of nonsurgical managenlent of patients with blunt splenic injury using detailed angiographic examinations and transcatheter arterial embo- lization. SUBJECTS.
Nonsurgical Management of Patients with Blunt Splenic Injury: Efficacy ofTranscatheter Arterial Embolization Akiyoshi
OBJECTIVE.
Hagiwara1
Tetsuo Yukioka Shoichi Ohta1 Toshiaki Nitatori2 Hiroharu Matsuda1 Shuji Shimazaki1
We evaluated injury
blunt splenic lization.
using
angiography was performed scatheter arterial embolization
estimated
RESULTS. injury. In three phy
because
patients,
performed
these
They
should
2). To
after revision Feb-
and Critical
Kyorin University School of Medicine, Mitaka-Si, Tokyo 181, Japan. Address A. Hagiwara.
Care Medicine,
6-20-2 Shinkawa, correspondence to
2Department of Radiology, Kyorin University Medicine, Tokyo 181, Japan.
School of
12 patients
was
with
this
splenic
more
undergo
problem.
trauma
used
trauma patients. been introduced
and
extensive
of splenic
with embo-
and repeat
circulatory not
status.
required
In
as these
angiography.
I 3 of the patients
arterial
are now
13been
the abdomen
grading
to attempt
systems
to guide
injury
without
detailed
16, 7]. CT
patients
to image
and
the
used
have
evaluation
28 remaining
did
not
meet
the
embolization
in have
therapy
appropriate
was
(10-121.
management
A major
remains
disadvantage
AJR 1996:167:159-166 0361-803X/96/1671-1 59
be responsible
for hemorrhage.
The
crucial
management
of
trauma
early
spleen
of
with for
the
by
blunt splenic
artery
to
vasculature
of
angiography
and
intervention
may
angiographic
Transcatheter splenic
potential. embolization
arterial is recognized
of the
as a safe and effec-
tive treatment for chronic idiopathic thrombocytopenia 1131. When applied to patients with
study
or nonsurgical
the
Nonsurgical
surgery.
have great therapeutic
surgical
in
function.
use of angiography
examination
injured
blunt
controversial
of splenic
preservation
for these patients (8, 9]. Whether these CT grading systems are sufficient to determine
point
surgery. Tranangiographic
patients, especially patients with injury solid organs. is rapid hemostasis. Therefore.
splenec-
conservative
treatments
in adult
showed
of CT imaging is the lack of information about vascular injuries of the spleen that may
Ray Society
scintigraphy
bed rest. Transcatheter
blunt traumatic injury to be at risk for sepsis salvage
similar
has been
and
management
who
avoid
and and
attempted 19, 1995: accepted
or unstable
treated
encourage
hildren
therapy
AJR:167, July 1996
arterial
injury with angiography was successful in 93% of patients. Our success rate for nonsurgical management of patients
tomy for are known
often
colloid
embolization
were
and the subsequent
C 5],
injury
arterial
criteria.
injury
injury
[I.
by 9911Tc_sulfur
in the remaining
splenic
Roentgen
of patients
in the remaining I 5 patients and was completely successful in I 3. Because one of I 3 patients died of a brain contusion, follow-up angiography and scintigraphy were per-
formed
© American
managenlent and transcatheter
in all patients except those requiring emergency was performed when patients had the following
of an associated
treatment of splenic CONCLUSION.
of Traumatology
examinations
Of 228 patients with blunt trauma. 3 1 patients had CT evidence of splenic of these 3 1 patients, emergency laparotomy was performed before angiogra-
transcatheter
necessary
Department
of nonsurgical
angiographic
( I ) extravasation of contrast material extending beyond or within the splenic paren(2) arterial disruption or major arteriovenous fistula. or (3) both. Splenic function was
subsequently
I
the efficacy
SUBJECTS AND METHODS. We prospectively studied 228 patients who had blunt abdominal injury and for whom CT was performed. When splenic injury was revealed by CT,
criteria: chyma.
