Effect of Prophylactic Embolization on Trauma Patients at High Risk of Splenectomy | Surgery | JN Learning | AMA Ed Hub [Skip to Content]
[Skip to Content Landing]

Effect of Prophylactic Embolization on Patients With Blunt Trauma at High Risk of SplenectomyA Randomized Clinical Trial

Educational Objective
To identify whether prophylactic splenic artery embolization in patients at high risk improves the rate of spleen rescue when compared with surveillance and embolization only if necessary.
1 Credit CME
Key Points

Question  For patients with blunt trauma at high risk of spleen rupture, does prophylactic splenic artery embolization improve the rate of spleen rescue compared with surveillance and embolization only if necessary?

Findings  In this randomized clinical trial, the number of patients with an at least 50% viable spleen detected on a computed tomography scan at 1 month was not significantly different between patients receiving immediate prophylactic splenic artery embolization and those receiving surveillance only, with embolization only if necessary. Many patients in the surveillance group received embolization within a few days and were hospitalized for significantly longer.

Meaning  For patients with severe splenic trauma, both strategies resulted in a spleen rescue rate greater than 93%.

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 Participants  In 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 Measures  The 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 undergoing pSAE compared with those receiving SURV. In view of the high proportion of patients in the SURV group needing SAE, both strategies appear defendable.

Trial Registration  ClinicalTrials.gov Identifier: NCT02021396

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Article Information

Accepted for Publication: May 9, 2020.

Corresponding Author: Catherine Arvieux, MD, PhD, Department of General and Digestive Surgery, CHU Grenoble Alpes, CS 10232, 38043 Grenoble Cedex 09, France (carvieux@chu-grenoble.fr).

Published Online: September 16, 2020. doi:10.1001/jamasurg.2020.3672

Author Contributions: Dr Arvieux had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Arvieux, Frandon, David, Lemoine, Bouzat, Bosson, Barbois, Thony.

Acquisition, analysis, or interpretation of data: Arvieux, Frandon, Tidadini, Monnin-Bares, Foote, Dubuisson, Lermite, Douane, Tresallet, Rodiere, Bosson, Vilotitch, Barbois, Thony.

Drafting of the manuscript: Arvieux, Frandon, Vilotitch.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Tidadini, Bosson, Vilotitch.

Obtained funding: Arvieux, Tidadini, Tresallet.

Administrative, technical, or material support: Tidadini, Monnin-Bares, Foote, Lermite, Tresallet, Lemoine, Bosson, Thony.

Supervision: Arvieux, Frandon, David, Bouzat, Bosson, Thony.

Conflict of Interest Disclosures: Dr Arvieux reported receiving grants from the French Ministry of Health, Hospital Clinical Research Program (PHRC) 2012, given to CHU Grenoble Alpes, during the conduct of the study. Dr David reported receiving personal fees from LFB Laboratory outside the submitted work. Dr Rodiere reported receiving grants from the French Ministry of Health, Hospital Clinical Research Program (PHRC) 2012, given to CHU Grenoble Alpes, during the conduct of the study. Dr Bouzat reported receiving grants from LFB Laboratory outside the submitted work. Dr Thony reported receiving grants from the French Ministry of Health, Hospital Clinical Research Program (PHRC) 2012, given to CHU Grenoble Alpes, during the conduct of the study. No other disclosures were reported.

Funding/Support: This study was supported by the French Ministry of Health, Hospital Clinical Research Program (PHRC) 2012.

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

The Splenic Arterial Embolization to Avoid Splenectomy (SPLASH) study group members: University Hospitals (CHU), Grenoble Alpes: Julio Abba, Myriam Coutard, Anne Ego, Julien Guelfi, Nicolas Huet, and Julien Picard; University Hospitals (CHU), Nîmes: Jean-Paul Bergi and Laurent Muller; University Hospitals (CHU), Bordeaux: Matthieu Biais and Yann Lebras; University Hospitals (CHU), Angers: Guillaume Bouhours, Antoine Bouvier, and Catherine Ridereau; University Hospitals (CHU), Lyon Sud: François Cotton, Guillaume Passot, Pierre-Jean Valette, and Eric Voiglio; University Hospitals (CHU), Montpellier: Jonathan Charbit and Françoise Guillon; University Hospitals (CHU), Nantes: Raphael Cinotti and Sylvie Metairie; University Hospitals (CHU), Pitié-Salpêtrière, Paris: Philippe Cluzel and Mathieu Raux; Regional University Hospital (CHRU), Lille, Toulon: Delphine Garrigue, Marc Haberlay, Jean-Robert Nzamushe, and Isabelle Plenier; Army Teaching Hospital (HIA), Sainte-Anne, Toulon: Charles Aarteaga, Tristan Monchal, and Bertrand Prunet; Hospitals (CH), Annecy-Genevois: Charles Daragon, Albrice Levrat, and Jean-Philippe Mestrallet; Hospitals (CH), Valence: Patrice Fernandez, Christophe Henry, and Thomas Martinilli; Army Teaching Hospital (HIA), Percy, Toulon: Jean Louis Daban, Emmanuel Hornez, Eric Meaudre, and Christophe Teriitehau; University Hospitals (CHU), Henri-Mondor, Créteil: Philippe Compagnon, Hassen Hentati, and Hicham Kobeiter; University Hospitals (CHU), Nord Marseille: Irchid Al-naasan, Thierry Bege, Katia Chaumoitre, Marc Leone, and Nathalie Lesavre; and Hospitals (CH), Chambéry: Marie Michoud, Melanie Terebus-loock, and Jean-Marc Thouret.

