Trauma Esplenico

Long-Term Incidence and Timing of Splenic
Pseudoaneurysm Formation after Blunt

Splenic Injury: A Descriptive Study
Takaki Hirano,1 Yudai Iwasaki,2 Yuko Ono,3 Tokiya Ishida,1 and Kazuaki Shinohara,1
Koriyama, Fukushima, Sendai, Miyagi, and Kobe, Japan
Background: Nonoperative management (NOM) has become a standard strategy for hemody-
namically stable patients with blunt splenic injury; however, delayed rupture of splenic pseudoaneur-
ysm (SPA) is a serious complication of NOM. In medical literature, data regarding the long-term
incidence of SPA are scarce, and the appropriate timing for performing follow-up contrast-enhanced
computed tomography (CT) has not yet been reported. This study aimed to elucidate the long-term
incidence and timing of SPA formation after blunt splenic injury in patients treated with NOM.
Methods: This descriptive study was conducted at a tertiary medical center in Japan. Patients
with blunt splenic injury who were treated with NOM between April 2014 and August 2020 were
included in the analysis. Included patients underwent repeated contrast-enhanced CT to detect
SPA formation. The primary outcome was the cumulative incidence of delayed formation of
SPA. We also evaluated differences in SPA formation between patients who received transcath-
eter arterial embolization (TAE; TAE group) and those who did not receive it (non-TAE group) on
admission day.
Results: Among 49 patients with blunt splenic injury who were treated with NOM, 5 patients
(10.2%) had delayed formation of SPA. All cases of SPA formation occurred within 15 days
of injury. The incidence of SPA formation was not significantly different between the TAE and
non-TAE groups (1/19 vs. 4/30, P ¼ 0.67).
Conclusions: SPA developed in 10% of patients within approximately 2 weeks after blunt
splenic injury. Therefore, performing follow-up contrast-enhanced CT in this period after injury
may be useful to evaluate delayed formation of SPA. Although our findings are novel, they
should be confirmed through future studies with larger sample sizes.
1
Disclosure of conflicts of interest: The authors of this work have Department of Anesthesiology and Emergency Medicine, Ohta
nothing to disclose. Nishinouchi Hospital, Koriyama, Fukushima, Japan.
Funding: This research did not receive any specific grant from fund- 2
Department of Anesthesiology and Perioperative Medicine, Tohoku
ing agencies in the public, commercial, or not-for-profit sectors. University Graduate School of Medicine, Sendai, Miyagi, Japan.
Ethics approval and consent to participate: This study was approved 3
by the Institutional Review Board at Ohta Nishinouchi Hospital (No. Department of Disaster and Emergency Medicine, Graduate School
40) on April 15, 2021. The committee waived the need for patient con- of Medicine, Kobe University, Kobe, Japan.
sent. Correspondence to: Yudai Iwasaki MD, Department of Anesthesi-
Consent for publication: Consent for publication was not applicable ology and Perioperative Medicine, Tohoku University Graduate School
because this manuscript did not obtain individual patient’s data. of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574,
Availability of data and materials: The datasets generated during Japan; E-mail: yudai.i0213@gmail.com
and/or analyzed during the current study are available from the corre- Ann Vasc Surg 2023; 88: 291–299
sponding author on reasonable request. https://doi.org/10.1016/j.avsg.2022.06.010
Author contributions: All authors contributed to the study design. Ó 2022 Elsevier Inc. All rights reserved.
Data were collected by Takaki Hirano and Yudai Iwasaki. Analysis Manuscript received: March 20, 2022; manuscript accepted: June 1,
was conducted by Takaki Hirano, Yudai Iwasaki, and Yuko Ono. 2022; published online: 9 July 2022
The first draft of the manuscript was written by Takaki Hirano, and
all authors commented and revised previous versions of the manuscript.
All authors read and approved the final manuscript.
291
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292 Hirano et al. Annals of Vascular Surgery
INTRODUCTION blunt splenic injury treated with NOM by utilizing

