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Role of Arterial Embolization in Non-Operative Management of Splenic Injuries

Role of Arterial Embolization in Non-Operative Management of Splenic Injuries. Jamaica Hospital Trauma Conference July 21 st , 2014 Greg Eckenrode. ADVANCING SCIENCE, ENHANCING LIFE. Management of Traumatic Spleen Injuries. Historically, nearly all splenic injuries were managed operatively

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Role of Arterial Embolization in Non-Operative Management of Splenic Injuries

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  1. Role of Arterial Embolization in Non-Operative Management of Splenic Injuries Jamaica Hospital Trauma Conference July 21st, 2014 Greg Eckenrode ADVANCING SCIENCE, ENHANCING LIFE

  2. Management of Traumatic Spleen Injuries • Historically, nearly all splenic injuries were managed operatively • Non-operative management developed in the pediatic population in the late 1960s • Increasing prevalence in adult population since the 1980s • Currently 50-70% of splenic injuries Stein DM, Scalea TM J Intensive Care Med. 2006;21(5):296.

  3. Operative Management • Hemodynamically unstable patients with evidence of abdominal bleeding • Positive FAST or DPA/DPL • Patients requiring abdominal exploration for other injuries • Intraperitoneal free air • Signs of peritonitis

  4. Operative Management • Hemodynamically stable patients • CT findings of contrast extravasation or vascular blush • High grade injuries (generally IV-V) • Age > 55 • Unable to safely observe patient

  5. Conventional Non-Operative Management • Admit to monitored care setting • Bed rest, NPO • Serial Hgb/Hct every 6 hours for 24 hours • Frequent vital signs, serial abdominal exams

  6. Splenic Angiography and Embolization • First applied to traumatic splenic injuries in 1995 • Multiple techniques • Distal selective • Proximal • Both • Intended to improve success of non-operative management

  7. Clinical Questions • Does splenic artery angiography and embolization improve non-operative management outcomes? • Which patients should undergo angiography and embolization?

  8. Western Trauma Association • 4 L1 trauma centers in the United States • 155 patients who underwent angiography and embolization for pseudoaneurysm, active bleeding on CT, significant hemopertoneum, and high grade injuries • Compared against the results of the Eastern Trauma Association study, which used conventional observation

  9. Comparison Results Haan, et al; J Trauma. 2004 Mar;56(3):542-7.

  10. Ullevaal University Hospital: 2006 • In 2002, implemented policy that all patients with splenic injury Grades III-V or ongoing bleeding underwent arterial embolization • Compared to all splenic injuries from 2000-2002, when arterial embolization was no performed at the hospital Gaardner, C, et al; J Trauma. 2006 Jul;61(1):192-8

  11. Study Outcomes

  12. Complications

  13. Multicenter Variation: 2010 • Compared 4 L1 trauma centers with variation in rates of splenic artery embolization in non-operative management • Rates ranged from 19% to 1% • Compared rates of splenic salvage and non-operative failure Bannerjee, et al; J Trauma Acute Care Surg. 2013 Jul;75(1):69-74

  14. Population Comparison Bannerjee, et al; J Trauma Acute Care Surg. 2013 Jul;75(1):69-74

  15. Management Comparison Bannerjee, et al; J Trauma Acute Care Surg. 2013 Jul;75(1):69-74

  16. Splenic Salvage Rate Bannerjee, et al; J Trauma Acute Care Surg. 2013 Jul;75(1):69-74

  17. Wake Forest - 2014 • Single site L1 Trauma Center • Prior to 2010, angiography and embolization performed for CT contrast blush • Starting in 2010, prospectively performed angiography and embolization on all Grade III-IV splenic injuries • Compared non-operative failure rates against recent historical controls from 2007-2009 period Miller, et al; J Am Coll Surg. 2014 Apr;218(4):644-8

  18. Study Group Comparison Miller, et al; J Am Coll Surg. 2014 Apr;218(4):644-8

  19. Study Results • 2010-2012: Non-operative failure rate of 5% • Failure rate of 25% in 16 protocol deviations (p=0.02) • 2007-2009: Non-operative failure rate of 15% (p=0.04)

  20. Conclusions • In historical comparisons, patients with splenic injuries who are candidates for non-operative management have better outcomes when SAE is utilized • Centers which perform a higher rate of SAE have higher rates of spelic salvage and lower rates of non-operative management failure

  21. Conclusions • Centers which implement a standard protocol mandating SAE for non-operative splenic injuries experience decreased rates of of non-operative failure and increased rates of splenic salvage

  22. Future Directions • No prospective, head-to-head randomized clinical trial of SAE in non-operative splenic injuries • Limited data with respect to cost effectiveness

  23. Splenic Injury Grading • Grade I: • Hematoma: Subcapsular, < 10% of surface area • Laceration: Capsular tear < 1 cm depth • Grade II • Hematoma: Subcapsular, 10 - 50 % of surface area • Laceration: Capsular tear 1 - 3 cm depth not involving trebecular vessel

  24. Splenic Injury Grading • Grade III • Hematoma • Subcapsular, > 50% of surface area • Subcapsular, expanding • Ruptured subcapsular or parenchymal • Intraparenchymal > 5cm • Laceration • > 3cm depth • Involving trabecular vessel

  25. Splenic Injury Grading • Grade IV • Laceration: segmental or hilar vessels with > 25% devascularization • Grade V • Hematoma: shattered spleen • Laceration: total devascularization

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