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- Springer Journals
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- Copyright © The Author(s) 2023
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- 10.1186/s42155-022-00345-8
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Abstract
Xu et al. CVIR Endovascular (2023) 6:1 CVIR Endovascular https://doi.org/10.1186/s42155-022-00345-8 Open Access ORIGINAL ARTICLE Proximal splenic artery embolization using a vascular plug in grade IV or V splenic trauma – a single centre 11-year experience 1,2* 1 1 1 1 Samuel S. Xu , Kevin Eng , Fabio Accorsi , Derek W. Cool , Daniele Wiseman , 1 1 Amol Mujoomdar and Leandro Cardarelli‑Leite heterogeneity of technique varies in both the literature Introduction and in practice (Habash et al., 2021; Haan et al., 2005; Splenic injury is one of the most common injuries follow- Ahuja et al., 2015; Quencer & Smith, 2019; Demetriades ing blunt abdominal trauma, reported in 32% of trauma et al., 2012; Banerjee et al., 2013). cases (Lynn et al., 2009). The non-operative manage - The main purpose of this study was to retrospectively ment (NOM) of hemodynamically stable patients has assess if proximal SAE with a vascular plug alone is effec - become the standard of care and splenic artery emboli- tive in stopping bleeding and achieving splenic salvage zation (SAE) is being used as an adjunct to observation for the treatment of grade IV or V splenic injuries. Fur- to increase the success rate of NOM (Habash et al., 2021; thermore, complication and mortality rates were com- Patil et al., 2020). pared between the use of additional coil embolization SAE is a well documented procedure for splenic versus vascular plug alone. trauma, originally described by Sclafani in 1981 (Sclafani, 1981), offering a splenic preservation treatment (Habash Materials and methods et al., 2021; Patil et al., 2020; Haan et al., 2005; Brahmb- A retrospective review was performed to include all hatt et al., n.d.; Olthof et al., 2017; Ahuja et al., 2015; splenic artery embolization procedures performed at the Cretcher et al., 2021). The technique of proximal embo - local tertiary care level I trauma centre, between Novem- lization, distal embolization, or combined embolization ber 2010 to January 2021. Institutional Research Eth- is well described in the literature, with comparable clini- ics Board approval was obtained. Informed consent was cal outcomes (Jambon et al., 2018; Frandon et al., 2014; waived by the review board for this study. Wong et al., 2017; Gheju et al., 2013; Quencer & Smith, Exclusion criteria included lack of pre-procedural 2019; Cinquantini et al., 2018) and overall good splenic imaging, splenic embolization procedure performed preservation. Generally, proximal embolization is per- for an indication other than blunt abdominal trauma, formed for global splenic trauma to decrease the perfu- distal embolization, non-vascular plug embolization, sion pressure to the spleen, while distal embolization is and splenic trauma grade III or lower (Fig. 1). The most used to embolize more focal injuries (Jambon et al., 2018; widely accepted grading classification of the splenic Quencer & Smith, 2019; Johnson et al., 2021). However, injuries is the American Association of the Surgery of Trauma (AAST) splenic injury scale (Kozar et al., 2018) *Correspondence: (Table 1) was used for injury grading. Patients included Samuel S. Xu sam.sh.xu@gmail.com in this study were hemodynamically stable, as hemody- University of Western Ontario, London, Ontario, Canada namically unstable patients were routinely taken to the Halton Healthcare Services, 3001 Hospital Gate, Oakville, ON L6M 0L8, operating room as per the local standard practice. The Canada CT for all patients were reviewed retrospectively by © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. Xu et al. CVIR Endovascular (2023) 6:1 Page 2 of 7 were documented and defined by the Society of Inter- ventional Radiology Adverse Event Classification (Kozar et al., 2018). New left sided pleural effusions were looked at specifically as an indicator for splenic inflammation and irritation, which is a described association in the literature of SAE for hypersplenism (Araten et al., 2014). Any follow-up imaging, as well as follow up clinical notes, were reviewed. Demographics and Preprocedural data A total of 121 patients underwent splenic embolization. Patients with non-traumatic etiology (n = 25), non-prox- imal embolization (n = 12), grade III splenic injury or lower (n = 4), and non-plug embolization (n = 4) were excluded, leaving 76 study patients. Preprocedural details are summarized in Table 2. On preprocedural CT, pseu- doaneurysms were present in 64 of the cases (84.2%). The most frequently reported number of pseudoaneurysms was more than five, totaling 26 cases (34.2%). Fig. 1 Patient inclusion Technique