repeated follow-up contrast-enhanced CT findings.
Nonoperative management (NOM) has become the We also aimed to investigate the appropriate timing
standard strategy for hemodynamically stable pa- for performing CT reexamination.
tients with blunt splenic injury.1 This management
approach originated from the realm of pediatric
blunt splenic trauma and became widely accepted MATERIALS AND METHODS
in adult patients.2,3 However, NOM can sometimes
fail owing to uncontrollable intra-abdominal hem- This descriptive study was conducted at a tertiary
orrhage. To prevent performing surgery for hemo- care facility in Japan. Annually, our institution re-
stasis, several investigators recommended the ceives approximately 5,000 patients through ambu-
selective use of transcatheter arterial embolization lance services, including 1,100e1,200 trauma
(TAE) as an adjunct to NOM. They reported that patients with various degrees of severity. The review
the use of TAE in cases of high-grade injuries and board at Ohta Nishinouchi Hospital (Fukushima,
contrast blush (CB) on computed tomography Japan) approved this study on April 15, 2020
(CT) resulted in a high success rate of NOM.4e6 (Approval No. 40). The committee waived the
Through the wide use of selective TAE, the overall need for patient consent.
success rate of NOM in adult patients with blunt The study included patients with blunt splenic
splenic injury was reported to be approximately trauma who were admitted to our intensive care
90%.6e10 The Eastern Association for the Surgery unit and were treated with NOM between April
of Trauma (EAST) practice management guideline 2014 and August 2020. NOM was defined as a man-
recommends that TAE for blunt splenic injury agement approach without involving emergency
should be considered for patients with the American abdominal surgery. Patients who were directly
Association for the Surgery of Trauma (AAST) grade transported from the emergency department to the
of >III, CB, moderate hemoperitoneum, or evidence operating room for emergency abdominal surgery
of ongoing splenic bleeding.2 were excluded from the study, as were those who
Despite the high success rates of NOM, delayed died within the first 24 hr from arrival to the hospi-
rupture of the spleen has become a rare, but serious, tal. The therapeutic decision for NOM was deter-
complication of NOM. A previous study reported mined by each physician’s discretion based on
death due to delayed rupture in one of 303 cases.11 their experience and the patient’s trauma severity.
Several studies have reported that 1e2% of Patients who were treated with NOM underwent
patients were readmitted to the hospital due to meticulous monitoring of hemodynamic parame-
post-discharge bleeding and underwent splenec- ters, serial abdominal findings, and repeated blood
tomy.12,13 Splenic pseudoaneurysm (SPA) following tests, including tests for hemoglobin and coagula-
splenic injury is a type of aneurysm that does not tion factor levels.
involve the 3 vessel layers, and rupture of the SPA Data were collected from our hospital-based
can be the cause of delayed rupture of the spleen.14 trauma database and patients’ electronic healthcare
A few retrospective observational studies indicated records. Patients’ characteristics included age, sex,
that SPA developed within approximately a week comorbidity, injury mechanism, the severity of the
