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Published online before print March 4, 2005, 10.1148/radiol.2351031132
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(Radiology 2005;235:57-64.)
© RSNA, 2005

Emergency Radiology

Blunt Splenic Injury: Usefulness of Transcatheter Arterial Embolization in Patients with a Transient Response to Fluid Resuscitation1

Akiyoshi Hagiwara, MD, Hideki Fukushima, MD, Atsuo Murata, MD, Hiroharu Matsuda, MD and Shuji Shimazaki, MD

1 From the Department of Traumatology and Critical Care Medicine, Kyorin University School of Medicine, 6–20-2 Shinkawa Mitaka-shi, Tokyo 181-8611, Japan. Received July 19, 2003; revision requested October 3; final revision received April 22, 2004; accepted June 17. Address correspondence to A.H. (e-mail: hagiwarapupu@jcom.home.ne.jp).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
 REFERENCES
 
PURPOSE: To evaluate the use of transcatheter arterial embolization (TAE) in hemodynamically unstable patients with blunt splenic injury in whom there is a transient response to initial fluid resuscitation.

MATERIALS AND METHODS: Human subject committee approval and informed consent were obtained. Angiography was performed in patients with contrast material extravasation and/or splenic injury of grade III or higher (American Association for the Surgery of Trauma criteria) at computed tomography (CT). TAE was performed when angiograms showed disruption of terminal splenic branches or arterial extravasation. Among 104 patients with splenic injury, the 15 patients (10 male, five female; mean age, 36.2 years) with a transient response to fluid resuscitation were the subjects of this study. A post hoc analysis was performed for CT grades, angiographic findings, associated injuries, and hemodynamic status in the subjects.

RESULTS: Among 15 patients with a transient response, two had grade III, 11 had grade IV, and two had grade V injuries at CT. Six patients had associated injuries that required TAE. TAE of the spleen and associated injuries was successfully performed in all patients. The mean systolic blood pressure and shock index at the start of TAE were 84.2 mm Hg ± 9.2 (standard deviation) and 1.46 ± 0.30, respectively, and those at the completion of TAE were 132.1 mm Hg ± 18.7 and 0.77 ± 0.21, respectively (P < .001). The fluid infusion rate within 24 hours after the completion of TAE (132.1 mL/h ± 71.1) was lower than that from the completion of the initial fluid resuscitation until the completion of TAE (1230.6 mL/h ± 264.8) (P < .001).

CONCLUSION: TAE for blunt splenic injury can be performed successfully even in hemodynamically unstable patients with a transient response to initial fluid resuscitation.

© RSNA, 2005


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
 REFERENCES
 
The use of nonsurgical treatment for blunt splenic injury has been extended to children who are hemodynamically stable (1), and Sclafani et al (2) reported a series of cases in which nonsurgical treatment by means of transcatheter arterial embolization (TAE) was successful. In a similar study, bleeding was controlled in 90% of hemodynamically stable patients, and splenic function was preserved in all patients who underwent TAE (3). The effectiveness of this treatment method has subsequently been validated in other reports, and TAE has become the treatment of choice for blunt splenic injury (4–6). However, to our knowledge, the appropriateness of performing TAE in patients with blunt splenic injury who are hemodynamically unstable has not yet been determined. In particular, the role of TAE in patients with blunt splenic injury who are hemodynamically unstable according to the Responses to Initial Fluid Resuscitation of Advanced Trauma Life Support criteria has not been determined.

In the present study, our purpose was to evaluate the use of TAE in hemodynamically unstable patients with blunt splenic injury in whom there is a transient response to initial fluid resuscitation determined on the basis of the Advanced Trauma Life Support criteria.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
 REFERENCES
 
Patients
All patients with blunt splenic trauma who were admitted to our institution between January 1999 and August 2002 were candidates for a prospective clinical study designed to minimize the need for surgery. This study was approved by the human subject committee at our institution. Written informed consent was obtained from each patient or from his or her guardian prior to the initiation of any study procedure.

Subsequent therapy was determined on the basis of the hemodynamic status of each patient. Patients with a systolic blood pressure of 90 mm Hg or lower and a shock index (heart rate divided by systolic blood pressure) of 1.0 or greater were considered to be in shock. Treatment policy for patients who were in shock at the time of admission was determined according to the Responses to Initial Fluid Resuscitation of Advanced Trauma Life Support criteria (7). In brief, patients in shock at admission were administered an initial fluid bolus (2000 mL or 20 mg per kilogram of body weight of Ringer lactate in adults or children, respectively) over 15–20 minutes, and patients were then placed in one of the following three groups on the basis of the subsequent hemodynamic response: the rapid-response group, in which patients showed immediate recovery from shock with preservation of hemodynamic stability once the initial fluid infusion was tapered to maintenance levels; the transient-response group, in which patients showed recovery from shock but began to show deterioration of perfusion indexes once fluid administration was tapered to maintenance levels; and the no-response group, in which there was a failure to respond to the initial fluid resuscitation.

