A PSEUDO-DILEMMA: ARE WE OVER-DIAGNOSING AND OVER-TREATING TRAUMATIC SPLENIC INTRAPARENCHYMAL PSEUDOANEURYSMS?
Sydney Radding, Melike N. Harfouche, Navpreet K. Dhillon, Ara Ko, Kristy L. Hawley, Rishi Kundi, John S. Maddox, Jason S. Radowsky, Joseph J. DuBose, David V. Feliciano, Rosemary A. Kozar, Thomas M. Scalea- Critical Care and Intensive Care Medicine
- Surgery
Abstract
Introduction
Splenic embolization for traumatic vascular abnormalities in stable patients is a common practice. We hypothesize that modern contrast-enhanced CT over diagnoses post-traumatic splenic vascular lesions such as intraparenchymal pseudoaneurysms (PSA) that may not require embolization.
Methods
We reviewed the experience at our high-volume center with endovascular management of blunt splenic injuries from Jan 2016-Dec 2021. Multidisciplinary review was used to compared initial CT findings to subsequent angiography, analyzing management and outcomes of identified vascular lesions.
Results
Of 853 splenic injuries managed overall during the study period, 255 (29.9%) underwent angiography of the spleen at any point during hospitalization. Vascular lesions were identified on 58% of initial CTs; extravasation (12.2%) and PSA (51.0%). Angiography was performed a mean of 22 hours after admission, with 38% done within 6 hours. Embolization was performed for 90.5% (231) of patients. Among the 130 patients with PSA on initial CT, 36 (27.7%) had no visible lesion on subsequent angiogram. From the 125 individuals who did not have a PSA identified on their initial CT, 67 (54%) had a PSA seen on subsequent angiography. On post-embolization CT at 48-72 hours, persistently perfused splenic PSAs were seen in 41.0% (48/117) of those with and 22.2% (2/9) without embolization. Only one of 24 (4.1%) patients with PSA on angiography observed without embolization required delayed splenectomy, whereas 6.9% (16/231) in the embolized group had splenectomy at a mean of 5.5
Conclusion
There is a high rate of discordance between CT and angiographic identification of splenic PSAs. Even when identified at angiogram and embolized, close to half will remain perfused on follow-up imaging. These findings question the use of routine angioembolization for all splenic PSAs.
Level of Evidence
IV
Study Type
Therapeutic/care management