Splenic artery embolization: technically feasible but not necessarily advantageous
Van der Cruyssen and Manzelli World Journal of Emergency Surgery
Splenic artery embolization: technically feasible but not necessarily advantageous
F. Van der Cruyssen 0 2
A. Manzelli 1
0 Third year master's student, Faculty of Medicine, Catholic University of Leuven (KU Leuven) , Gasthuisberg , Belgium
1 Department of Upper Gastrointestinal Surgery, Royal Devon & Exeter Hospital , Exeter , UK
2 Third year master's student, Faculty of Medicine, Catholic University of Leuven (KU Leuven) , Gasthuisberg , Belgium
Background: The spleen is the second most commonly injured organ in cases of abdominal trauma. Management of splenic injury depends on the clinical status of the patient and can include nonoperative management (NOM), splenic artery embolization (SAE), surgery (operative splenic salvage or splenectomy), or a combination of these treatments. In nonoperatively managed cases, SAE is sometimes used to control haemorrhage. However, the indications for SAE have not been clearly defined and, in some cases, the potential complications of the procedure may outweigh its benefits. Review of the literature: Through review of the literature we address the question of when SAE is indicated in combination with NOM of splenic injury, and whether SAE may delay needed surgical treatment in some cases. This systematic review highlighted the use of imperfect and inconsistent scoring systems in the diagnosis of splenic injury, the lack of consensus regarding indications for SAE, and the potential for severe morbidities associated with this procedure. Based on current literature and evidence we provide a new, non-verified, decision algorithm. Conclusions: NOM+ SAE involves potential risks and operative management may be preferable to SAE for certain patients. To clarify current literature, we propose a new algorithm for blunt abdominal trauma that should be validated prospectively. New evidence-based protocols should be developed to guide diagnosis and management of patients with splenic trauma.
Splenic artery; Embolization; Blunt splenic injury; Nonoperative management; Operative splenic salvage; Splenectomy; Trauma
Abdominal injury occurs in approximately 20–30 % of
all trauma patients. The spleen is the second most
commonly injured organ in both blunt and penetrating
abdominal trauma [
Raza et al. reviewed 1285 cases of abdominal
trauma over a ten-year period; 26 % of these suffered
a splenic injury. Of the patients in the initial study
group, 89.91 % were managed without surgery and
30 % of these had a splenic injury. The initial
presentation of splenic injury can be variable and depends
on the severity of the associated injuries, the amount
of blood lost, and the mechanism of trauma. Routine
diagnostic workup of suspected splenic injury includes
chest radiographs, abdominal ultrasound, a focused
assessment with sonography for trauma (FAST) scan,
or CT imaging. Abdominal CT imaging with
intravenous contrast is the preferred imaging method in
hemodynamically stable patients; when the patient is
in an unstable condition, a FAST scan that shows the
presence of free within the abdomen can indicate that
emergency surgery is necessary. Physicians and
surgeons should remain alert for concomitant injuries to
the liver (the organ most frequently injured by blunt
abdominal trauma) and other intra-abdominal organs.
Splenic artery embolization (SAE) is increasingly
being used in medical practice. This trend started in the
1970s when Maddison reported the first successful
SAE in a patient with esophageal varices, hepatic
cirrhosis, and recurrent gastrointestinal bleeding [
1975, Chuang and Reuter reported successful SAE
after splenic injury in ten dogs [
]. In 1985, Sclafani
et al. reported that embolization of 107 arterial
injuries yielded an 82.2 % success rate [
]. There was
a further evolution towards proximal SAE or more
distal and selective embolization of the branches of
the splenic artery.
Until the 1990s splenectomy remained the
treatment of choice for splenic injury, but nonoperative
management (NOM) became increasingly popular in
the pediatric setting around 1992 when Haller et al.
reported on the safety of NOM of solid organ injuries
in children [
]. Sclafani reported in 1995 a study of
172 patients and the use angiography with subsequent
use of proximal embolization of the splenic artery
when extravasation was present [
]. In his study
NOM was used in stable patients with no
extravasation on angiography, splenectomy or splenorrhaphy
was performed in unstable patients or in patients with
associated injuries or disease. Overall splenic salvage
rate was 88 % with a splenic salvage rate of 97 % in
the patients managed non-operatively.