Disclaimer: This study’s contents are solely the responsibility of the authors.

Meeting Presentation: This paper was presented at the Journees Francophones de Radiologie Diagnostique et Interventionelle; October 14, 2019; Paris, France.

Data Sharing Statement: See Supplement 3.

Additional Contributions: Jean-Francois Timsit, MD, PhD, University Hospital Bichat, assisted with the study design and was not compensated. Helene Sabbah, MSc, Myriam Coutard, MSc, and Marylaure Gavard, MSc, Grenoble Alpes University Hospital (CHU), assisted with regulatory procedures and study safety and were not compensated. Tiphaine Voliot, Medsharing, assisted with development of the electronic case report form and was compensated.

References
1.
Zarzaur  BL , Rozycki  GS .  An update on nonoperative management of the spleen in adults.   Trauma Surg Acute Care Open. 2017;2(1):e000075. doi:10.1136/tsaco-2017-000075 PubMedGoogle Scholar
2.
Requarth  JA , D’Agostino  RB  Jr , Miller  PR .  Nonoperative management of adult blunt splenic injury with and without splenic artery embolotherapy: a meta-analysis.   J Trauma. 2011;71(4):898-903. doi:10.1097/TA.0b013e318227ea50 PubMedGoogle ScholarCrossref
3.
Zarzaur  BL , Croce  MA , Fabian  TC .  Variation in the use of urgent splenectomy after blunt splenic injury in adults.   J Trauma. 2011;71(5):1333-1339. doi:10.1097/TA.0b013e318224d0e4 PubMedGoogle ScholarCrossref
4.
Arnoletti  JP , Karam  J , Brodsky  J .  Early postoperative complications of splenectomy for hematologic disease.   Am J Clin Oncol. 1999;22(2):114-118. doi:10.1097/00000421-199904000-00002 PubMedGoogle ScholarCrossref
5.
Aiolfi  A , Inaba  K , Strumwasser  A ,  et al.  Splenic artery embolization versus splenectomy: analysis for early in-hospital infectious complications and outcomes.   J Trauma Acute Care Surg. 2017;83(3):356-360. doi:10.1097/TA.0000000000001550 PubMedGoogle ScholarCrossref
6.
Demetriades  D , Scalea  TM , Degiannis  E ,  et al.  Blunt splenic trauma: splenectomy increases early infectious complications: a prospective multicenter study.   J Trauma Acute Care Surg. 2012;72(1):229-234. doi:10.1097/TA.0b013e31823fe0b6 PubMedGoogle ScholarCrossref
7.
Altamura  M , Caradonna  L , Amati  L , Pellegrino  NM , Urgesi  G , Miniello  S .  Splenectomy and sepsis: the role of the spleen in the immune-mediated bacterial clearance.   Immunopharmacol Immunotoxicol. 2001;23(2):153-161. doi:10.1081/IPH-100103856 PubMedGoogle ScholarCrossref
8.
Kotsanas  D , Al-Souffi  MH , Waxman  BP , King  RW , Polkinghorne  KR , Woolley  IJ .  Adherence to guidelines for prevention of postsplenectomy sepsis: age and sex are risk factors: a five-year retrospective review.   ANZ J Surg. 2006;76(7):542-547. doi:10.1111/j.1445-2197.2006.03775.x PubMedGoogle ScholarCrossref
9.
Bain  IM , Kirby  RM .  10 Year experience of splenic injury: an increasing place for conservative management after blunt trauma.   Injury. 1998;29(3):177-182. doi:10.1016/S0020-1383(97)00170-8 PubMedGoogle ScholarCrossref
10.
Harbrecht  BG , Zenati  MS , Ochoa  JB ,  et al.  Management of adult blunt splenic injuries: comparison between level I and level II trauma centers.   J Am Coll Surg. 2004;198(2):232-239. doi:10.1016/j.jamcollsurg.2003.10.007 PubMedGoogle ScholarCrossref
11.
Haan  JM , Biffl  W , Knudson  MM ,  et al; Western Trauma Association Multi-Institutional Trials Committee.  Splenic embolization revisited: a multicenter review.   J Trauma. 2004;56(3):542-547. doi:10.1097/01.TA.0000114069.73054.45 PubMedGoogle ScholarCrossref