abdominal and interventional radiologists not involved CT technique in the procedures, blinded to the clinical outcomes, and CT were acquired on 64 slice CT scanners (GE Light- splenic injury was graded using the AAST splenic injury speed, Boston, MA, USA) between November 2010 to scale (Kozar et al., 2018). October 2019. Subsequently, all images were acquired on The time between the acquisition of the initial CT (con - 128 or 320 slice CT scanners (Canon Aquilion, Tokyo, sidered time of diagnosis of the splenic injury) to the time Japan). CT protocol during initial trauma acquisition of to the start of the embolization procedure was calcu- the thorax, abdomen, and pelvis was performed follow- lated in hours. Splenic artery diameter and the presence ing injection of a dual bolus IV contrast technique. Initial of splenic pseudoaneurysms and its size were recorded. injection of 90 cc of Omnipaque 350 is given, followed Procedural details including the type and diameter of the by 15 cc of normal saline, both at 3 cc/sec. Following a plug and coils (if used) were recorded. Radiation dose, 15 second pause, a 50 cc injection of Omnipaque 350 is if available due to change in software and infrastructure performed with a 20 cc injection of normal saline, both resulting in loss of data, was also recorded. at 4 cc/sec (Fig. 2a). A check on the scanner is then per- Technical success was defined as completion of formed by the radiologist or radiology resident on call the procedure with successful proximal deployment for decision of obtaining delayed images, acquired at of the plug with decreased flow through the splenic 5 minutes post injection (Fig. 2b). CT parameters are set artery. Clinical success was defined as the cessation at kV 120, helical pitch 65, rotation time 0.35 seconds, of bleeding and maintained hemodynamic stability 0.5 mm slice thickness with 2 mm thick reformats. Follow within 30 days of the embolization. All adverse events Table 1 Summary of 2018 AAST spleen injury scale for CT Findings AAST Grade CT Imaging Criteria I Subcapsular hematoma < 10% surface area; parenchymal laceration < 1 cm depth or capsular tear II Subcapsular hematoma 10–50% surface area or hematoma < 5 cm; parenchymal laceration 1–3 cm III Subcapsular hematoma > 50% surface area or ruptured subcapsular or intraparenchymal hema‑ toma ≥5 cm; parenchymal laceration > 3 cm depth IV Presence of splenic vascular injury or active bleeding confined to the spleen; laceration with vessel involvement resulting in > 25% devascularization V Presence of splenic vascular injury with active bleeding beyond the spleen; shattered spleen Xu et al. CVIR Endovascular (2023) 6:1 Page 3 of 7 Table 2 Preprocedural details including CT findings Procedural technique Procedures were performed by six different interven - Number of tional radiologists. Access was through the common fem- Patients or Mean Values oral artery under ultrasound guidance. A combination of 7 or 8-Fr valved RDC guiding catheters (Vista Brite; Mean Age (years) 42.3 ± 17.0 Cordis, FL, USA) or 6 Fr Raabe sheaths (Cook Medical, AAST Grade IND, USA) and 5-Fr Cobra 2 or Sim 1 catheters were Grade 4 73 (96.1%) used to select the splenic artery (Fig. 3a). The vascular Grade 5 3 (3.1%) plugs were oversized by 50–100% in relation to the diam- Mean Splenic Artery Diameter (mm) 6.4 ± 1.1 eter of the splenic artery measured on pre-procedural Pseudoaneurysm Present 64 (84.2%) imaging and then deployed proximally within the splenic Mean Size of Pseudoaneurysms (mm) 9.2 ± 4.7 artery, covering the origin of the dorsal pancreatic artery Number of Pseudoaneurysms (Fig. 3b). This location was chosen since plugs tend to be One 8 (10.5%) challenging to navigate distally through tortuosity. Two 10 (13.2%) The Amplatzer’s type I (AVP; Abbot, IL, USA) plugs Three 3 (3.9%) ranging from 8 to 12 mm in size were used in most Four 17 (22.4%) cases. In two occasions, a Micro Vascular Plug (MVP; More than Five 26 (34.2%) Medtronic, Ireland) was deployed through a 2.8-Fr TRAUMA EVENT microcatheter (Progreat; Terumo, Japan) due to dif- Motor vehicle collision 37 ficulty in placing a sheath into the splenic artery. Plug Fall 20 and coil sizes were determined based on pre-procedural motorcross/atv/snowmobile 9 CT measurements. In most cases, the operators did not Assault 5 wait for complete angiographic occlusion of the splenic other 5 artery following plug deployment to terminate the pro- cedure. However, some operators decided to add a coil proximal to the plug to achieve faster occlusion. Closure of the femoral puncture was with either a closure device up imaging includes CT of the abdomen and pelvis with or manual compression, which was case and operator similar CT parameters. Non-contrast, arterial (25 sec- dependent. onds) and portal venous (55 seconds) phase acquisitions are acquired following injection of 100 cc of