The first large multi-institutional study was published
in 2000 by Peitzman et al. [
]. In this EAST study 1488
patients with blunt splenic injury were reviewed. The
authors report operative management in 38,5 % of the
patients and immediate operative management was
proportional to the grade of injury. In patient groups
with a larger hemoperitoneum, more laparotomies were
performed. They further report a NOM failure rate of
10,8 % of which 60,9 % within the first 24 h of
admittance. 54,8 % of the patients were successfully managed
In 2005 Haan reported on 648 patients in a single
institution study with splenic salvage rates of 90 %
after SAE and 100 % after planned NOM [
of NOM increased with higher injury grades but 80 %
of grade IV and V injuries were successfully managed
nonoperatively. Interestingly, a 40 % failure rate was
reported when an arteriovenous fistula was present,
even after embolization.
Currently, between 60 and 80 % of splenic injuries
are managed without surgery and the reported
success rates for NOM range between 85 and 94 %.
NOM can be combined with SAE when certain
conditions are met, and retrospective studies have
reported higher success rates and higher splenic
salvage rates when NOM is combined with SAE [
However, no consensus has been reached on the
correct indications for combining NOM and SAE,
especially in higher grade splenic injuries. In the current
literature, the use of NOM in combination with SAE
for treatment of blunt splenic injury is dependent on
multiple factors, which are: the grade of the splenic
injury, the injury severity score (ISS), patient age, the
presence of contrast blush on CT, active extravasation
on angiography, need for transfusion, the presence of
significant hemoperitoneum, and the presence of
splenic artery pseudoaneurysms. Most trauma
protocols consider hemodynamic instability or a high-grade
splenic lesion (IV–V) to be indications for emergency
laparotomy. Operative splenic salvage (OSS) or
splenectomy can then be attempted. However, based on the
currently available literature the use of NOM, SAE, or
OSS is controversial. Retrospective review of data,
small study groups, and changes in protocols or in
standard practice make it difficult to draw conclusions
regarding the optimal management of splenic injuries.
Methods & results
We reviewed the literature and used critical
interpretive synthesis methodology in the following discussion.
A search of the following databases was conducted
during October 2015: Medline database, Trip
database, EMBASE, Web of Science, Cochrane Library,
and Scopus. We also manually searched the reference
lists of the retrieved articles. Our search terms included:
splenic injury, embolization, operative, management.
We included original research articles that reported on
splenic injury in combination with embolization therapy,
operative, and nonoperative management. Papers were
excluded if they focused specifically on adolescent,
pediatric, or neonatal populations and if they included
specific diagnostic groups. Guidelines, surveys, and
meta-analyses were also excluded. The search was
executed sequentially and is documented in Table 1. All
articles were assessed for relevance by reading the
abstract and, where needed, the entire paper using the
Duplicates were excluded and the final selection of
articles was based on their relevance and quality. Papers were
excluded if no full text could be obtained. To select
highquality studies, we assessed all articles following the
Critical Review Form for Quantitative Studies and
guidelines from Law et al. [
]. An overview of the selected
articles is presented in Table 2. Excluded articles are also
presented in Table 2 for reference. Despite the large
amount of articles retrieved, we were not able to carry out
a meta-analysis because of the heterogeneity of study
methods, data and quality of articles.
