Effect of Prophylactic Embolization on Patients With Blunt Trauma at High Risk of Splenectomy

Abstract

IMPORTANCE Splenic arterial embolization (SAE) improves the rate of spleen rescue, yet the advantage of prophylactic SAE (pSAE) compared with surveillance and then embolization only if necessary (SURV) for patients at high risk of spleen rupture remains controversial. OBJECTIVE To determine whether the 1-month spleen salvage rate is better after pSAE or SURV. DESIGN, SETTING, AND PARTICIPANTSIn this randomized clinical trial conducted between February 6, 2014, and September 1, 2017, at 16 institutions in France, 133 patients with splenic trauma at high risk of rupture were randomized to undergo pSAE or SURV. All analyses were performed on a per-protocol basis, as well as an intention-to-treat analysis for specific events.INTERVENTIONS Prophylactic SAE, preferably using an arterial approach via the femoral artery, or SURV. MAIN OUTCOMES AND MEASURESThe primary end point was an intact spleen or a spleen with at least 50% vascularized parenchyma detected on an arterial computed tomography scan at 1 month after trauma, assessed by senior radiologists masked to the treatment group. Secondary end points included splenectomy and pseudoaneurysm, secondary SAE after inclusion, complications, length of hospital stay, quality-of-life score, and length of time off work or studies during the 6-month follow-up.RESULTS A total of 140 patients were randomized, and 133 (105 men [78.9%]; median age, 30 years [interquartile range, 23-47 years]) were retained in the study. For the primary end point, data from 117 patients (57 who underwent pSAE and 60 who underwent SURV) could be analyzed. The number of patients with at least a 50% viable spleen detected on a computed tomography scan at month 1 was not significantly different between the pSAE and SURV groups (56 of 57 [98.2%] vs 56 of 60 [93.3%]; difference, 4.9%; 95% CI, −2.4% to 12.1%; P = .37). By the day 5 visit, there were significantly fewer splenic pseudoaneurysms among patients in the pSAE group than in the SURV group (1 of 65 [1.5%] vs 8 of 65 [12.3%]; difference, −10.8%; 95% CI, −19.3% to −2.1%; P = .03), significantly fewer secondary embolizations among patients in the pSAE group than in the SURV group (1 of 65 [1.5%] vs 19 of 65 [29.2%]; difference, −27.7%; 95% CI, −41.0% to −15.9%; P < .001), and no difference in the overall complication rate between the pSAE and SURV groups (19 of 65 [29.2%] vs 27 of 65 [41.5%]; difference, −12.3%; 95% CI, −28.3% to 4.4%; P = .14). Between the day 5 and month 1 visits, the overall complication rate was not significantly different between the pSAE and SURV groups (11 of 59 [18.6%] vs 12 of 63 [19.0%]; difference, −0.4%; 95% CI, −14.4% to 13.6%; P = .96). The median length of hospitalization was significantly shorter for patients in the pSAE group than for those in the SURV group (9 days [interquartile range, 6-14 days] vs 13 days [interquartile range, 9-17 days]; P = .002).CONCLUSIONS AND RELEVANCE Among patients with splenic trauma at high risk of rupture, the 1-month spleen salvage rate was not statistically different between patients...

Endovascular management of traumatic pseudoaneurysms

“…Further, additional studies have pointed out the advantages of endovascular management in having lower risk than traditional surgical approaches while allowing for precise localization of the PA as well as assessment of the collateral vasculature (Hemp and Sabri 2015;Clark et al 2017;Salam et al 1992). Recent randomized controlled data has additionally shown that prophylactic splenic artery embolization after high risk splenic trauma results in fewer splenic PAs, secondary embolizations, and shorter hospitalizations, without increasing complication rates or compromising future splenic viability compared to surveillance (Arvieux et al 2020).…”

Follow-up strategies for patients with splenic trauma managed non-operatively: the 2022 World Society of Emergency Surgery consensus document

“…Arvieux et al [ 86 ] randomized 140 patients with splenic trauma at high risk of rupture (AAST Grade III with large pelvic hemoperitoneum and/or serious damage with a New Injury Severity Score of 15 or more, Grade IV splenic trauma, or Grade V splenic trauma with persisting vascularization of the spleen) to prophylactic SAE (pSAE) or surveillance and then embolization only if necessary (SURV); 133 patients were retained in the study. For the primary endpoint (1-month spleen salvage), data from 117 patients (57 who underwent pSAE and 60 who underwent SURV) were analyzed.…”

Update on Nonoperative Management of the Injured Spleen

“…A recent randomized trial from France, however, comparing prophylactic SAE vs surveillance and embolization only if necessary found no difference in splenic salvage rates between groups, with both reporting rates greater than 93%. 32 Splenic angioembolization was avoided in 68% of patients in the surveillance group. Of note, the authors did not comment on the indications for patients who ultimately underwent SAE in the observation group.…”