ROLE OF ENDOVASCULAR TREATMENT OF SPLEEN INJURY IN NON-OPERATIVE MANAGEMENT OF HIGH-RISK PATIENTS

Summary

Objective: Determination of indications for angiographic treatment of injured spleen.

Type of thesis: Short summary and case report.

Material and methodology: Case report and short overview of literature.

Conclusion: In haemodynamically stable patients with spleen injury grade ≤ 4. the risk of secondary rupture may be significantly reduced by angiographic treatment. However, this requires an active and differentia­ted approach in individual cases.

Keywords:

endovascular treatment – Spleen – associated injury – continued bleeding

INTRODUCTION

Spleen is the most commonly injured abdominal organ [5]. The initial imaging examination such as multidetector computed tomography determines the grade of injury [3]. The original American Association for the Surgery of Trauma (AAST) classification evaluated only the anatomical-morphological basis of the injury. However, this classification was not able to predict further deve­lopment of injuries. It was revised in 2018 and factors such as vascular lesions [7] are evaluated (Table 1).

In haemodynamically stable patients, nonoperative injury management with or without endovascular treatment is the trend [12]. The risk of continued bleeding increases in patients over 55 years of age, in associated injury with ISS (Injury Severe Score) above 25, haemodynamic instability, and vascular abnormalities in the imaging examination [9]. In case report, the authors deal with patients with continued bleeding and indications of preventive non-selective embolisation in high-risk patients.

MATERIAL AND METHODOLOGY

A 67-year-old patient was initially examined at the emergency medicine department after falling from a height of about 7–8 metres. On admission he was conscious, hypotensive - BP 93/64, without tachycardia, hyposa­turation 85 %. Clinically pale, thready pulsation on the periphery, grinding sounds of the ribs on the left and pelvic instability. On admission - laboratory leukocytosis 15x10⁹/L, haemoglobin (HB) 125 g/L, thrombocytes 181 x10⁹/L, coagulation and biochemical markes were normal. No free fluid on cavity ultrasound. On the X-ray, rib fractures on the left and type B pelvic ring fracture. Estimated blood loss around 2,000 mL. The patient was examined at CT (Computed tomography) with a trauma protocol, where a serial fracture of ribs on the left with hemopneumothorax, a type B pelvic ring fracture and an acetabular fracture on the right with a haematoma in the pelvic muscles and contrast media (CM) extravasation, splenic laceration with a subcapsular haematoma without CM leak were determined (Fig. 1, 2). Furthermore, stable fractures of the thoracic and lumbar spine. Due to active haemorrhage from the pelvis, the patient was indicated for vasography, where the source of bleeding from a. obturoatoria and a. pudenda interna on the right was treated. Selective angiography of truncus coe­liacus was also performed during the procedure, where extravasation was proved in a. lienalis distribution and non-selective embolisation of the splenic artery was not performed (Fig. 3).

During the performance, the patient was unstable; the need for intubation and drainage of the left hemithorax, from which air freely left and also 100mL of haemorrhagic fluid. Following the angiographic treatment, the pelvis was subsequently stabilized at the operating theater with an external fixation device and a sacroiliac (SI) screw on the right. He was then admitted to the intensive care unit (ICU), where his condition gradually stabilised. At the ICU, he had clinical, laboratory and ultrasound monitoring. Laboratory - normalisation of leukocytosis to 7.95x10⁹/L, gradual decrease of HB to 92 g/L, which was attributed to the initial haemorrhage in the pelvic area and rib fractures; biochemistry and coa­gulation were normal. Daily control ultrasound of cavities, which in the left subphrenic area was not effective enough due to the subcutaneous emphysema, therefore, on day 4 of the hospitalisation, a control CT of the torso was performed, where there were no signs of haemorrhage or subcapsular haematoma progression. On day 6 of the hospitalisation, he was transferred to the standard ward in a stabilised condition. Here on the next day at 6.40 am there was sudden worsening of the condition, the patient was not responding, bradycardia 50/min, hyposa­turation 77 %, inaudible breathing on the right. Intubation, puncture and drainage of the right hemithorax were performed urgently to eliminate tension pneumothorax, drain without flowout. At 6.45 am, cardiopulmonary resuscitation was started due to pulseless electrical acti­vity. Circulation restored spontaneously after 10 minutes. Hypotension 100/70 and hyposaturation persist; need to support circulation with noradrenaline 70mL/hour. On the CT scan of brain and torso, there was an extensive hemoperitoneum with an active leak in the spleen area, as well as successive embolisation in a. pulmonalis on the right (Fig. 4, 5, 6, 7).