after injury.8,15 Consistent with these findings, injury, grade of splenic injury based on the AAST
another report presented a case of delayed SPA for- grade, presence of CB on CT, indication for angiog-
mation detected on day 5 after injury.16 raphy and TAE, NOM failure, angiographic findings,
However, the long-term incidence and timing of duration of hospital stay, and mortality. In our institu-
delayed SPA formation are poorly understood. tion, emergency TAE was defined as TAE done within
Moreover, the optimal timing for CT reexamination 24 hr after arrival to the hospital, and indications
and follow-up period for SPA detection also remain for such were generally considered based on
controversial.17 The EAST practice management hemodynamic parameters, high injury grade, and
guidelines state that the need for repeated imaging CB detection on contrast-enhanced CT. We defined
remains the unanswered question.2 In our institu- NOM failure as patients who subsequently under-
tion, we currently conduct a follow-up of these pa- went any abdominal surgery after admission in accor-
tients using long-term CT according to the injury dance with the literature.10 Radiologic findings,
severity. However, the effectiveness of this manage- including splenic injury grade and presence of SPA
ment approach remains unclear. formation or CB, were interpreted by 2 doctors: one
Therefore, we aimed to determine the long-term was a board-certified emergency physician and the
incidence and timing of delayed SPA formation after other was a board-certified interventional radiologist.
Volume 88, January 2023 Long-term incidence of splenic pseudoaneurysm 293
Fig. 1. Flowchart showing the selection of patients with blunt splenic injury for inclusion in the analysis. ED, emer-
gency department; OR, operating room.
The primary outcome was the cumulative inci- were considered to indicate statistical significance.
dence of delayed formation of SPA. We followed All statistical analyses were performed using
the included patients with repeated contrast- R software (version 4.0.4).
enhanced CT to detect SPA formation during their
hospitalization and even after discharge. The timing
and duration of the follow-up CT were based on RESULTS
physicians’ discretion. The primary outcome was
Patient Characteristics and Splenic
assessed based on the findings of follow-up CT.
Pseudoaneurysm Formation
The timing and duration of follow-up CT were
determined based on the severity of the injury, A total of 49 patients with blunt splenic injury
initial CT findings, and the need for emergency treated with NOM were included in this study
TAE. Delayed formation of SPA was defined as an (Fig. 1). Patient demographics are summarized in
SPA that was first detected on a contrast-enhanced Table I. The mean age of the entire cohort was
CT scan beyond 48 hr after injury, as reported in a 41.0 (SD: 21.7) years, and 75.5% of the patients
previous study.11 We also examined the differences were male. The mean Injury Severity Score (ISS)
in the cumulative incidence of SPA formation be- was 29.6 (SD: 11.1). The predominant mechanism
tween patients who received TAE (TAE group) and of injury was traffic accident (42 of 49, 85.7%).
those who did not receive it (non-TAE group) on Regarding splenic injury grade, 5 patients (10.2%)
admission day. were classified as grade I, 24 (49.0%) as grade II,