12.
Liu  PP , Lee  WC , Cheng  YF ,  et al.  Use of splenic artery embolization as an adjunct to nonsurgical management of blunt splenic injury.   J Trauma. 2004;56(4):768-772. doi:10.1097/01.TA.0000129646.14777.ff PubMedGoogle ScholarCrossref
13.
Sabe  AA , Claridge  JA , Rosenblum  DI , Lie  K , Malangoni  MA .  The effects of splenic artery embolization on nonoperative management of blunt splenic injury: a 16-year experience.   J Trauma. 2009;67(3):565-572. doi:10.1097/TA.0b013e3181b17010 PubMedGoogle ScholarCrossref
14.
Gaarder  C , Dormagen  JB , Eken  T ,  et al.  Nonoperative management of splenic injuries: improved results with angioembolization.   J Trauma. 2006;61(1):192-198. doi:10.1097/01.ta.0000223466.62589.d9 PubMedGoogle ScholarCrossref
15.
Capecci  LM , Jeremitsky  E , Smith  RS , Philp  F .  Trauma centers with higher rates of angiography have a lesser incidence of splenectomy in the management of blunt splenic injury.   Surgery. 2015;158(4):1020-1024. doi:10.1016/j.surg.2015.05.025 PubMedGoogle ScholarCrossref
16.
Banerjee  A , Duane  TM , Wilson  SP ,  et al.  Trauma center variation in splenic artery embolization and spleen salvage: a multicenter analysis.   J Trauma Acute Care Surg. 2013;75(1):69-74. doi:10.1097/TA.0b013e3182988b3b PubMedGoogle ScholarCrossref
17.
Schnüriger  B , Inaba  K , Konstantinidis  A , Lustenberger  T , Chan  LS , Demetriades  D .  Outcomes of proximal versus distal splenic artery embolization after trauma: a systematic review and meta-analysis.   J Trauma. 2011;70(1):252-260. doi:10.1097/TA.0b013e3181f2a92e PubMedGoogle ScholarCrossref
18.
Haan  J , Ilahi  ON , Kramer  M , Scalea  TM , Myers  J .  Protocol-driven nonoperative management in patients with blunt splenic trauma and minimal associated injury decreases length of stay.   J Trauma. 2003;55(2):317-321. doi:10.1097/01.ta.0000083336.93868.f7 PubMedGoogle ScholarCrossref
19.
Ekeh  AP , McCarthy  MC , Woods  RJ , Haley  E .  Complications arising from splenic embolization after blunt splenic trauma.   Am J Surg. 2005;189(3):335-339. doi:10.1016/j.amjsurg.2004.11.033 PubMedGoogle ScholarCrossref
20.
Zarzaur  BL , Dunn  JA , Leininger  B ,  et al.  Natural history of splenic vascular abnormalities after blunt injury: a Western Trauma Association multicenter trial.   J Trauma Acute Care Surg. 2017;83(6):999-1005. doi:10.1097/TA.0000000000001597 PubMedGoogle ScholarCrossref
21.
Stassen  NA , Bhullar  I , Cheng  JD ,  et al; Eastern Association for the Surgery of Trauma.  Selective nonoperative management of blunt splenic injury: an Eastern Association for the Surgery of Trauma practice management guideline.   J Trauma Acute Care Surg. 2012;73(5)(suppl 4):S294-S300. doi:10.1097/TA.0b013e3182702afc PubMedGoogle ScholarCrossref
22.
Kozar  RA , Crandall  M , Shanmuganathan  K ,  et al; AAST Patient Assessment Committee.  Organ injury scaling 2018 update: spleen, liver, and kidney.   J Trauma Acute Care Surg. 2018;85(6):1119-1122. doi:10.1097/TA.0000000000002058 PubMedGoogle ScholarCrossref
23.
Smith  SR , Morris  L , Spreadborough  S ,  et al.  Management of blunt splenic injury in a UK major trauma centre and predicting the failure of non-operative management: a retrospective, cross-sectional study.   Eur J Trauma Emerg Surg. 2018;44(3):397-406. doi:10.1007/s00068-017-0807-5 PubMedGoogle ScholarCrossref