In order to further support the literature review we
propose a new, non-verified, algorithm for blunt
abdominal trauma, based on existing algorithms presented
in the literature and modified according to our findings
Hemodynamically unstable patients
Abdominal trauma with hemodynamic instability is an
absolute indication for operative management in most
protocols. However, in cases of splenic injury, SAE
and NOM is increasingly being performed even in
patients that are hemodynamically unstable. The use
of NOM or SAE in hemodynamically unstable
patients is highly controversial and should be further
studied. Delays in diagnostic testing and inappropriate
selection of hemodynamically unstable patients for
this treatment protocol could increase morbidity and
mortality rates, as some authors have suggested [
Importantly, there has been little research on
managing patients with transient hemodynamic stability,
although Hagiwara et al. did report successful SAE in
15 patients with transient responses to fluid
Most studies in the literature are retrospective case
series that describe the immediate technical success of
SAE without comparisons with surgical treatment or a
purely conservative approach. Operative intervention
by means of splenectomy is thought to increase
morbidity and mortality rates, but this is biased by higher
injury severity scores in patients that are surgically
managed. A large study of 11,793 patients by Zarzaur
et al. (2011) could not confirm a correlation between
splenectomy and in-hospital mortality when the data
were corrected for demographic, physiologic, and
injury-related factors [
]. The risk of overwhelming
post-splenectomy sepsis has been advocated as a
concern and relative contraindication for splenectomy;
however, this rare complication occurs in only
approximately 0.9 % of splenectomy cases and is
preventable by immunization [
]. A recent, large,
population-based study classified 9719 patients with
splenic injuries into two groups, splenectomy or
nonsplenectomy, and compared these against a control
group of 30,413 patients with other abdominal injuries.
This study warned of a two-fold increased risk of
developing type II diabetes post-splenectomy [
contrast, some authors have reported higher morbidity
after SAE than after surgical intervention [
addition, there is evidence of splenic functional
alterations after SAE, although research suggests that no
immunizations are necessary after NOM combined
with SAE [
]. In a 2010 paper, Shih and colleagues
demonstrated a cytokine hyporesponse after SAE [
therefore, SAE should not be considered definitively
safer than splenectomy.
Hemodynamically stable patients
SAE, as opposed to pure conservative management, is
even more difficult to advocate in hemodynamically
stable patients. In a 2015 study, Olthoff et al. looked
at the management of 253 patients with splenic injury
in Dutch trauma centers taking into account
hemodynamic instability on admission, high-grade
injury, and ISS [
]. Although the rate of NOM was
comparable between the five trauma centers reviewed,
the use of SAE for splenic injuries was highly variable
between the centers, illustrating the lack of consensus
that exists regarding the management of blunt splenic
In hemodynamically stable patients, retrospective
studies have shown that NOM has a reduced failure
rate when combined with SAE [
prospective studies and certain retrospective studies have
failed to confirm these findings [
studies have been published that show increased numbers
of both minor and major complications, leading to an
increase in time spent in the hospital, with the use of
]. Moreover, there is no consensus on
the follow-up management and imaging of patients
with splenic injuries. Given the lack of evidence in
the literature, Olthof et al. published a study in 2013
using the Delphi method to reach an expert opinion
on the optimal management and follow-up protocol
for blunt splenic injury [
]. In several questionnaires,
trauma surgeons and interventional radiologists have
tried to reach consensus on the indications for, and
optimal follow-up management and imaging to use
with, NOM combined with SAE. Almost all of the
experts used the American Association for the Surgery
of Trauma (AAST) scoring system to grade splenic
injuries (Table 3). They all agreed on the use of
NOM with or without SAE in small graded injuries
(I–II) with no or only a small hemoperitoneum. In
high-grade injuries (III–V) with a large
hemoperitoneum and active contrast extravasation half of the
experts would still attempt NOM + SAE, but most of
them would not make a second attempt if the initial
SAE failed. Most importantly, they all agreed that
rapid intervention is needed for SAE to succeed.
Current recommendations are that intervention
should be performed within 60 min of admission in
stable patients with active contrast extravasation and
within 15 to 30 min when a large hemoperitoneum is
present. No consensus was reached on management
after failure of the initial NOM, or on the appropriate
length of stay (LOS) in the hospital.