Continuous variables were expressed as means ± 11 (22.4%) as grade III, 9 (18.4%) as grade IV, and
standard deviations (SDs) or as medians with the none as grade V. Of the 5 grade I patients, 3 under-
first and third quartiles. Categorical variables went follow-up contrast-enhanced CT for >2 weeks
were expressed as numbers and proportions. Dif- and 2 underwent follow-up contrast-enhanced CT
ferences in continuous variables between the TAE for <2 weeks. Only 1 patient had failure of NOM
and non-TAE groups were compared using Stu- (1 of 49, 2.0%). This patient underwent emergency
dent’s t-test or the Wilcoxon rank-sum test based TAE for splenic injury on the day of admission and
on data distribution for each variable. The underwent distal pancreatectomy together with
Shapiro-Wilk test was used to verify the data distri- splenectomy for a traumatic pancreatic abscess
bution. The cumulative incidence of SPA was rather than for a rebleeding of the spleen after
assessed using the Kaplan-Meier method, and admission. Only 1 patient died due to multiple organ
between-group differences were compared using failure 51 days after injury. Nineteen patients
the log-rank test. Two-sided P values of <0.05 (38.8%) received emergency TAE as an adjunct to
Table I. Characteristics of patients with and without emergency transcatheter arterial embolization
Emergency TAE
Variable Total (n ¼ 49) No (n ¼ 30) Yes (n ¼ 19) P value
Age (years), mean (SD) 41.0 (21.7) 44.4 (23.3) 35.6 (18.1) 0.17
Male, n (%) 37 (75.5) 20 (66.7) 17 (89.5) 0.14
Hypertension, n (%) 9 (18.4) 8 (26.7) 1 (5.3) 0.13
Diabetes mellitus, n (%) 7 (14.3) 5 (16.7) 2 (10.5) 0.86
Hematologic disease, n (%) 1 (2.0) 1 (3.3) 0 (0) 1.0
Liver disease, n (%) 1 (2.0) 1 (3.3) 0 (0) 1.0
Charlson risk index, n (%) 0.57
0 39 (79.6) 23 (76.7) 16 (84.2)
1 7 (14.3) 4 (13.3) 3 (15.8)
2 2 (4.1) 2 (6.7) 0 (0)
3 1 (2.0) 1 (3.3) 0 (0)
Mechanism, n (%) 0.64
Traffic accident 42 (85.7) 25 (83.3) 17 (89.5)
Fall 5 (10.2) 4 (13.3) 1 (5.3)
Others 2 (4.1) 1 (3.3) 1 (5.3)
SBP on admission (mm Hg), n (%) 0.44
0 0 (0) 0 (0) 0 (0)
1e49 0 (0) 0 (0) 0 (0)
50e75 3 (6.1) 2 (6.7) 1 (5.3)
76e89 1 (2.0) 0 (0) 1 (5.3)
>89 45 (91.8) 28 (93.3) 17 (89.5)
GCS score on admission, n (%) 0.87
3 3 (6.1) 2 (6.7) 1 (5.0)
4e5 1 (2.0) 1 (3.3) 0 (0)
6e8 0 (0) 0 (0) 0 (0)
9e12 5 (10.2) 3 (10.0) 2 (10.5)
13e15 40 (81.6) 24 (80.0) 16 (84.2)
RR on admission (bpm), n (%) 0.18
0 0 (0) 0 (0) 0 (0)
1e5 0 (0) 0 (0) 0 (0)
6e9 0 (0) 0 (0) 0 (0)
10e29 35 (71.4) 24 (80.0) 11 (57.9)
>29 14 (28.6) 6 (20.0) 8 (42.1)
RTS, median [IQR] 7.84 [7.55e7.84] 7.84 [7.55e7.84] 7.84 [7.55e7.84] 0.77
TRISS, median [IQR] 0.95 [0.85e0.98] 0.94 [0.79e0.98] 0.95 [0.88e0.98] 0.55
AIS abdomen, n (%) 0.09
0 1 (2.0) 1 (3.3) 0 (0)
1 0 (0) 0 (0) 0 (0)
2 13 (26.5) 11 (36.7) 2 (10.5)
3 20 (40.8) 12 (40.0) 8 (42.1)
4 15 (30.6) 6 (20.0) 9 (47.4)
5 0 (0) 0 (0) 0 (0)
6 0 (0) 0 (0) 0 (0)
ISS, mean (SD) 29.59 (11.11) 29.17 (12.06) 30.26 (9.70) 0.74
Splenic injury grade (AAST), n (%) 0.002
I 5 (10.2) 5 (16.7) 0 (0)
II 24 (49.0) 19 (63.3) 5 (26.3)
III 11 (22.4) 4 (13.3) 7 (36.8)
IV 9 (18.4) 2 (6.7) 7 (36.8)
V 0 (0) 0 (0) 0 (0)
Emergency angiography, n (%) 29 (59.2) 10 (33.3) 19 (100.0) <0.001
Emergency TAE, n (%) 19 (38.8)
Surgery (NOM failure), n (%) 1 (2.0) 0 (0) 1 (5.3) 0.82
(Continued)
Table I. Continued
Emergency TAE
Variable Total (n ¼ 49) No (n ¼ 30) Yes (n ¼ 19) P value
Delayed formation of SPA, n (%) 5 (10.2) 4 (13.3) 1 (5.3) 0.67