Omnipaque 350 with 20 cc of saline at 4 cc/sec. Fig. 2 CT in a trauma patient in a) mixed arterial and portal venous phase in a dual bolus injection and b) delayed phases demonstrating a grade IV splenic injury with large lacerations (solid white arrow) and pseudoaneurysms (solid black arrow). There is no extravasation of contrast as confirmed on Xu et al. CVIR Endovascular (2023) 6:1 Page 4 of 7 Fig. 3 Embolization technique. A Digital subtraction angiography (DSA) of the splenic artery after selective catheterization with a C2 catheter acquired in the same patient prior to embolization. Region of hyperemia in the lower spleen (solid black arrow) and suspected pseudoaneurysms corresponding to the region of grade IV injury. Note the origin of the dorsal pancreatic artery (solid white arrow) and the greater pancreatic artery (open white arrow). B DSA of the celiac axis following proximal embolization. A vascular plug (open black arrow) has been deployed, covering the origin of the dorsal pancreatic artery and slightly proximal to the origin. There is decreased flow in the splenic artery, without residual hyperemia or pseudoaneurysms Statistical analysis Table 3 Procedural and post procedural details The data, including adverse event rates, radiation dose, procedural and follow-up details Number of mortality, and periprocedural data, was analyzed using Patients or Mean the appropriate statistical tests on SPSS Software (Ver- Values sion 25, IBM, Armonk NY, USA). Analysis between cat- Time to Procedure from CT (hours) 10.9 ± 14.6 egorical groups was performed using a Chi-square test. Additional coil embolization 18 (23.7%) If nominal data was analyzed with comparison of means, average coil size (mm) 10.7 ± 1.5 t tests were utilized. p < 0.05 was considered statistically average plug size (mm) 10.8 ± 1.4 significant. moderate to severe adverse events Splenic Infarct 14 (14.6%) Other 3 (3.1%) Results New Left Pleural Effusion 11 (11.5%) Procedural data and outcomes Procedural and post procedural details are summarized Mortality 4 (4.2%) in Table 3. The technical success rate was 100%. Clini - follow-up ct available 35 cal success rate was achieved in 72/76 patients (94.7%). time to follow-up CT (DAys) 422 ± 860 Splenic preservation was successful in 73/76 patients Minimum time to follow-up CT (days) 0 (96.1%). Within the total study population, moderate to maximum time to follow-up CT (days) 3259 severe adverse events occurred in 12 patients (15.8%), of which 7/12 were new splenic infarctions < 33% of the parenchyma (9.2%). The other adverse events included the polytrauma, and not directly related to the splenic puncture site pseudoaneurysm (1/12), splenic hema- embolization procedure. toma (1/12), and persistent splenic pseudoaneurysms or bleeding resulting in patient hemodynamic instability necessitating splenectomy (3/12). New left sided pleural Comparison of vascular plug alone and additional coil effusions developed in 8/76 of the patients (10.5%) fol - embolization lowing the procedure, that resolved prior to discharge There was a statistically significant difference between without intervention. Overall mortality of the patients the rate of adverse events between the two emboliza- was 2.6% (2/76 patients), with one patient succumbing to tion groups. Moderate to severe adverse events occurred other injuries not related to their splenic trauma. How- in 6/58 patients (10.3%) with vascular plug alone, and ever, the cause of death in the patients was secondary to 6/18 patients (33.3%) with combination emboliza- tion (p = 0.03), as presented in Table 4. There was no Xu et al. CVIR Endovascular (2023) 6:1 Page 5 of 7 Table 4 Complications between vascular plug and vascular plug embolization (Habash et al., 2021; Jambon et al., 2018; with coil embolization Quencer & Smith, 2019; Zhu et al., 2011). Combined embolization, such as with plug and coil moderate to severe adverse events Vascular Vascular Plug (n = 58) Plug + Coil in proximal SAE, is described in the literature (Habash (n = 18) et al., 2021; Patil et al., 2020; Brahmbhatt et al., n.d.; Quencer & Smith, 2019; Zhu et al., 2011). However, there Splenic Infarct 4 3 are no dedicated analyzes comparing the use of com- Puncture site pseudoaneurysm 0 1 bined embolic agents to single embolic agents. Due to Hematoma 1 0 local practice, it was possible to compare the outcomes Persistent bleeding 0 2 in proximal splenic artery embolization with the use of Persistent pseudoanuerysm 1 0 a plug versus plug and coils. Interestingly, this demon- strated a statistically significant increased adverse event rate in the group of patients that had embolization statistically significant difference between the two groups with both plug and coils (p = 0.036). The most common for mortality rate (1/58 vs. 1/17; p = 0.42) or the develop- adverse event was splenic infarct. One postulation