In search of better criteria for determining the need
for intervention, Koca et al. correlated the results of
NOM with the American Association for the Surgery of
Trauma (AAST) splenic injury grade (see below) [
They found that hemodynamically stable patients can
safely be treated with NOM, including patients with
multi-organ injuries and higher grade splenic injuries.
Most injuries are lower grade injuries (I–III), and not
surprisingly transfusion is correlated with the injury
grade. A 2008 article by Gonzalez et al. added the degree
of hemoperitoneum and associated injuries as predictive
factors for NOM failure [
]. In 2004, Wahl and
colleagues retrospectively analyzed 164 patients with blunt
splenic injuries; [
] after univariate analysis they found
that lower blood pressure, higher ISS, lower pH, and
more packed RBC transfusions are the best indicators of
the need for operative intervention. Age, heart rate,
splenic abbreviated injury scale score, and GCS did not
significantly correlate with the need for operative
management. Similarly, Tugnoli et al. (2014) presented the
algorithm used in the Bologna-Maggiore Hospital; in
293 patients with splenic injuries admitted between 2009
and 2013 [
] they reported a NOM success rate of
95.8 %. All hemodynamically stable cases with active
contrast extravasation or grade V injuries were
embolized, preferably proximally within the splenic artery.
In a 2015 AAST prospective observational study, Zarzaur
et al. investigated the risk of delayed splenectomy after
NOM with or without SAE [
]. They found that the only
risk factor for delayed splenectomy was the finding of active
extravasation at presentation; thus calling for closer
observation of patients with this finding irrespective of whether
SAE was performed. Patients with grade I injury had no
risk for delayed splenectomy. In cases with higher grade (II
to V) injuries, the authors advocated close observation for
10–14 days. In the 2005 study of Haan et al. the presence
of arteriovenous fistula on CT imaging was predictive for
40 % of failure rates in nonoperatively managed patients
]. The presence of vascular lesions (arteriovenous fistulas,
pseudoaneurysms) and impact on NOM success rates was
further investigated by several authors. In a 2014 study, the
Wake Forest University investigated failure rates after
angiography with subsequent embolization, ignoring presence
or absence of any vascular lesion, for all grade III to V
splenic injuries in stable patients in a protocolized manner
and comparing this to a historic control group [
168 patients 67 % were managed nonoperatively with an
overall NOM failure rate of 5 %. In the patient group where
protocol was violated the failure rate was 25 % compared to
3 % in the protocol group (P = 0.03). Comparing this to a
historic control group, 52 % patients underwent NOM with
a significant higher failure rate of 15 % (P = 0.04). For each
injury grade they reported lower failure rates in the study
group compared to the control group and when protocol
was followed. However, they did not reach statistical
significance when comparing patients treated according to
protocol or patients deviating from protocol in injury grades IV
and V. The authors did not report on complications or on
splenic function after embolization in their study group, no
data is available whether proximal or distal embolization
Another prospective study from Parihar et al. [
found a shorter LOS in SAE patients (5.4 days compared
with 6.6 days for NOM patients without SAE), as well as
higher hemoglobin concentrations and systolic blood
pressures. A recent study, which used propensity score
analysis, found no statistically significant difference
between observation and embolization in the subsequent
splenectomy rate [
Many scoring systems have been developed to grade
splenic injuries, among which the AAST grading system
for splenic injury (Table 3) is the most popular. Two
separate studies have correlated CT findings with the
AAST injury grade and subsequent need for
intervention. In the study by Barquist et al. [
], four radiologists
retrospectively reviewed 200 CT images of patients who
had undergone splenectomy; the operative grading of
the splenic injuries was used as a gold standard. The
weighted kappa score for intrarater reproducibility was
0.15–0.77 and the interrater kappa score was 0–0.84
(mean 0.23). In the study by Cohn et al. [
radiologists reviewed CT scans of 300 patients with liver and
splenic injuries using the AAST grading system.