Duration of hospital, median [IQR] 36.00 [15.00e64.00] 33.00 [17.50e64.00] 39.00 [14.00e67.00] 0.94
Duration of ICU, median [IQR] 3.00 [2.00e5.00] 3.00 [2.00e4.00] 4.00 [3.00e5.50] 0.056
30-day mortality, n (%) 0 (0) 0 (0) 0 (0) NA
180-day mortality, n (%) 1 (2.0) 1 (3.3) 0 (0) 1.0
AIS, Abbreviated Injury Scale; GCS, Glasgow Coma Scale; ICU, intensive care unit; IQR, interquartile range; N/A, not applicable; RR,
respiratory rate; RTS, Revised Trauma Score; SBP, systolic blood pressure; TRISS, Trauma and Injury Severity Score.
NOM. Although there were no significant differ- managed by observation alone, and the SPA
ences in the demographic characteristics between resolved spontaneously.
patients with and without emergency TAE, those
who received emergency TAE had a higher splenic
injury grade (Table I). DISCUSSION
The median follow-up duration of contrast-
enhanced CT was 55 days (interquartile range, Our study demonstrated the long-term incidence
12e196). The longest follow-up duration was and timing of SPA formation after blunt splenic
1,170 days. The frequency and timing of CTs for all injury treated with NOM. Five of 49 patients devel-
patients are shown in Table II. Delayed SPA forma- oped SPA during the follow-up period, and delayed
tion occurred in 5 of 49 (10.2%) patients, and all rupture was not observed in our study cohort. The
cases of SPA formation occurred within 15 days of incidence of delayed SPA formation was in agree-
injury (range, 8e15). The details of the dates of ment with the findings of previous studies.8,15,18,19
SPA formation in each of the 5 cases are shown in We believe that our study reports 2 clinically impor-
Table III. One example image of delayed pseudoa- tant findings: (1) that SPA formation occurred
neurysms is shown in Figure 2. No SPA formation within 15 days (range, 8e15) and (2) that TAE
was detected after this period even with repeated application during hospital admission tended to
contrast-enhanced CT and long-term follow-up. reduce the formation of SPA.
The Kaplan-Meier curve showed information on Previous studies reported that most cases of
the cumulative incidence of delayed SPA formation delayed SPA formation were detected approxi-
in the total cohort (Fig. 3). mately within a week of the injury.8,15 Based on
The cumulative incidence of delayed SPA forma- these data, some studies recommended performing
tion in patients stratified by emergency TAE is follow-up CT approximately 1 week after injury15
shown in Figure 4. Although the difference did not or within 48 hr after admission.18 However, the
reach statistical significance, patients who did not timing of SPA formation in our study was later
receive emergency TAE tended to have a higher cu- than that reported in published studies. This finding
mulative incidence of SPA than those who received suggests that performing follow-up contrast-
it (1/19 vs. 4/30, P ¼ 0.67). enhanced CT after approximately 2 weeks, in addi-
tion to performing one at admission and within a
week, might be a useful approach to evaluate
Clinical Course of the Delayed
delayed formation of SPA. Nevertheless, the optimal
Formation of Splenic Pseudoaneurysm
timing of follow-up CT is unclear in splenic grade I
The characteristics of the 5 injured patients who patients, due to the lack of SPA formation in grade
developed SPA are listed in Table III. Delayed I patients in this study. The difference in the timing
formation of SPA was found in 1 of 24 (4.1%) pa- of SPA formation between our study and the previ-
tients with grade II injury, 3 of 11 (27%) with ous studies might be due to the variation in patients’
grade III, and 1 of 9 (11%) with grade IV in terms severity. The EAST guideline states that hemody-
of splenic injury grade. There was no delayed for- namically unstable patients should be managed
mation of SPA in patients with grade I injury. Of with urgent laparotomy.2 According to the guide-
the 5 patients, emergency TAE was performed lines, previous studies8,15,18 were limited in terms
during the first admission in only 1 patient of the adaptation of NOM to hemodynamically sta-
(20%). The remaining 4 patients with SPA were ble patients. Compared with these, NOM with TAE
managed by selective TAE. One patient was was chosen even in patients with hemodynamic
Table II. Frequency and timing of computed tomography for all patients
Total number of
contrast-enhanced
Patient CT (times) First CT Second CT Third CT Fourth CT Fifth CT Sixth CT Seventh CT Eighth CT Ninth CT
#1 2 Day 1 Day 7
#2 9 Day 1 Day 6 Day 13 Day 20 Day 83 Day 142 Day 294 Day 504 Day 861
#3 3 Day 1 Day 15 Day 125
#4 5 Day 1 Day 10 Day 39 Day 108 Day 193
#5 4 Day 1 Day 19 Day 132 Day 300
#8 2 Day 1 Day 4
#9 2 Day 1 Day 16
#11 2 Day 1 Day 8
#12 6 Day 1 Day 8 Day 30 Day 92 Day 182 Day 365
#13 3 Day 1 Day 2 Day 11
#15 2 Day 1 Day 4
#16 4 Day 1 Day 9 Day 36 Day 120
#17 2 Day 1 Day 8
#18 3 Day 1 Day 32 Day 144
#19 3 Day 1 Day 9 Day 30
#20 3 Day 1 Day 8 Day 35
#21 1 Day 1
#23 4 Day 1 Day 2 Day 9 Day 34
#25 3 Day 1 Day 7 Day 179
#26 1 Day 1
#28 3 Day 1 Day 10 Day 35
#31 8 Day 1 Day 10 Day 35 Day 95 Day 248 Day 454 Day 820 Day 1170
#32 2 Day 1 Day 28
#33 1 Day 1
#34 2 Day 1 Day 12
#35 3 Day 1 Day 8 Day 43
#37 3 Day 1 Day 4 Day 18
#38 2 Day 1 Day 8
#39 3 Day 1 Day 9 Day 32
#40 3 Day 1 Day 8 Day 28
#41 7 Day 1 Day 15 Day 27 Day 42 Day 84 Day 93 Day 182
#44 1 Day 1
#45 4 Day 1 Day 9 Day 35 Day 133
#46 4 Day 1 Day 2 Day 9 Day 51
#47 4 Day 1 Day 11 Day 31 Day 61
#48 1 Day 1
Days of CT examination were counted from the day of admission.
instability in our institution. Due to this difference was 30 in our study, and this value is higher than
in NOM indication, more severe patients might be that reported in previous studies.8,18 Moreover,
included in this study. In fact, the median ISS value our findings suggest that performing routine long-
Table III. Characteristics of patients with delayed SPA formation