for the ment of a new left sided pleural effusion (6/58 vs. 2/18; increased rate of splenic infarct may be due to the theo- p = 0.61). There was no statistically significant difference retical faster time to complete occlusion with the addi- for the time to embolization, if pseudoaneurysms were tion of coils. As a result, collateral vessels may not be present on the preprocedural CT, number of pseudoa- established to perfuse the spleen in certain patient popu- neurysms present, or grade of the splenic trauma (all lations, resulting in ischemia, and ultimately infarct, of p > 0.05). The radiation dose was available in 31 cases, the spleen. Additionally, with addition of coils, the land- which showed no difference between the two groups, ing zone of the embolic agents is longer, which could with mean dose with the use of plug alone 0.5 ± 0.5 Gy result in the occlusion of the ostia of potential collateral and combination embolization 0.5 ± 0.4 Gy (p = 0.17). vessels to the spleen. Other factors could be involved, but further studies would be required to establish this rela- tionship. A potential benefit of proximal SAE with plugs Discussion alone could include a “plug and forget” approach where This study offers a new perspective in proximal splenic the operator would deploy the plug without having to artery embolization, with the use of plug alone in com- chase it with a coil or wait for complete stasis of flow to parison to combination embolization with additional terminate the intervention. This offers reassurance in the coils. There is a significant decrease in adverse events procedural outcomes, such that there should theoreti- with the use of vascular plug alone, that contributes cally be a decrease in need for additional radiation with to overall splenic preservation. The importance of the need for less repeat angiographic images and fluoroscopy spleen in maintaining the body’s immune system and time following deployment of the plug. Furthermore, the antibody production is well known, with knowledge procedural time should also theoretically decrease in this that open splenectomy is strongly associated with sys- approach as the need for further embolization was shown temic infection (Demetriades et al., 2012). Therefore, to not needed to achieve a desired outcome of hemody- splenic preservation treatment options are important in namic stability in this study. the management of splenic trauma, with splenic artery The literature reported adverse event rates up to embolization widely accepted as a safe and effective 20–29% for major adverse events, which include splenic treatment in patients with hemodynamically stable grade infarct, splenic abscess, and continued bleed necessitat- III or higher splenic injury (Haan et al., 2005; Brahmb- ing open splenectomy (Habash et al., 2021; Wu et al., hatt et al., n.d.; Cretcher et al., 2021; Quencer & Smith, 2008; Ekeh et al., 2013). This is comparable to moderate 2019). Technical success was achieved in all patients in to severe adverse events per the new SIR guidelines, and this study with grade IV or higher splenic trauma, com- the rate of moderate to severe adverse events is lower parable to the rates described in the literature (Habash with proximal SAE than distal SAE as described in sev- et al., 2021; Frandon et al., 2014; Cinquantini et al., 2018). eral reviews (Brahmbhatt et al., n.d.; Frandon et al., 2014; Cessation of bleeding and maintained hemodynamic sta- Wong et al., 2017; Quencer & Smith, 2019; Cinquan- bility occurred in 94.7% of the patients, comparable to tini et al., 2018). The most common adverse event in literature rates of both distal and proximal SAE (Habash this study was splenic infarct, occurring in seven of the et al., 2021; Frandon et al., 2014; Banerjee et al., 2013; Wu patients (9.2%). Three patients required open splenec - et al., 2008; Ekeh et al., 2013). The splenic salvage rate in tomy within 1–5 days following embolization, which was this study was 96.1%, comparable to the reported litera- documented as severe adverse events, but are considered ture rates in proximal SAE with the use of coil and plug Xu et al. CVIR Endovascular (2023) 6:1 Page 6 of 7 treatment failure rather than a complication of the leads to possible cofounding factors that are not fully procedure. accounted for in the analysis such as patient past med- Following SAE, the development of a left-sided pleu- ical history, medication history or associated traumatic ral effusion has been described, thought to be from injuries. Additionally, this is a single centre review, irritation of the diaphragm from inflammation in which could limit the range of external validity. Fur- upper pole splenic embolizations (Habash et al., 2021; thermore, not all data points where available for the Cinquantini et al., 2018; Araten et al., 2014; Wu et al., entirety of the study population. Moreover, as