Twentyone percent of the patients with splenic injuries visible
on CT images required intervention. Cohn et al. reached
the same conclusion as Barquist et al.; the sensitivity of
the AAST injury grade for predicting the need for
intervention is poor and interrater variability, even among
experienced radiologists, is high. Both thus concluded
that the AAST scoring system is unreliable because even
experienced radiologists often underestimate the
magnitude of the injury, and other factors should also be
considered when evaluating indications for surgery or
angiography. The authors also evaluated kappa scores
for the reporting of contrast blush on CT imaging and
found that they were similarly variable, although
contrast blush on CT imaging is considered a major
indication that intervention is needed.
In 2001, Protetch et al. reported that the incidence of
contrast blush was related to the grade of injury, with
3.2 % of grade I/II injuries and up to 37.6 % of grade IV
and V injuries showing a contrast blush in CT images
]. Interventions were more frequent when a contrast
blush was present, but multivariate regression analysis
showed no correlation between finding a contrast blush
and splenic intervention. This was confirmed by both
Thompson et al. and Michailidou et al.; both also
reported that the size of the contrast blush was correlated
with the need for intervention [
]. They both found
that similar cut-off values (1 cm and 1.5 cm) indicated
the need for intervention. Other factors that also
correlated with the need for intervention in splenic injury
were injury grade, hypotension on admission to the
emergency department, and age. The findings of these
studies support the need for better protocols and
parameters to allow proper assessment of the need for
intervention in cases of splenic trauma.
In 2007, Marmery et al. suggested a new grading
system for splenic injury that takes into account active
bleeding or splenic vascular injury (including splenic
pseudoaneurysms and arteriovenous fistulas) [
new grading system was statistically significantly better
than the AAST grading system in terms of its ability to
predict the need for splenic arteriography (P = 0.0036) or
the combination of arteriography and surgery (P =
0.0006). Table 4 presents the proposed new grading
There has been much research published, and work is
still ongoing, to understand the complications after SAE
compared with those after surgery and NOM. All of the
treatment modalities for splenic injury are associated
with high morbidity rates. Specific morbidities associated
with SAE include pancreatitis, splenic infarction,
postembolization syndrome, and intestinal perforation.
Two retrospective studies examined the complications
that occur after SAE [
]. Ekeh et al. reviewed 1383
patients with blunt splenic injury over an 11-year period;
78.5 % were treated nonoperatively, and of this group
8.1 % underwent SAE. Major complications including
splenic infarction, splenic abscess, contrast-induced
Table 4 Newly proposed Multi-Detector CT (MDCT) grading
system, reproduced from Marmery et al. (2007)
● Subcapsular hematoma < 1-cm thick
● Laceration < 1 cm deep into parenchyma
● Subcapsular hematoma 1–3-cm thick
● Parenchymal hematoma 1–3-cm diameter
● Laceration 1–3 cm deep into parenchyma
● Splenic capsular disruption
● Subcapsular hematoma > 3-cm thick
● Parenchymal hematoma > 3-cm diameter
● Laceration > 3 cm deep into parenchyma
● Active intraparenchymal and subcapsular splenic bleeding
● Splenic vascular injury (pseudoaneurysm or arteriovenous
● Shattered spleen
● Active intraperitoneal bleeding
renal insufficiency, and splenic cysts occurred in 14 % of
the patients who underwent SAE. Wu et al. reported
that 28.5 % of patients who underwent SAE experienced
major complications. Distal embolization was associated
with more major complications than proximal SAE.
Minor complications (pleural effusion, coil migration,
and fever) occurred in 34 % and 61.9 % of the patients
in the SAE groups in the studies by Ekeh et al. and Wu
et al., respectively.
In 2004, Haan et al. reported SAE complication rates
in 140 patients and reported a splenic salvage rate of
87 % [
]. This rate indirectly correlated with injury
severity scores. More than 80 % of the grade IV and V
injuries in their study were successfully managed
nonoperatively. No significant difference was noted in
patients older than 55 years of age. The presence of a
significant hemoperitoneum did not alter success rates;
however, the presence of arteriovenous fistulas did. They
concluded that complications after SAE are common,
but do not seem to influence outcomes.