Intravenous contrast material–enhanced helical computed tomography (CT) of the abdomen and pelvis was performed in patients who were hemodynamically stable at admission or who had been in shock and showed a rapid response or a transient response. In patients showing no response, the decision to perform emergency laparotomy was based on the Focused Assessment with Sonography for Trauma protocol without CT (8).

In the present study, a post hoc analysis was performed for patients in the transient-response group as part of our prospective study in which TAE was performed in patients with splenic injury. The hospital charts of the patients were reviewed (A.H., H.F.). One hundred four patients with splenic injury were admitted to our hospital between January 1999 and August 2002. Thirty-three patients were hemodynamically stable at admission, and 71 patients were in shock. Among patients in shock, 22 showed a rapid response, 18 showed a transient response, and 31 showed no response to initial fluid resuscitation.

Among 18 patients with a transient response, three were excluded from this study as follows: One patient could not undergo angiography. This patient was a 27-year-old man with a completely shattered spleen at CT who was injured in a motorcycle accident, became profoundly hypotensive (systolic blood pressure, ≤60 mm Hg) after CT, and required splenectomy. The other two patients died after TAE. One of these was a 22-year-old woman who was injured in an accident between a pedestrian and a train and died of cerebral hernia due to a brain contusion 2 days after TAE. The other was a 65-year-old man who was injured in a fall and died of abdominal compartment syndrome caused by continuous hemorrhage from a pelvic fracture 2 days after TAE. The cause of death was not related to splenic injury in any patients.

The remaining 15 patients with a transient response who were available for follow-up were the subjects of this study. There were 10 male and five female patients with a mean age (± standard deviation) of 34.5 years ± 19.5 (range, 6–69 years). The mean age was 39.6 years ± 18.4 (range, 6–69 years) among male patients and 34.6 years ± 20.5 (range, 9–59 years) among female patients (P = .58, Student t test).

CT Examinations
Helical CT (Xvision; Toshiba, Tokyo, Japan) was routinely performed with intravenous contrast enhancement (iopamidol, Iopamiron 300, 300 mg of iodine per milliliter; Nihon Schering, Osaka, Japan) by using 2 mL per kilogram of body weight (maximum, 100 mL) injected with a power injector at a rate of 2 mL/sec. CT scanning was started 60 seconds after the start of the intravenous injection of contrast medium. Scanning was performed from the lung bases to the pelvis with a collimation of 10 mm and a table speed of 10 mm/sec. Oral contrast material was not administered.

Splenic injuries detected at CT were graded according to the American Association for the Surgery of Trauma splenic injury scale (Table 1) (9). Hemoperitoneum on CT images was quantified as follows: score of 0, not detected; 1+, detected in a single anatomic area such as the Morrison pouch (hepatorenal space), perihepatic space, or perisplenic space; 2+, detected in two or more anatomic spaces, such as the pericolic gutter and perivesicular space; and 3+, detected throughout the pelvis.


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  		TABLE 1. American Association for the Surgery of Trauma Splenic Injury Scale (1994 Revision)

 
Angiography and TAE
Angiography (Infinix/DP; Toshiba) and TAE were performed by one of two investigators (A.H. or H.F.). Angiography was performed within 1 hour after CT if the injury was categorized as a splenic injury of CT grade III or higher. Angiography was also performed if there was contrast material extravasation, regardless of the splenic injury CT grade. Angiography for complicated injuries was performed as follows: Angiography for liver or renal injury was performed when the injury was of CT grade III or higher according to the organ injury scale of the American Association for the Surgery of Trauma (10–12). Angiography for pelvic fracture was performed when contrast material extravasation was observed in an extrapelvic hematoma or when the hematoma compressed the bladder in the pelvic cavity, regardless of whether contrast material extravasation was detected (13). In patients with other injuries, angiography was performed in the region showing contrast material extravasation on CT images. In addition, if patients had external arterial hemorrhage that was difficult to control (eg, massive arterial hemorrhage from the nose or in the mouth owing to facial fracture), simultaneous angiography for complicated injuries was performed.

The surgery suite was ready to be used, and the surgical staff was on call during the radiologic studies. Digital subtraction angiography was performed to shorten the time of examination.

TAE was performed in all patients with the following angiographic findings: contrast material extravasation that extended beyond the splenic parenchyma (group 1), contrast material extravasation within the splenic parenchyma (including pseudoaneurysm) (group 2), or disruption of the main portion of terminal arteries and/or polar splenic arteries without contrast material extravasation or detection of a major arteriovenous fistula (group 3). Terminal arteries include a superior terminal artery, an inferior terminal artery, and a medial terminal artery, which arise from the main trunk of the splenic artery near the splenic hilum (14).

