 67, Number 3, September 2009 A 16-Year Experience With Splenic Trauma

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2007;243:88 –95.
10. Haan JM, Marmery H, Shanmuganathan K, Mirvis SE, Scalea TM.
over the past ten years, scanning for not only hepatic but also splenic
Experience with splenic main coil embolization and significance of new injuries still seems to result in considerable inconsistency.
or persistent pseudoaneurym: reembolize, operate, or observe. J Trauma. My second question is, did you investigate the discrep-
2007;63:615– 619. ancy? I would like to know this especially when surgery was
11. Marmery H, Shanmuganathan K, Alexander MT, Mirvis SE. Optimiza-
tion of selection for nonoperative management of blunt splenic injury: performed after failed non-operative management.
comparison of MDCT grading systems. AJR Am J Roentgenol. 2007; Smith and Cioffi recommended a low threshold for
189:1421–1427. surgery in their 2006 paper. Furthermore, they were con-
12. Wei B, Hemmila MR, Arbabi S, Taheri PA, Wahl WL. Angioemboli- cerned about the ramifications of splenic artery embolization.
zation reduces operative intervention for blunt splenic injury. J Trauma.
2008;64:1472–1477. I always have two such concerns. One is the inference of
13. Rajani RR, Claridge JA, Yowler CJ, et al. Improved outcome of adult an operation based on the surgical feasibility of spleen preser-
blunt splenic injury: a cohort analysis. Surgery. 2006;140:625– 631; vation. In my experience splenectomy was performed in approx-
discussion 631– 632.
14. Peitzman AB, Heil B, Rivera L, et al. Blunt splenic injury in adults:
imately 65 percent of the initially operated group but in 85
Multi-institutional Study of the Eastern Association for the Surgery of percent of the delayed operation group. Smith et al described
Trauma. J Trauma. 2000;49:177–187; discussion 187–189. that splenic injuries are best treated by early operation to achieve
15. Haan J, Scott J, Boyd-Kranis RL, Ho S, Kramer M, Scalea TM. maximum splenic preservation. I agree with this.
Admission angiography for blunt splenic injury: advantages and pitfalls.
J Trauma. 2001;51:1161–1165.
Another consequence that concerns me is the training
16. Harbrecht BG, Ko SH, Watson GA, Forsythe RM, Rosengart MR, Peitzman of surgeons with trauma experience. A decrease in the num-
AB. Angiography for blunt splenic trauma does not improve the success rate ber of operations leads to a shortage of surgical experience
of nonoperative management. J Trauma. 2007;63:44 – 49. among the younger surgeons.
17. Haan JM, Bochicchio GV, Kramer N, Scalea TM. Nonoperative man-
agement of blunt splenic injury: a 5-year experience. J Trauma. 2005; In Group 3 you operated on 58 patients over a period of
58:492– 498. five years. If you have two younger doctors to educate, each of
18. Cadeddu M, Garnett A, Al-Anezi K, Farrokhyar F. Management of them can only operate on an average of five patients per year.
spleen injuries in the adult trauma population: a ten-year experience. I do have high regard for the development of angioem-
Can J Surg. 2006;49:386 –390.
19. Haan JM, Biffl W, Knudson MM, et al. Splenic embolization revisited: bolization. However, I do not believe that this strategy will
a multicenter review. J Trauma. 2004;56:542–547. benefit traumatized patients 20 or 30 years down the road for
20. Davis KA, Fabian TC, Croce MA, et al. Improved success in nonoperative whom emergency surgery is inevitable.
management of blunt splenic injuries: embolization of splenic artery Surgeons see less trauma cases in Japan than you see so
pseudoaneurysms. J Trauma. 1998;44:1008 –1013; discussion 1013–1015.
21. Malangoni MA, Dillon LD, Klamer TW, Condon RE. Factors influenc- this issue is more critical. If an emergency doctor to under-
ing the risk of early and late serious infection in adults after splenectomy stands embolization well but not surgical techniques makes a
for trauma. Surgery. 1984;96:775–783. decision of primary management, embolization tends to be
22. Harbrecht BG, Zenati MS, Ochoa JB, Puyana JC, Alarcon LH, Peitzman
AB. Evaluation of a 15-year experience with splenic injuries in a state
overused with the occasional unfavorable consequences.
trauma system. Surgery. 2007;141:229 –238. Thus, I think we must establish clear borderlines be-
tween recommendations for surgery and the embolization as
soon as possible by lowering the surgical threshold.
DISCUSSION
My last question is what is your opinion about the
Dr. Naoyuki Kaneko (Japan): Dr. Fabian, Britt, AAST
indications for embolization in the light of such two ramifi-
members and guests, I would like to thank you for giving me
cations? Regardless, I think very highly of your effort to treat
the opportunity to discuss Dr. Sabe’s paper here.
more severe splenic injuries with embolization. Thank you.
I would like to discuss the paper from a surgical
viewpoint. Although the rate of splenic artery embolization Dr. Frederick A. Moore (Houston, Texas): A hundred
was significantly higher in Group 3 than in Group 2 in your and fifteen or 33 percent of your non-operative patients in the
study, the splenic salvage rate was similar between them. third group underwent angioembolization.
Furthermore, in patients initially managed non-opera- That incidence of angioembolization I think only the
tively, the mortality rate was a little higher among the patients University of Maryland exceeds that. And the University of
in Group 3 than in Group 2. Maryland has popularized the concept of screening angiography
I am aware that many factors such as ISS and surgical where a lot of people go from the CT scan to the angio suite.
technique affect these results. However, that you might have And you listed some indications. One of the things
tried to over-manage the patients with embolization is debatable. you didn’t mention in the indication is hemodynamic
Thus, my first question is, was there not some inappro- stability. If you read the MIMS papers they take, tend to
priate decisions at the time of patients selection for emboli- take people who are hemodynamically unstable to angiog-
zation? The title of the article by Smith and Cioffi in 2006, raphy. Do you do that?
namely Splenic Artery Embolization, Have We Gone too Second, do all patients who undergo the initial angio-
Far? is quite impressive for me. gram get embolized? You had 25 delayed angiograms so my