In 2008, Wei et al. published a retrospective study
showing lower complication rates after SAE even with higher
splenic Abbreviated Injury Scores in this group compared
with the operatively managed group (6 % vs. 36 %, P < 0.01)
]. They found that the introduction of SAE reduced
operative interventions by 16 % between 2000 and 2006 in
their Level 1 center. A French prospective multicenter
study investigated complication rates in 91 patients [
Twenty percent underwent splenectomy with a
postsurgical morbidity of 15 %. Fifteen patients (16 %)
underwent embolization and 67 were initially managed
nonoperatively. In the embolization group with severe injury
(grade III–V), the morbidity was 73 %. The splenectomy
group with severe injury had a total morbidity of 70 %. The
NOM group had a morbidity of 58 %. Specific morbidities
after NOM, surgery, and SAE were 10, 15, and 47 % (P =
0.02), respectively. The study concluded that embolization
should not be used as a prophylactic measure, but should
only be used in cases with active bleeding. We could not
find well-designed studies comparing complication rates
between the three treatment modalities.
Other factors to be considered
Need for transfusion
In their 2015 study of 253 patients, Olthoff et al. found
a very large variation but no significant difference in the
need for transfusion between patients treated with SAE
and those treated with NOM [
]. The mean number of
transfused blood products was 5.5 units (±9.9) in the
NOM group versus 9.1 units (±17.2) in embolized
patients (P = 0.75). Rosati et al. reported on the need for
transfusion in patients requiring immediate splenectomy
(70 %), embolization (46.5 %), and NOM (25.9 %), but
failed to adjust these data for injury severity and
]. They found that the need for transfusion
was a major risk factor for mortality (adjusted OR = 2.63;
CI 1.27 – 5.42, P = 0.009). Dent et al. compared
transfusion rates between NOM, early embolization, and
operative management [
]. They reported a 2.1-unit
difference in the transfusion rate (P < 0.01) of the NOM
group versus the operative management group, and
found no statistically significant difference between
transfusion rates in the early embolization and operative
management groups without correcting for confounders.
They also found no difference in transfusion rates when
they compared patients who underwent early
embolization versus late embolization.
Impact of direct supervision
A retrospective review in 2011 investigated the impact
of direct supervision (DS) or indirect supervision (IS) on
the management of splenic injuries [
]. Using data from
506 cases the authors found significant differences in
compliance with protocols (DS, 95 % vs. IS, 82 %, P <
0.001), operation rates (DS 16 %, vs. IS, 8 %, P = 0.016),
ICU use (IS, 84.1 % vs. DS, 73.0 %, P = 0.029), hospital
costs (IS, $142.956 ± $36.219 vs. DS, $62.981 ± $8.784, P
= 0.048), and use of SAE without indication (IS, 8 vs.
DS, 0). Interestingly, there were no reported differences
in mortality or splenectomy rates.
Time to intervention and volume of the centers.
In 2014, Olthof et al. retrospectively examined the
time to intervention in patients undergoing SAE and
patients undergoing surgery in a cohort of 96 adults [
In hemodynamically stable patients, the median time to
intervention for patients in the SAE group was 117 min
compared with 105 min for patients in the surgery
group. The differences in time to intervention or
reintervention, and the complication rates were not
significantly different between the two patient groups. There
was a higher transfusion rate for patients in the splenic
surgery group; the median number of transfused units of
packed RBCs was eight for hemodynamically unstable
patients undergoing SAE versus 24 for patients
undergoing splenic surgery (P = 0.09). A report published in
2015 reviewed 10,405 records in the National Trauma
Data Bank to find a correlation between high and low
angio centers and to investigate any relationship between
angiography use and its timing or splenectomy after
]. They concluded that early angiography
is associated with higher splenic salvage rates but found
no statistically significant difference in splenectomy rates
between the high and low angiography volume centers.
We could not find any articles comparing the
relationship between time to intervention and success or
complication rates between patients undergoing NOM, SAE,
or splenic surgery.