Received December ruary 20, 1996.
detailed
injury, transcatheter arterial was described as effective in one 1l4J. but its use for patients with such splenic
embolization
injury remains controversial. The purpose of this study
was to evaluate
the efficacy
management
patients detailed
of nonsurgical
with splenic angiographic
injury
examination
by
of
use
of
of
the
159
Hagiwara
splenic
vasculature
catheter
arterial
Subjects
and
in tandem
with
Methods clinical
study
was
performed
at
our institution from January 1992 to December 1993. After initial evaluation and resuscitation, all patients
with
blunt
abdominal
hemodynamically resuscitation,
men and (lopamiron
stable.
with
underwent pelvis.
injury
CT
Nihon
was administered
of
were
without
imaging
A solution
300:
or
who
62c4
fluid
IV as a bolus
concentration
of greater
than
injury).
patients
who
hemody-
namically unstable, and patients who had other severe visceral injuries (e.g., liver injury. renal injury,
or mesenteric
bleeding Patients
injury)
was suspected. included
angiography Angiography
within
in the
protocol
3 hr of the
included
or digital subtraction aortogram or celiac administration
and in whom
arteriograni
of 76%
CT
was obtained
after of 4-5
at a rate
was obtained
mI/sec
of
(ftr
of contrast
of the spleen
a
Denmarkl)
into
five
groups
on
the
basis of angiographic findings and a modification of the classification of Fisher et al. [ 151. The five groups included patients in whom we saw ( I) extravasation
of
material
contrast
beyond the splenic parenchyma: within the splenic parenchyma: culature without extravasation,
(2)
extending
such
Through
a
Unibody
infusion
Grades
Grade 1
ofSplenlc
3 4
vas-
as disruption
160
INI
or
less than
was
by the
from
each
of
Human
Sub-
Informed
con-
patient
was
variance,
(or guardian).
performed
with
a paired
Students’s
approximate
test.
t
.05 was considered
two-
A p value
of
significant.
evidence
artery.
placed
Stasis
splenic
used. I8
of the splenic
Coils
2 or 3.
performed
of an approimages trunk
of the
material
in the
as the end
point
Finally.
celiac
delivery.
to confirm
occlusion
who
department
and
transcatheter
admitted
clinical
for
of the
There
protocol
hemodynamically
was in any
patient
and
who
because
hemorrhage
of peritonitis
were
a provision
unstable
intraabdominal signs
signs
or
required
CT scanning
Contrast-enhanced routinely
on days
patients
who
I , 7, and
2 1 after
of who
an emer-
underwent
celiac
was
transcatheter
arteriography
For arterial
was
women (mean
SD,
±
22.3
±
score
[ 17]
12. 1 years
injury
severity
(mean
± SD. 22.2 ± I 2.8).
injured
by being
accidents
(ii
by
=
falls
3;
=
blunt CT
underwent
being (ii
=
struck
by cars
and by the 31
laparotomy
this study. associated
Two of injuries
and renal mpture) injury.
splenic
grade
were vehicle
5; 16%), Three of
emergency from severe 2
4 to 50
in motor
of the pancreas
and CT grade patient with CT
The
old). from
The patients
10%).
and were excluded these patients had (disruption
ranged
involved
16; 52%),
=
7; 23%), assaults (ii (ii
with showed
of splenic injury. They included six and 25 men who were 4-54 years old
4 splenic
Another injury
sud-
denly became hypotensive after CT and required emergency laparotomy. The remaining 28 patients were enrolled in the Transcatheter arterial embolization was not required for I 3 of 28 patients, who were treated grading
with by
severity nificantly
for
lower
these
transcatheter
these
angiography
of
intrasplenic
were
for patients
arterial analysis
I 3 patients,
results of severity in Table 2. The
1 3 patients
than those
(J) < .05; two-way
placement
repeated
rest. The are shown
bed CT
grades
required
repeated
admission.
admitted 3 1 (14%)
protocol.
Physical
of vital
intervals.
arte-
to the emergency
observation.
monitoring
at short
for suspension
underwent
were
patients
injuries,
patients
on
artery.
patients
increasing
was
used
repeated
or a 3-
in group
of contrast was
of the
catheter
measuring
of coil
was
trunk
in the main
artery
for the termination
main
only. by
the 228
were
Therapeutics,
a 5-French
coils
Results Of
(Tracker-
Target
in the
selected were
showed
approved
analysis
analysis
abdominal
pledgets
For patients embolization
steel
size.
became
was obtained
Bjaeverskov.
microcatheter
placed
stainless
repeated
CT
sig-
who
embolization
of variance). showed
arterial
For dis-
branches
Injury
Criteria Seen on CT Scans
Parenchymal laceration(s) 1-3 cm deep; central or subcapsular hematoma(s) 3 cm deep; central or hematoma(s) >3 cm
Fragmentation ofthree tions; devascularization (nonenhancement)
sponge
through
#{149}V*Treatment
Capsular avulsion; superficial laceration(s) or subcapsular hematoma