Splenic
Age AIS injury grade Emergency Day SPA Management Success
(years) Sex Mechanism abdomen ISS (AAST) TAE was diagnosed for SPA of NOM
68 Male Fall 4 24 IV No 10 TAE Yes

17 Female Traffic 3 14 III No 8 Observation Yes
57 Male Others 2 29 II No 15 TAE Yes
43 Male Traffic 3 29 III No 9 TAE Yes
17 Male Traffic 4 24 III Yes 11 TAE Yes
AIS, Abbreviated Injury Scale.
Fig. 2. An example image of delayed pseudoaneurysms. shows a pseudoaneurysm in the spleen (white arrow).
(A) CECT on arrival shows a splenic injury without pseu- (D) Splenic artery angiography shows the pseudoaneur-
doaneurysms and contrast medium extravasation. (B) ysm (black arrow) in the distal of superior terminal branch
CECT on day 4 after admission does not show pseudoa- artery. CECT, contrast-enhanced computed tomography.
neurysms. (C) CECT on day 11 after admission first
term follow-up CT may not be necessary. In previ- been discharged. However, no patient developed
ous studies,8,15 the maximum period for follow-up SPA after 15 days.
CT was limited to within 25 days of injury because The degree of trauma in patients with emergency
follow-up CT was performed only during intensive TAE was more severe than that in patients without
care unit or hospital stay. In contrast, we performed the emergency TAE. Nonetheless, in our study, pa-
follow-up contrast-enhanced CT for a median of tients who received emergency TAE tended to
55 days (interquartile range, 12e196) and up to have a lower incidence of delayed SPA formation
1,170 days after injury, even if the patient had than those who did not receive emergency TAE.
Fig. 4. Cumulative incidence of delayed formation of