The patient was indicated for revision surgery. Revision of the abdominal cavity and splenectomy were performed from the midline laparotomy. Total blood loss about 3,000 mL. Peroperative finding - lacerated spleen of the distal pole, freely in the abdominal cavi­ty, proximal pole at the stem of aa. gastricae breves. Histological finding - confirmed splenic laceration into two main pieces, capsule removed, total weight 254 g. Microscopic finding - haemorrhage and fissures in the parenchyma, normal architecture of the spleen, without secondary pathology. From the Operating theater he was admitted to the intensive care unit, where instability persists with a combination of haemorrhagic and cardiogenic shock. Patient extubated on the 6^th post-operation day. Subsequently, after stabilization of his condition, he was transferred to the standard ward, where he conti­nued his established therapy and rehabilitation. The patient was then transferred to the surgical department in the place of residence; vaccination after a splenectomy was secured there. The patient is regularly checked at the trauma outpatient clinic. Pelvic fractures healed, He is self-sufficient.

DISCUSSION

The spleen is the most commonly injured abdominal organ [5]. It has been found that its function in the immune system is very important, which is why efforts to preserve spleen have been increasing in recent years [1]. However, the indications to perform an urgent splenectomy remains unchanged for the time being. Haemodynamically stable patients without haemorrhage on the imaging scan are indicated for a conservative procedure, following mostly the observation on the ICU. If the imaging scan shows active haemorrhage in the form of an increasing extravasation fluid, there is a possibility of an endovascular treatment [4]. The techniques of the treatment and their possible complications remain to be debated - either proximal non-selective embolisation of the splenic artery, or selective distal embolisation at the site of haemorrhage. Some groups of authors prefer non-selective embolisation at higher injury grades with multiple sour­ces of haemorrhage and distal embolisation in segmental arteries haemorrhage [11].

However, there is still a group of haemodynamically stable patients with higher grades of injury or risk factors such as age, high ISS, and vascular abnormalities, where the risk of secondary rupture and forced splenectomy increases significantly in a conservative procedure without angiographic treatment [4]. Despite the fact that angioembolisation is indicated when active haemorrhage is found at the initial imaging scan, angiographic treatment should also be considered for mid- and upper-grade injuries without active haemorrhage or lower injury grades with concurrent risk factors [13]. The initial CT scan may be modified by the timing of arterial bolus of contrast, so some abnormalities may not be visible [10]. However, the additional angiography has the opportunity to detect hidden abnormalities and treat them. The performing of non-selective embolisation in higher injury grades without an active leak as well as in high-risk patients significantly reduces the risk of secondary rupture [2]. The difference between embolisation techniques is minimal [4, 11].

Complications of angiographic procedure most commonly include haemorrhage, injury to other organs, abscess, spleen infarction, acute pancreatitis [4]. Residual immunological function after angiographic performance is not entirely clear, but vaccination is not routinely re­commended [1].

Spleen embolisation treatment is mentioned in the Czech literature [7]. We have experience with angiographic treatment of the spleen at our site; however, it is not a common practice and routine. In 2016–2017, 10 patients with spleen injuries underwent angiogra­phic treatment, of which 8 patients were embolised with a success rate of 87.5 % [13]. As yet, however, indication for angiography is not subject to protocol at our site and depends mainly on the experience and discretion of the attending traumatologist. There is certainly the potential for a higher number of embolisations. So far, the follow-up time is short and further processing is underway.

CONCLUSION

In haemodynamically stable patients with spleen injury grade ≤ IV. the risk of secondary rupture may be significantly reduced by angiographic treatment. However, this requires an active and differentiated approach in individual cases. In most cases, proven extravasation is indicated for selective distal embolisation. In patients without CM extravasation, but with risk factors such as age > 55 years, ISS ≥ 25, vascular abnormalities and AAST ≥ III, non-selective proximal embolisation should always be considered.

MUDr. Jana Kluková

jana.klukova@fnhk.cz