The methods used for TAE depended on the angiographic findings. For patients in group 1, a 3-F microcatheter (Tracker-18 Unibody infusion catheter; Target Therapeutics, Fremont, Calif) was inserted into the splenic branch that showed contrast material extravasation extending beyond the splenic parenchyma. The tip of the microcatheter was placed in the proximal position of the splenic branch that was as close as possible to the injured site showing contrast material extravasation. Gelatin sponge pledgets (which were cut into 1–3-mm3 cubes with small straight scissors) and/or stainless steel coils were used. First, gelatin sponge particles or stainless steel coils (MWCE-35 embolization coils or MWCE-18S-Tornado embolization microcoils; Cook, Bloomington, Ind) were injected into the splenic arterial branch showing contrast material extravasation extending beyond the splenic parenchyma. When splenic arteriograms showed that splenic hemorrhage in patients in groups 2 or 3 persisted, stainless steel coils were placed in the main trunk of the splenic artery. For patients in groups 2 and 3, TAE was performed by using only stainless steel coils of appropriate size placed in the main trunk of the splenic artery. Finally, celiac arteriography was repeated to confirm occlusion of the splenic artery. TAE for complicated injuries was performed by using gelatin sponge pledgets and/or stainless steel coils when angiograms showed contrast material extravasation.

The time allocated for angiography was limited to 1 hour. The total maximum load of contrast material used for CT and angiography was 200 mL (4 mL per kilogram of body weight in children). Emergent laparotomy was considered for patients who became profoundly hypotensive (systolic blood pressure, ≤60 mm Hg) and did not respond to fluid resuscitation during the CT or angiographic procedures.

Interpretation of CT Images and Angiograms
Findings on CT images and angiograms were reviewed by two investigators (A.H., H.F., with at least 5 and 10 years of experience, respectively). When they reached a consensus, these consensus findings and other patient data (eg, from radiographs, sonograms, or charts) were presented to three investigators (A.M., H.M., S.S., each with at least 25 years of experience) for endorsement of the interpretation during the meeting held on the same or following day. When the two investigators (A.H., H.F.) did not reach consensus, each CT and angiographic finding was presented at the meeting, and interpretation of each finding was established in consultation with all the meeting members.

Care and Follow-up after TAE
All patients who underwent TAE were admitted to an intensive care unit for observation. Physical examination and monitoring of vital signs were repeated every 15 minutes to 2 hours.

Follow-up after TAE was performed as previously reported (3). In short, contrast-enhanced CT was performed on the 2nd, 7th, and 21st days following admission. In addition, technetium 99m (99mTc) sulfur colloid scintigraphy was performed some time between the 7th and 10th days to determine the degree of splenic reticuloendothelial function. CT was performed monthly until the splenic hematoma was completely resorbed.

The follow-up study was performed by one investigator (A.H.). Evaluation of the uptake of 99mTc sulfur colloid by the spleen was performed on the basis of the report described by the Department of Nuclear Medicine at our institution. The healing process of the splenic injuries was reviewed by A.H. At the end of the follow-up period, scintigraphic and CT findings were reviewed by three investigators (A.M., H.M., S.S.).

Analysis of Hemodynamic Status
The systolic blood pressure and shock index in 15 patients undergoing TAE were investigated at admission, at the start of TAE, and at the completion of TAE. In addition, the rate of fluid administration (in milliliters required per hour) from the completion of the initial fluid resuscitation until the completion of TAE and within 24 hours after the completion of TAE was observed (A.H.).

Statistical Analysis
The analysis was performed by using a commercially available statistical software package (SPSS version 11.5 J; SPSS, Tokyo, Japan). Data were expressed as means ± standard deviations. P values of less than .05 were considered to show statistical significance. The Levene test for equal variance was performed to investigate the homogeneity of the values of systolic blood pressure and shock index at admission, at the start of TAE, and at the completion of TAE. When homogeneity was obtained, a repeated measure one-way analysis of variance was performed. When the null hypothesis–that there was equality among the population mean of systolic blood pressure or shock index at admission, at the start of TAE, and at the completion of TAE–was rejected, the multiple comparison was performed by using the Tukey honestly significant difference test. The Levene test for equal variance was also performed to investigate the homogeneity of the volume of fluid resuscitation from the completion of the initial fluid resuscitation until the completion of TAE, as well as that within 24 hours after the completion of TAE. When homogeneity was obtained, the paired Student t test was performed.