© 2009 Lippincott Williams & Wilkins 571


Sabe et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 67, Number 3, September 2009

question is do you routinely get CT scans before hospital And we think that in addition to that we have selected
discharge as recommended by President Fabian? out those patients that would more likely have qualified
And the last is one about technique. There is a contro- previously for splenic preservation and now moved those into
versy about doing main splenic artery embolization versus the group that never gets operated.
polar embolization. And which technique do you do? So splenectomy for those patients who do require
And what is you complication of angioembolization in operation is going to be more common because the degree of
regards to failure to stop bleeding and local complications of injury is high.
abscess and infarcted spleens? Thank you very much. We are fortunate to have 24/7 interventional radiology
Dr. Richard J. Mullins (Portland, Oregon): Congrat- coverage. And that clearly allows us to do this. And there are
ulations on an excellent presentation. Following some of not all hospitals that have that sort of resource-intensive
these non-operative spleen injured patients in my experience radiology support available.
is challenging.They have fever, pain, pleural effusions, and Clearly Dr. Kaneko, the skills of surgeons who will be
return to the ER after hospital discharge with abdominal pain doing splenorrhaphy will be challenged in our environment.
and bloating. Is that your experience? Did you have to work However, I think as you can see from some of the
pretty hard to get some of these patients through the non- questions that were asked that this is not common at all
operative management? institutions so I think there still will be plenty of opportunities
The majority of splenectomies done in this country for for people to experience splenic preservation in training.
injury are done in smaller hospitals, not comparable to your Dr. Moore, as I mentioned, this is very resource-
Level I trauma center where you can have experts perform an intensive. Overall our failure rate for splenic artery emboli-
angiogram within minutes. Do you recommend a surgeon in zation is about 5 to 6 percent.
a smaller hospital in rural community outside Cleveland who Some of those are technical failures in that the radiologist
is called to evaluate a patient who presents with a bleeding is unable to do the cannulation to even get an angiogram. But
spleen injury, transfer that patient to Metro Hospital so that most of these are failures after the angiogram has been done.
the patient can get their splenic artery embolization? Or is it We typically take unstable patients directly to the
all right for the surgeon in a smaller hospital to just take out operating room and do not advocate that they should have
the spleen and get the job done?
angiography or, for that matter, even CT scan. We do not do
Dr. Ronald J. Simon (New York, New York): Enjoyed
routine follow-up CTs on these patients, however.
your paper very much. You showed a reduction in mortality
Dr. Mullins asked about the variability in practice in
in your first group versus your second and third groups.
hospitals. And, Richard, you are expert in pointing out to us the
Did you look at whether or not morbidity in your and
differences that occur between Level I trauma centers and
mortality in your general trauma population was also reduced
trauma centers that may not have the same capabilities or
during these time periods because you guys just got better in
taking care of patients and that the difference between Groups surgeons.
1, Group 2 and Group 3 actually had nothing to do with And we would agree with your observations previously
splenic artery embolization but just had to do with improved published that this doesn’t work for everyone. And I don’t
quality of care over the last ten years? Thank you. believe that there is anything wrong with a surgeon, regard-
Dr. Joseph P. Minei (Dallas, Texas): I have a question less of where they practice, taking a patient to operation in
regarding discretionary use of A gram and protocol-driven order to do what is right for the patient.
use of A gram and the question is, is really how good are your There was a question asked about whether or not our
surgeons at predicting this outcome? improvements were due to the protocol or perhaps due to
That is, what are the A gram results of discretionary use other factors that may affect our overall mortality.
versus protocol-driven use? Are the discretionary use A We did not examine this specifically but I would just tell you
grams have a lot higher positive rate versus the protocol use. that in my opinion I don’t believe that our mortality decreased by 50
And the second question is what are the complication percent in our patients overall. But we did clearly, clearly did not
rate? Did you notice a higher complication in the protocol- examine it so I don’t have that data for you.
driven group with so many more A grams done? Thank you. Dr. Minei, the one thing I would tell you is that for our
Dr. Mark A. Malangoni (Cleveland, Ohio): Thank protocol-driven patients there was no real difference in com-
you all for your questions. And I will try and address them all. plications in the two groups.
For Dr. Kaneko, 7 of 109 patients that had initial splenic We had thought initially that by using splenic artery
artery embolization failed and that compares to 1 of 46 embolization at the onset in these high risk patients that we
patients that had late splenic artery embolization. might be able to improve overall splenic salvage. That was not
So you can see our failure rate was higher in that group or the case.
in the group that had initial SAE. And it may be because we are We had a small but incremental improvement in pa-
not quite as precise as we wish to be in selecting patients for splenic tients that had non-operative management.
artery embolization who will have that done successfully. And I think it goes back to our overall goal is that if we
It’s very clear that what we’ve done by using this can get this right we should be able to decrease our rate of
protocol is we’ve moved more patients that we would operate failures from 3 percent to even lower. And that’s what we’re
on initially into the non-operative management group. striving to do. Thank you all very much.

572 © 2009 Lippincott Williams & Wilkins