Costs & Length of stay
Different authors have investigated the costs of SAE
versus surgical management. Wahl et al. reported no
significant cost differences between these two treatment
modalities (SAE, $49.300 ± $40.460 vs. OM, $54.590
± $34.760) [
]. This was confirmed by Wei et al., who
found the costs associated with SAE to be $47,000
± $31,000 and the costs associated with OM to be
$40,000 ± $34,000 [
]. Both authors assessed the LOS
and differences in LOS in patients who received different
treatments. Wahl et al. found an average LOS of 45 ±
26 days for patients who went directly to the operating
theatre, compared with 14 ± 15 days for patients who
underwent SAE (P < 0.02). Wei et al. found that the
average LOS in the surgical group was 14 ± 10 days and
in the SAE group was 12 ± 12 days (P > 0.05). Bruce et al.
also came to the same conclusion in their 2011 study;
] in that study the median total hospital charges were
$41,269 (± $31,128) for the NOM + SAE group
compared with $46,356 (± $11,334) for the OM group (P =
0.545). They did report higher procedure-related charges
for OM patients compared with patients undergoing
NOM + SAE ($28,709 ± $6941 vs. $19,062 ± $14,025; P =
0.16); however, this was offset by more charges for a
greater number of radiological evaluations in the other
Based on the literature review we propose a new,
nonverified, decision algorithm for splenic trauma. We hope
this can further serve as a tree of order in the vast
amount of publications concerning this topic. We stress
that this algorithm is not verified and should be further
verified in well designed, prospective studies, is it to be
used in daily practice.
The term hemodynamically unstable is not clearly
defined in most literature and it is often unclear if authors
included or excluded transient responders. The nature
of the patient’s response to fluid therapy is important
and should be considered in all splenic trauma
protocols. Most authors agree that surgical intervention is
indicated when the patient is hemodynamically unstable.
In close relation with response to fluid resuscitation is
time to intervention, which is an important factor to
consider from the start. Higher splenic salvage rates are
achieved when earlier intervention is possible and expert
opinion states that intervention is recommended within
one hour of admittance. In prospect, when the time to
intervention will be several hours OM or NOM may be
better options than SAE, depending on the clinical
presentation. Clinicians and surgeons should always keep in
mind that pre- and post-intervention delays make it
increasingly difficult to operate because of the several
surgical and nonsurgical issues that can develop (e.g.,
clotting of the intraperitoneal hemorrhage, infection,
and development of comorbidities). Non responders
should be triaged promptly with a minimal delay
towards surgical intervention.
There is a distinction between major and minor
complications and treatment-specific morbidities. While it is
difficult to correlate complications with the embolization
procedure, especially in small studies, it is interesting to
look at treatment-specific complications and associated
risk-benefit ratios; however, no well-designed studies
compare NOM, NOM + SAE, and OM for the treatment
of splenic trauma. Until such studies are available, we
should look at the clinical value and possible risks of an
intervention on a patient-specific level while considering
all factors, and keeping in mind the relatively high
complication rate after SAE. It is important to avoid the bias
of expecting operative interventions to have higher
complication rates than SAE, which seems like a less invasive
procedure. Increased use of NOM with or without SAE
should not erode clinical judgment and surgical skills.
Currently there is no evidence of reduced transfusion
rates when SAE is used in conjunction with NOM
compared with NOM alone. Transfusion rates are higher in
patients who undergo an operative intervention and are
a risk factor for mortality; however, no studies are
available that compare similar patient groups and their
corresponding transfusion rates.
Multiple studies have reported on the cost
effectiveness of splenic injury management: operative
intervention brings the costs of surgery and of higher
transfusion rates; however, conversely NOM + SAE
requires higher imaging costs and there is ultimately no
significant difference between the costs of the two
We reviewed the different scoring systems and the use
of imaging for diagnosing splenic injuries. As imaging
modalities improve smaller bleeds are increasingly being
visualized. It is known that these bleeds can be
selflimiting; however, no studies have shown the clinical
significance of these small bleeds and other radiological
findings such as pseudoaneurysms and arteriovenous
fistulas. Additional studies will be needed to assess
whether embolization is superior to NOM in these cases.