The sensitivity of contrast material extravasation at CT for extravasation at angiography was calculated as the ratio of patients with CT evidence of contrast material extravasation to patients with angiographic evidence of contrast material extravasation. The positive predictive value of contrast material extravasation at CT for extravasation at angiography was calculated as the ratio of patients with angiographic evidence of contrast material extravasation to patients with CT evidence of contrast material extravasation.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
 REFERENCES
 
Demographics and Clinical Characteristics
The 15 patients who showed a transient response to initial fluid resuscitation had a mean injury severity score of 32.8 ± 10.6. The mean systolic blood pressure and shock index at the time of admission were 77.6 mm Hg ± 12.4 and 1.59 ± 0.43, respectively. Three patients were injured in motorcycle accidents, one in a fall, four in car accidents, three in accidents between a pedestrian and an automobile, and one in an accident between a bicycle and an automobile. The other three patients were injured in other ways.

CT and Angiographic Findings
All 15 patients underwent contrast-enhanced CT immediately after admission. Two patients had CT grade III, 11 had CT grade IV, and two had CT grade V splenic injury (Table 2). Contrast material extravasation on CT images was observed in all patients with the exception of one patient with a CT grade III splenic injury. She was noncooperative, and the quality of the CT image was compromised by motion artifact. All patients had a fluid collection in two or more anatomic regions on CT images. Angiography was performed in all 15 patients. All patients had angiographic evidence of contrast material extravasation. Thus, the sensitivity and positive predictive value of contrast material extravasation at CT for extravasation at angiography were 93% (14 of 15) and 100% (14 of 14), respectively.


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  		TABLE 2. Clinical and Radiologic Findings in 15 Patients with Blunt Splenic Trauma

 
Table 2 shows the relationship between the angiographic findings and the CT grade of splenic injury. As the CT grade increased, the number of patients with contrast material extravasation extending beyond the splenic parenchyma on angiograms also increased. Embolization of only the main trunk of the splenic artery was performed in one patient with CT grade III and eight patients with CT grade IV injuries (Fig 1). Embolization of both splenic arterial branches and the main trunk of splenic artery was performed in three patients with CT grade IV and two patients with CT grade V injuries (Fig 2). Embolization of only the splenic arterial branches was performed in one patient with a CT grade III injury.



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  		Figure 1a. Images obtained in a 25-year-old man with grade IV splenic injury from a motorcycle accident. (a) Transverse contrast-enhanced CT scan shows splenic parenchymal fragmentation (arrowheads) with intra- and extraparenchymal extravasations of contrast material (straight arrows). Some free intraperitoneal fluid (curved arrows) is seen adjacent to the liver. (b) Anteroposterior selective splenic arteriogram shows multiple areas of extravasation (arrows) within the splenic parenchyma. The splenic artery was embolized by placing stainless steel coils in the main trunk via a standard 5-F catheter. (c) Anteroposterior celiac arteriogram obtained after TAE shows complete occlusion (large arrow) of the splenic artery, but the remaining splenic parenchyma is enhanced through collateral flow from the gastroepiploic artery (small black arrow), dorsal pancreatic artery (small white arrow), and great pancreatic artery (black arrowhead) to the caudal pancreatic artery (white arrowhead). Contrast material extravasation is not seen. (d) On day 7 after injury, transverse contrast-enhanced CT scan shows splenic fragmentation (arrows) and a large hematoma (arrowheads) around the fragments. (e) Anterior 99mTc-sulfur colloid scintigram obtained on day 8 shows preservation of splenic function (arrow).

 


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  		Figure 1b. Images obtained in a 25-year-old man with grade IV splenic injury from a motorcycle accident. (a) Transverse contrast-enhanced CT scan shows splenic parenchymal fragmentation (arrowheads) with intra- and extraparenchymal extravasations of contrast material (straight arrows). Some free intraperitoneal fluid (curved arrows) is seen adjacent to the liver. (b) Anteroposterior selective splenic arteriogram shows multiple areas of extravasation (arrows) within the splenic parenchyma. The splenic artery was embolized by placing stainless steel coils in the main trunk via a standard 5-F catheter. (c) Anteroposterior celiac arteriogram obtained after TAE shows complete occlusion (large arrow) of the splenic artery, but the remaining splenic parenchyma is enhanced through collateral flow from the gastroepiploic artery (small black arrow), dorsal pancreatic artery (small white arrow), and great pancreatic artery (black arrowhead) to the caudal pancreatic artery (white arrowhead). Contrast material extravasation is not seen. (d) On day 7 after injury, transverse contrast-enhanced CT scan shows splenic fragmentation (arrows) and a large hematoma (arrowheads) around the fragments. (e) Anterior 99mTc-sulfur colloid scintigram obtained on day 8 shows preservation of splenic function (arrow).