splenic pseudoaneurysm, stratified by transcatheter arte-
Fig. 3. Cumulative incidence of delayed formation of rial embolization. The inset in the figure shows the same
splenic pseudoaneurysm in the total cohort. The inset data on an enlarged y axis.
in the figure shows the same data on an enlarged y axis.
Although the incidence of SPA formation was not during the generalization of our findings in terms
significantly different between the 2 groups, emer- of the incidence and timing of SPA formation.
gency TAE may have an essential role in preventing However, the incidence of SPA observed in this
subsequent SPA formation. This result was sup- study was in agreement with that of previous
ported by the fact that adjunctive TAE improved studies.8,15,18,19 Hence, we believe that our find-
NOM success rates4e6 and that SPA rupture was ings can be applied to most patients with blunt
the main cause of NOM failure.8 Indeed, the NOM splenic injury, although the strategy followed was
failure rate in all patients in this study was 2.0% slightly different. The second limitation was the
(1 of 49 patients), which is lower than that of variation in the timing and frequency of perform-
8.3% (95% confidence interval, 6.7e10.2) reported ing follow-up CT. In our institution, patients
in a previous meta-analysis.7 This discrepancy may considered to be at high risk of SPA formation
have been due to differences in initial TAE indica- (e.g., high-grade injury or presence of CB at the
tion. In our institution, emergency TAE is generally initial CT) tended to have a long follow-up period.
performed even for grade III injury patients. Emer- Although this trend was reasonable in clinical prac-
gency TAE is also applied to patients who should tice, we could not set the precise schedule and
have undergone laparotomy according to the timing of the follow-up CT. Some patients did not
EAST guideline. This inclusion criterion is slightly visit our institution, which might have led to with-
more aggressive than the EAST recommendations.2 drawal bias. In fact, among all 49 patients, follow-
In contrast, the previous meta-analysis7 included up CT over 60 days was performed only for 24 pa-
observational studies wherein TAE was not applied tients in our analysis. However, because we were
for high-grade injury patients. Therefore, a large able to follow-up approximately 73% (36 of 49)
prospective observational study or a randomized of patients for more than 15 days and SPA forma-
controlled study is needed to confirm the utility of tion was not detected after 15 days from injury
TAE to prevent SPA formation. onset, this effect of withdrawal bias was considered
This study had some limitations. First, our study to be small. The third limitation was the small
had a retrospective descriptive design, and we did number of eligible patients from a single center.
not follow any strict protocol for NOM manage- Therefore, the results of this study may not be
ment and TAE indication. Decision-making for generalizable to other settings.
TAE induction depended on the physician’s discre- Despite these limitations, this study has
tion. Consequently, compared with previous strengths, as it was the first observational study to
studies, patients in this study who had more severe evaluate the long-term clinical history of SPA after
conditions might have been managed by NOM blunt splenic injury treated with NOM by utilizing
together with TAE instead of operative manage- long-term repeat contrast-enhanced CT. Thus far,
ment. Therefore, caution should be exercised no previous studies have conducted follow-up
contrast-enhanced CT for patients until after achieved with selective embolization. J Trauma 2004;56:
discharge or confirmed whether SPAs were formed 1063e7.
7. Requarth JA, D’Agostino RB Jr, Miller PR. Nonoperative
in the long term. Our findings may have clinical im- management of adult blunt splenic injury with and without
plications in terms of the duration of follow-up CT in splenic artery embolotherapy: a meta-analysis. J Trauma
cases of blunt splenic injury treated with NOM. A 2011;71:898e903. discussion 903.
large-sample, multicenter prospective trial is war- 8. Davis KA, Fabian TC, Croce MA, et al. Improved success in
ranted to confirm our findings. nonoperative management of blunt splenic injuries: emboli-
zation of splenic artery pseudoaneurysms. J Trauma
1998;44:1008e13. discussion 1013-1005.
9. Miller PR, Chang MC, Hoth JJ, et al. Prospective trial of
CONCLUSIONS angiography and embolization for all grade III to V blunt
splenic injuries: nonoperative management success rate
In conclusion, we demonstrated the long-term inci- is significantly improved. J Am Coll Surg 2014;218:
dence and timing of delayed SPA formation after 644e8.
blunt splenic injury treated with NOM. Delayed 10. Gaarder C, Dormagen JB, Eken T, et al. Nonoperative man-
agement of splenic injuries: improved results with angioem-
SPA formation was detected within 15 days after
bolization. J Trauma 2006;61:192e8.
injury onset. Our results suggest that performing 11. Davies DA, Fecteau A, Himidan S, et al. What’s the inci-
follow-up contrast-enhanced CT within approxi- dence of delayed splenic bleeding in children after blunt
mately 2 weeks after injury onset might be useful trauma? An institutional experience and review of the liter-
to detect delayed SPA formation. ature. J Trauma 2009;67:573e7.
12. Zarzaur BL, Vashi S, Magnotti LJ, et al. The real risk of sple-
nectomy after discharge home following nonoperative man-
agement of blunt splenic injury. J Trauma 2009;66:1531e6.
The authors thank their colleagues at the Department of discussion 1536-1538.
Anesthesiology and Emergency Medicine, Ohta Nishinouchi 13. McIntyre LK, Schiff M, Jurkovich GJ, et al. Failure of
Hospital for their assistance in data acquisition and for their nonoperative management of splenic injuries: causes and
consequences. Arch Surg 2005;140:563e8. discussion
contribution to this study.
568-569.
14. Hiraide A, Yamamoto H, Yahata K, et al. Delayed rupture of
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Long-Term Incidence and Timing of Splenic

Pseudoaneurysm Formation after Blunt

INTRODUCTION blunt splenic injury treated with NOM by utilizing

Variable Total (n ¼ 49) No (n ¼ 30) Yes (n ¼ 19) P value

Variable Total (n ¼ 49) No (n ¼ 30) Yes (n ¼ 19) P value

Delayed formation of SPA, n (%) 5 (10.2) 4 (13.3) 1 (5.3) 0.67

Days of CT examination were counted from the day of admission.

Table III. Characteristics of patients with delayed SPA formation

68 Male Fall 4 24 IV No 10 TAE Yes

AIS, Abbreviated Injury Scale.

Fig. 4. Cumulative incidence of delayed formation of

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