Studies have shown important interrater and intrarater
differences in image evaluation in cases of splenic injury,
and more specifically in the assessment of a contrast
blush on CT imaging. Contrast blush is considered an
important parameter for assessment of the need for
intervention but recent studies have shown that the size
of the contrast blush is what matters. Though whether a
cut-off value of 1 cm or 1.5 cm is more suitable for
determining the optimal treatment is not yet known.
According to the literature, the presence of a
hemoperitoneum does not alter the success rates of SAE.
The MDCT grading system proposed by Marmery et al.
has shown a better correlation with the need for
intervention than the conventionally used AAST grading
system. Currently, there is no consensus on the use of
one grading system that correlates well with the need for
intervention, and most published studies have used the
AAST grading system. Lack of standardized grading
makes it difficult to compare older studies with recent
and future studies. Interpreting CT images and grading
the splenic injury is difficult and should be performed by
experienced radiologists using the proposed grading
system with a consistent technique. We propose the use of
specific image analysis protocols to achieve a consistent
approach and improve future studies. We propose the
use of the MDCT grading system in our decision
The treatment plan should be managed by experienced
trauma surgeons or interventional radiologists using a
multidisciplinary approach when possible. It should be
clear who is responsible for assessing the indications for
SAE, NOM, or OM. The literature has shown better
results when protocols are in place; and ideally there
should be consensus on who is responsible for initiating
The current literature is unclear on the correct
indications for NOM ± SAE versus surgery for splenic trauma.
To further clarify current evidence we propose, a
nonverified, decision algorithm for blunt abdominal trauma.
A prospective well designed study is needed to validate
our decision algorithm. Consensus on the management
of blunt splenic injury between radiologists, trauma
surgeons and emergency medicine physicians could reduce
conflicting data, improve current protocols, and avoid
harm to patients. More prospective data and
welldesigned studies, taking into account other factors
including long term results and morbidity, on the
management of splenic trauma are needed.
Additional file 1: Table 1. Search results and number of articles
retrieved after applying the selection criteria.After the initial search, all
articles were entered in a reference database (Mendeley). Table 2.
Summary table of articles that met inclusion criteria after initial selection.
Articles marked in grey were excluded. Table 3. Traditionally used
American Association for the Surgery of Trauma (AAST) scoring system
for splenic injuries. Figure 1. Algorithm for management of splenic trauma
modified from Ekeh and Tugnoli.8, 32 Abbreviations: HD: hemodynamically;
BP: blood pressure; FAST: Focused Assessment with Sonography for Trauma;
ICU: Intensive Care Unit; SAE: splenic artery embolization; MDCT: Multidetector
CT grading (Table 4); NOM: non operative management; CE: contrast
extravasation; IV: intravenous. (ZIP 126 kb)
AAST: American Association for the Surgery of Trauma; BP: Blood pressure;
CE: Contrast extravasation; DS: Direct supervision; FAST scan: Focused
assessment with sonography for trauma; GCS: Glasgow coma scale;
HD: Hemodynamically; ICU: Intensive care unit; IS: Indirect supervision;
ISS: Injury severity score; IV: Intravenous; LOS: Length of stay;
MDCT: Multidetector computer tomography; NOM: Nonoperative
management; OM: Operative management; OR: Operating room;
OSS: Operative splenic salvage; RBCs: Red blood cells; SAE: Splenic artery
Availability of data and materials
All datasets and figures supporting the conclusions of this article are
included within the article and its Additional file 1.
FvdC and AM were responsible for the study concept and design.
FvdC carried out the literature search. Both authors critically reviewed the
manuscript for important intellectual content. AM was the study supervisor.
Both authors read and approved the final version of the manuscript.
The authors declare that they have no competing interests.
Consent for publication
Written consent was obtained from both patients.
Ethics approval and consent to participate
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