 


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  		Figure 1c. Images obtained in a 25-year-old man with grade IV splenic injury from a motorcycle accident. (a) Transverse contrast-enhanced CT scan shows splenic parenchymal fragmentation (arrowheads) with intra- and extraparenchymal extravasations of contrast material (straight arrows). Some free intraperitoneal fluid (curved arrows) is seen adjacent to the liver. (b) Anteroposterior selective splenic arteriogram shows multiple areas of extravasation (arrows) within the splenic parenchyma. The splenic artery was embolized by placing stainless steel coils in the main trunk via a standard 5-F catheter. (c) Anteroposterior celiac arteriogram obtained after TAE shows complete occlusion (large arrow) of the splenic artery, but the remaining splenic parenchyma is enhanced through collateral flow from the gastroepiploic artery (small black arrow), dorsal pancreatic artery (small white arrow), and great pancreatic artery (black arrowhead) to the caudal pancreatic artery (white arrowhead). Contrast material extravasation is not seen. (d) On day 7 after injury, transverse contrast-enhanced CT scan shows splenic fragmentation (arrows) and a large hematoma (arrowheads) around the fragments. (e) Anterior 99mTc-sulfur colloid scintigram obtained on day 8 shows preservation of splenic function (arrow).

 


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  		Figure 1d. Images obtained in a 25-year-old man with grade IV splenic injury from a motorcycle accident. (a) Transverse contrast-enhanced CT scan shows splenic parenchymal fragmentation (arrowheads) with intra- and extraparenchymal extravasations of contrast material (straight arrows). Some free intraperitoneal fluid (curved arrows) is seen adjacent to the liver. (b) Anteroposterior selective splenic arteriogram shows multiple areas of extravasation (arrows) within the splenic parenchyma. The splenic artery was embolized by placing stainless steel coils in the main trunk via a standard 5-F catheter. (c) Anteroposterior celiac arteriogram obtained after TAE shows complete occlusion (large arrow) of the splenic artery, but the remaining splenic parenchyma is enhanced through collateral flow from the gastroepiploic artery (small black arrow), dorsal pancreatic artery (small white arrow), and great pancreatic artery (black arrowhead) to the caudal pancreatic artery (white arrowhead). Contrast material extravasation is not seen. (d) On day 7 after injury, transverse contrast-enhanced CT scan shows splenic fragmentation (arrows) and a large hematoma (arrowheads) around the fragments. (e) Anterior 99mTc-sulfur colloid scintigram obtained on day 8 shows preservation of splenic function (arrow).

 


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  		Figure 1e. Images obtained in a 25-year-old man with grade IV splenic injury from a motorcycle accident. (a) Transverse contrast-enhanced CT scan shows splenic parenchymal fragmentation (arrowheads) with intra- and extraparenchymal extravasations of contrast material (straight arrows). Some free intraperitoneal fluid (curved arrows) is seen adjacent to the liver. (b) Anteroposterior selective splenic arteriogram shows multiple areas of extravasation (arrows) within the splenic parenchyma. The splenic artery was embolized by placing stainless steel coils in the main trunk via a standard 5-F catheter. (c) Anteroposterior celiac arteriogram obtained after TAE shows complete occlusion (large arrow) of the splenic artery, but the remaining splenic parenchyma is enhanced through collateral flow from the gastroepiploic artery (small black arrow), dorsal pancreatic artery (small white arrow), and great pancreatic artery (black arrowhead) to the caudal pancreatic artery (white arrowhead). Contrast material extravasation is not seen. (d) On day 7 after injury, transverse contrast-enhanced CT scan shows splenic fragmentation (arrows) and a large hematoma (arrowheads) around the fragments. (e) Anterior 99mTc-sulfur colloid scintigram obtained on day 8 shows preservation of splenic function (arrow).

 


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  		Figure 2a. Images obtained in a 37-year-old woman with grade IV splenic injury from a fall. (a) Transverse contrast-enhanced CT scan shows multiple areas of contrast material extravasation (straight black arrows) around the injured spleen with a perisplenic hematoma (arrowheads) and a small low-attenuation area (white arrows) in the quadrate lobe of the liver (abbreviated injury score: grade 2 liver injury). Free intraperitoneal blood (curved arrows) is seen around the spleen and liver. (b) Anteroposterior celiac arteriogram shows extravasation (arrow) extending beyond the splenic parenchyma from the middle branch of the splenic artery. TAE was performed as follows: Gelatin sponge particles were injected into the splenic arterial branch via a 3-F microcatheter, and steel coils were placed in the main trunk via a standard 5-F catheter. (c) Anteroposterior celiac arteriogram obtained after TAE shows complete occlusion (arrow) of the splenic artery. (d) On day 7 after injury, transverse contrast-enhanced CT scan shows an intrasplenic hematoma (arrow) with intraperitoneal blood (arrowheads) around the spleen. The noninjured splenic parenchyma is enhanced. (e) Posterior 99mTc-sulfur colloid scintigram also obtained on day 7 shows preservation of splenic function (arrows).