the use 2008; Ekeh et al., 2013). This is a known adverse event of the embolic agents is up to the interventionist at the described in SAE for hypersplenism (Araten et al., time of the procedure and not standardized, there may 2014), and this was investigated in this study as a sur- be other procedural factors not documented that could rogate marker for degree of splenic inflammation that ultimately skew the results if the sicker or more com- SAE caused. This occurred in eight of the patients in plex patients were heavily represented in one group this study (10.5%), which is lower than Wu et al (Wu over the other. et al., 2008) (33%) that had distal embolization patients Follow-up imaging was limited in this study, with only and Ekeh et al (Ekeh et al., 2013) (17%) that saw a simi- 35 patients getting CT scans in the same institution after lar number in both proximal, distal, and combined the embolization. This would limit the assessment of the SAE. There was no statistically significant difference in cessation of bleeding or resolution of the pseudoaneu- the rate of left pleural effusion based on embolization rysm from an imaging perspective. If the patient was techniques in this study. The overall percentage of this clinically stable, the local clinical practice, and to appro- adverse event was similar in literature reports, with a priately utilize resources, favor to not further image the higher rate reported in distal upper splenic emboliza- patient. This would not significantly limit the assessment tions (Araten et al., 2014; Wu et al., 2008; Ekeh et al., of clinical success in this study, as patients that did not 2013). Interestingly, the adverse event rates in this require further imaging were clinically stable, although study were similar to the literature despite the proxi- there remains a possibility of under-representing persis- mal embolization location being placed over the dorsal tent small pseudoaneurysms. pancreatic artery origin. This suggests good alternative collaterals are available proximal to this vessel origin Conclusion to maintain flow to the surrounding solid organs. The Overall, this study supports the use of proximal SAE in mortality rate between the two groups in this study was high grade hemodynamically stable splenic injury with a not significantly different and were due to polytrauma single vascular plug for stopping bleeding and promoting with other injuries that the patient ultimately suc- splenic salvage. This study suggests there are increased cumbed to. adverse events in the use of combined embolization in In the setting of proximal SAE, the procedure time proximal SAE compared to just plug embolization. How- and radiation dose has been described in literature to ever, larger studies and randomized trials would be help- be decreased in comparison to distal SAE (Quencer & ful in further evaluating this association. Smith, 2019; Johnson et al., 2021; Zhu et al., 2011). In comparison of plug to coil, Zhu et al. (Zhu et al., 2011) found that the procedure time was not significantly dif - Abbreviations AAST American Association of the Surgery of Trauma ferent, with a trend toward decrease in the plug alone NOM Non‑operative management group. However, the radiation dose was significantly SAE Splenic artery embolization decreased with the use of a plug compared to coil for Acknowledgements proximal SAE (Zhu et al., 2011). Similar results have None. been reported with other reviews and studies (Jambon et al., 2018; Johnson et al., 2021). Due to a migration of Authors’ contributions S. Xu – Main author and results analysis. K. Eng and F. Accorsi – Data gathering the data storage system at the local institute during the and initial submissions. D. Cool, A. Mujoomdar, D. Wiseman – Clinical supervi‑ study data review period, the details of procedure length sors and editors. L. Cardarelli‑Leite – Principal investigator. The author(s) read were not available for review, and the total radiation and approved the final manuscript. dose was only available in 31 cases. This showed no sta - Funding tistically significant difference between the use of plug None. and combination embolization, which is likely due to the Availability of data and materials small sample size. The datasets generated and/or analysed during the current study are not There are limitations to this study. First, as a ret- publicly available due to local ethics restrictions, but certain anonymized data rospective cohort review, the nature of the study may be available from the corresponding author on reasonable request. Xu et al. CVIR Endovascular (2023) 6:1 Page 7 of 7 Kozar RA, Crandall M, Shanmuganathan K et al (2018) Organ injury scal‑ Declarations ing 2018 update: spleen, liver, and kidney. 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Journal
CVIR Endovascular – Springer Journals
Published: Jan 11, 2023