 


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  		Figure 2b. Images obtained in a 37-year-old woman with grade IV splenic injury from a fall. (a) Transverse contrast-enhanced CT scan shows multiple areas of contrast material extravasation (straight black arrows) around the injured spleen with a perisplenic hematoma (arrowheads) and a small low-attenuation area (white arrows) in the quadrate lobe of the liver (abbreviated injury score: grade 2 liver injury). Free intraperitoneal blood (curved arrows) is seen around the spleen and liver. (b) Anteroposterior celiac arteriogram shows extravasation (arrow) extending beyond the splenic parenchyma from the middle branch of the splenic artery. TAE was performed as follows: Gelatin sponge particles were injected into the splenic arterial branch via a 3-F microcatheter, and steel coils were placed in the main trunk via a standard 5-F catheter. (c) Anteroposterior celiac arteriogram obtained after TAE shows complete occlusion (arrow) of the splenic artery. (d) On day 7 after injury, transverse contrast-enhanced CT scan shows an intrasplenic hematoma (arrow) with intraperitoneal blood (arrowheads) around the spleen. The noninjured splenic parenchyma is enhanced. (e) Posterior 99mTc-sulfur colloid scintigram also obtained on day 7 shows preservation of splenic function (arrows).

 


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  		Figure 2c. Images obtained in a 37-year-old woman with grade IV splenic injury from a fall. (a) Transverse contrast-enhanced CT scan shows multiple areas of contrast material extravasation (straight black arrows) around the injured spleen with a perisplenic hematoma (arrowheads) and a small low-attenuation area (white arrows) in the quadrate lobe of the liver (abbreviated injury score: grade 2 liver injury). Free intraperitoneal blood (curved arrows) is seen around the spleen and liver. (b) Anteroposterior celiac arteriogram shows extravasation (arrow) extending beyond the splenic parenchyma from the middle branch of the splenic artery. TAE was performed as follows: Gelatin sponge particles were injected into the splenic arterial branch via a 3-F microcatheter, and steel coils were placed in the main trunk via a standard 5-F catheter. (c) Anteroposterior celiac arteriogram obtained after TAE shows complete occlusion (arrow) of the splenic artery. (d) On day 7 after injury, transverse contrast-enhanced CT scan shows an intrasplenic hematoma (arrow) with intraperitoneal blood (arrowheads) around the spleen. The noninjured splenic parenchyma is enhanced. (e) Posterior 99mTc-sulfur colloid scintigram also obtained on day 7 shows preservation of splenic function (arrows).

 


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  		Figure 2d. Images obtained in a 37-year-old woman with grade IV splenic injury from a fall. (a) Transverse contrast-enhanced CT scan shows multiple areas of contrast material extravasation (straight black arrows) around the injured spleen with a perisplenic hematoma (arrowheads) and a small low-attenuation area (white arrows) in the quadrate lobe of the liver (abbreviated injury score: grade 2 liver injury). Free intraperitoneal blood (curved arrows) is seen around the spleen and liver. (b) Anteroposterior celiac arteriogram shows extravasation (arrow) extending beyond the splenic parenchyma from the middle branch of the splenic artery. TAE was performed as follows: Gelatin sponge particles were injected into the splenic arterial branch via a 3-F microcatheter, and steel coils were placed in the main trunk via a standard 5-F catheter. (c) Anteroposterior celiac arteriogram obtained after TAE shows complete occlusion (arrow) of the splenic artery. (d) On day 7 after injury, transverse contrast-enhanced CT scan shows an intrasplenic hematoma (arrow) with intraperitoneal blood (arrowheads) around the spleen. The noninjured splenic parenchyma is enhanced. (e) Posterior 99mTc-sulfur colloid scintigram also obtained on day 7 shows preservation of splenic function (arrows).

 


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  		Figure 2e. Images obtained in a 37-year-old woman with grade IV splenic injury from a fall. (a) Transverse contrast-enhanced CT scan shows multiple areas of contrast material extravasation (straight black arrows) around the injured spleen with a perisplenic hematoma (arrowheads) and a small low-attenuation area (white arrows) in the quadrate lobe of the liver (abbreviated injury score: grade 2 liver injury). Free intraperitoneal blood (curved arrows) is seen around the spleen and liver. (b) Anteroposterior celiac arteriogram shows extravasation (arrow) extending beyond the splenic parenchyma from the middle branch of the splenic artery. TAE was performed as follows: Gelatin sponge particles were injected into the splenic arterial branch via a 3-F microcatheter, and steel coils were placed in the main trunk via a standard 5-F catheter. (c) Anteroposterior celiac arteriogram obtained after TAE shows complete occlusion (arrow) of the splenic artery. (d) On day 7 after injury, transverse contrast-enhanced CT scan shows an intrasplenic hematoma (arrow) with intraperitoneal blood (arrowheads) around the spleen. The noninjured splenic parenchyma is enhanced. (e) Posterior 99mTc-sulfur colloid scintigram also obtained on day 7 shows preservation of splenic function (arrows).

 
Six patients had complicated injuries with contrast material extravasation seen at angiography. Among patients with splenic injuries of CT grade III, two had complicated injuries: one had an unstable pelvic fracture with arterial bleeding (abbreviated injury score, or AIS, grade 4 pelvic fracture), and the other had an AIS grade 4 pelvic fracture and renal injury (CT grade III) with disruption of the renal cortex but without collecting system rupture. Among patients with splenic injury of CT grade IV, four had complicated injuries: two patients had a hepatic injury (CT grade IV) with large parenchymal disruption of the right lobe, one patient had a CT grade IV hepatic injury and an AIS grade 4 pelvic fracture, and the remaining patient had a LeFort type III facial fracture with arterial bleeding and a CT grade IV hepatic injury.

TAE was performed in all 15 patients. Contrast material extravasation was not detected at angiography after TAE in any patient.

Hemodynamic Status in Patients Who Underwent TAE
Among the 15 patients who underwent TAE, the mean systolic blood pressure and shock index at the start of TAE were 84.2 mm Hg ± 9.2 and 1.46 ± 0.30, respectively, and the mean systolic blood pressure and shock index at the completion of TAE were 132.1 mm Hg ± 18.7 and 0.77 ± 0.21, respectively (P < .001, Tukey honestly significant difference test; Table 3). The rate of fluid administration from the completion of the initial fluid resuscitation until the completion of TAE was 1230.6 mL/h ± 264.8, and the total volume ranged from 1000 to 1820 mL. The rate of fluid administration within 24 hours after the completion of TAE was 132.1 mL/h ± 71.1. The rate before TAE was greater than that after TAE (P < .001, two-tailed paired Student t test with the Levene test; Table 3).


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  		TABLE 3. Hemodynamic Status in 15 Patients Undergoing TAE for Blunt Splenic Trauma

 
Follow-up of Patients Who Underwent TAE
Follow-up studies were performed for all 15 patients. CT was performed on the 2nd, 7th, and 21st days after treatment and monthly thereafter until the low-attenuation area disappeared. Scintigraphy was performed between 7 and 10 days after TAE. Images obtained at scintigraphy showed splenic uptake in all patients, and the uptake areas corresponded well to the distribution of splenic parenchyma seen on contrast-enhanced CT images obtained on the 7th day after treatment (Figs 1, 2). No complications were associated with TAE. Within 6 months after TAE, 13 patients with CT grade III or IV had complete resolution of the low-attenuation area in the spleen on CT images. The remaining two patients who had CT grade V injuries had complete resolution within 12 months after TAE.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES
 
In patients with splenic injury, the indications for TAE on the basis of hemodynamic criteria currently remain undecided. In the present study, hemodynamic status in patients was classified according to the Response to Initial Fluid Resuscitation of Advanced Trauma Life Support criteria, which were used as a reference standard for the initial therapy of injuries. In addition, the definitive criteria to indicate use of TAE in patients in shock, which had been very ambiguous, were established. In brief, TAE could be safety performed in those patients who showed a transient response, in whom recovery from shock could be achieved, even transiently, by means of administration of 2000 mL of Ringer lactate for 15–20 minutes. Our results could demonstrate the position of TAE in patients with splenic injury more clearly than before. A hemodynamic status equal to or more stable than that in patients with a transient response to fluid resuscitation and contrast material extravasation at contrast-enhanced CT were indications for TAE. These patients have been indicated for surgery because of an unstable hemodynamic status (15). However, we believe nonsurgical management can be successfully performed by using TAE even in these patients.

Two major methods for TAE of splenic injuries have been advocated. One method is coil embolization of the proximal splenic artery (2,3), which decreases arterial pressure in the spleen but allows continued perfusion through collateral arteries. The other method is superselective embolization of the bleeding arterial branch or branches with a microcatheter (16). To completely arrest the hemorrhage from splenic injury and to minimize infarct due to embolization, it is important to correctly choose one of these two methods of TAE on the basis of the features of arterial injuries. Patients in shock require quick treatment. Therefore, patients with splenic injuries who are in shock require three things: complete hemostasis, minimization of the infarct, and speedy treatment.

If arterial injuries belong to only group 1 (contrast material extravasation seen extending beyond the splenic parenchyma), TAE will be completed only with superselective embolization to ensure complete hemostasis. However, the arterial injuries in group 1 are sometimes complicated with arterial injuries in group 2 (contrast material extravasation seen within the splenic parenchyma) and/or group 3 (either disruption of the main portion of the terminal arteries and/or polar splenic arteries without contrast material extravasation or detection of the major arteriovenous fistula); such complications are often observed with severe splenic injuries. In such cases, a catheter should be inserted into each artery to embolize it individually when only superselective embolization is applied, which results in time-consuming treatment.

Such a time-consuming treatment method may create very dangerous factors that deteriorate the condition in patients, especially in patients in shock. The amount of hemorrhaging time is prolonged because of the time-consuming treatment and this leads to the development of critical risk factors including acidosis, hypothermia, and coagulopathy. Therefore, the combined use of superselective embolization and coil embolization of the proximal splenic artery is useful in those patients with splenic injury who have a group 1 arterial injury that is complicated with a group 2 and/or group 3 injury. We believe that the combined use of superselective embolization, which ensured complete hemostasis for group 1 injuries, and main splenic artery embolization, which can be performed promptly, simply, and easily for hemorrhages in group 2 or 3 injuries, can provide prompt and accurate hemostasis for patients, even for those in shock.

In regions other than the area of injury, the splenic parenchyma was clearly visualized at follow-up CT performed on the 7th hospital day in all patients, including those patients who underwent embolization of the main trunk of the splenic artery. Reconstitution of blood flow might have been the result of recanalization of the splenic artery or collateralization by the dorsal pancreatic, gastroepiploic, and left gastric arteries (3). Furthermore, results at scintigraphy confirmed preservation of splenic reticuloendothelial function, and therefore use of pneumococcal vaccination and penicillin prophylaxis to prevent postsplenectomy infection was unnecessary.

The patients in whom systolic blood pressure did not normalize with fluid resuscitation were classified as nonresponders, and CT was not performed in these patients. However, CT was performed when the systolic blood pressure improved transiently, even if these patients were still in shock. Shanmuganathan et al (6) reported that the accuracy of contrast-enhanced CT is 83% for predicting the need for treatment of splenic injury. In our study, the sensitivity of contrast-enhanced CT for depicting arterial hemorrhage from the injured spleen was 93% (14 of 15 patients). Therefore, when CT images show contrast material extravasation from an injured spleen, hemorrhage from the splenic artery is contributing to hypovolemia, and TAE should be performed if the clinical conditions permit.

We used TAE as the treatment of choice even in patients with multiple injuries accompanied by arterial hemorrhage. In these patients, the primary cause of shock may not be the splenic injury. The effectiveness and safety of TAE in patients with hepatic injury, renal injury, pelvic fracture, and facial injury have been well documented (10–13,16). Arterial hemorrhage from these injuries, including hemorrhage from pelvic fractures and facial injuries that are difficult to manage surgically, can be arrested by means of TAE during angiography, since a catheter is already positioned in the artery. The use of TAE offers the advantage of providing the ability to control hemorrhage simultaneously in different regions during a single procedure.

Blood loss in patients with a transient response is reported to be 20%–40% of the total blood volume (7). These patients often have multiple injuries. In our study, six of 15 patients had multiple injuries associated with arterial hemorrhage. The limitations of TAE for splenic injury might have been more clearly defined if patients with only splenic injuries had been the subjects of the study. However, these patients might not be representative of the patient population who undergo TAE. Therefore, both patients with multiple injuries and those with isolated splenic injuries were included in this study.

There were some limitations to this study. Patients who could not recover from shock after the initial fluid resuscitation (no-response group) were excluded from this study, and emergent surgery was performed in these patients following the evaluation of sonographic findings, without performing CT. This was a small series that included only patients with a transient response to initial fluid resuscitation. Furthermore, during our study period, one patient with a transient response at the time of admission developed profound shock after CT and underwent emergency surgery. When the number of subjects is increased in future studies, the number of patients with an apparent transient response but in need of emergency surgery may increase.

The results of this study support the routine use of TAE in patients with blunt splenic trauma who are in hemorrhagic shock at admission and show at least a transient response to initial fluid resuscitation. No patients died of their splenic injuries, no patients developed complications due to TAE, and splenic reticuloendothelial function was preserved in all patients in this study. Studies of TAE should be expanded to include patients who show a transient response to initial fluid resuscitation.


   FOOTNOTES
 
Abbreviation: TAE = transcatheter arterial embolization

Authors stated no financial relationship to disclose.

Author contributions: Guarantor of integrity of entire study, A.H.; study concepts and design, A.H., H.F.; literature research, A.H.; clinical studies, all authors; data acquisition, A.H., H.F.; data analysis/interpretation, A.H.; statistical analysis, A.H.; manuscript definition of intellectual content and editing, all authors; manuscript preparation, revision/review, and final version approval, A.H.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
 REFERENCES
 

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S. W. Anderson, J. C. Varghese, B. C. Lucey, P. A. Burke, E. F. Hirsch, and J. A. Soto
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