24.
Lauerman  MH , Brenner  M , Simpson  N , Shanmuganathan  K , Stein  DM , Scalea  T .  Angioembolization significantly improves vascular injuries in blunt splenic trauma.   Eur J Trauma Emerg Surg. 2019. doi:10.1007/s00068-019-01151-z PubMedGoogle Scholar
25.
Sugg  SL , Gerndt  SJ , Hamilton  BJ , Francis  IR , Taheri  PA , Rodriguez  JL .  Pseudoaneurysms of the intraparenchymal splenic artery after blunt abdominal trauma: a complication of nonoperative therapy and its management.   J Trauma. 1995;39(3):593-595. doi:10.1097/00005373-199509000-00034 PubMedGoogle ScholarCrossref
26.
Coccolini  F , Montori  G , Catena  F ,  et al.  Splenic trauma: WSES classification and guidelines for adult and pediatric patients.   World J Emerg Surg. 2017;12:40. doi:10.1186/s13017-017-0151-4 PubMedGoogle ScholarCrossref
27.
Coccolini  F , Fugazzola  P , Morganti  L ,  et al.  The World Society of Emergency Surgery (WSES) spleen trauma classification: a useful tool in the management of splenic trauma.   World J Emerg Surg. 2019;14:30. doi:10.1186/s13017-019-0246-1 PubMedGoogle ScholarCrossref
28.
David  JS , Lambert  A , Bouzat  P ,  et al.  Fibrinolytic shutdown diagnosed with rotational thromboelastometry represents a moderate form of coagulopathy associated with transfusion requirement and mortality: a retrospective analysis.   Eur J Anaesthesiol. 2020;37(3):170-179. doi:10.1097/EJA.0000000000001096 PubMedGoogle ScholarCrossref
29.
Stevenson  M , Segui-Gomez  M , Lescohier  I , Di Scala  C , McDonald-Smith  G .  An overview of the injury severity score and the new injury severity score.   Inj Prev. 2001;7(1):10-13. doi:10.1136/ip.7.1.10 PubMedGoogle ScholarCrossref
30.
Lavoie  A , Moore  L , LeSage  N , Liberman  M , Sampalis  JS .  The New Injury Severity Score: a more accurate predictor of in-hospital mortality than the Injury Severity Score.   J Trauma. 2004;56(6):1312-1320. doi:10.1097/01.TA.0000075342.36072.EF PubMedGoogle ScholarCrossref
31.
Olthof  DC , Joosse  P , van der Vlies  CH , de Haan  RJ , Goslings  JC .  Prognostic factors for failure of nonoperative management in adults with blunt splenic injury: a systematic review.   J Trauma Acute Care Surg. 2013;74(2):546-557. doi:10.1097/TA.0b013e31827d5e3a PubMedGoogle ScholarCrossref
32.
Khatsilouskaya  T , Haltmeier  T , Cathomas  M , Eberle  B , Candinas  D , Schnüriger  B .  Thromboembolic prophylaxis with heparin in patients with blunt solid organ injuries undergoing non-operative treatment.   World J Surg. 2017;41(5):1193-1200. doi:10.1007/s00268-016-3820-7 PubMedGoogle ScholarCrossref
33.
Marot  V , Murgier  J , Carrozzo  A ,  et al.  Determination of normal KOOS and WOMAC values in a healthy population.   Knee Surg Sports Traumatol Arthrosc. 2019;27(2):541-548. doi:10.1007/s00167-018-5153-6 PubMedGoogle ScholarCrossref
34.
Cochran  WG .  The χ2 test of goodness of fit.   Ann Math Statistics. 1952;23(3):315–345. doi:10.1214/aoms/1177729380 Google ScholarCrossref
35.
Gamblin  TC , Wall  CE  Jr , Royer  GM , Dalton  ML , Ashley  DW .  Delayed splenic rupture: case reports and review of the literature.   J Trauma. 2005;59(5):1231-1234. doi:10.1097/01.ta.0000197270.25280.7c PubMedGoogle ScholarCrossref
36.
Bessoud  B , Duchosal  MA , Siegrist  CA ,  et al.  Proximal splenic artery embolization for blunt splenic injury: clinical, immunologic, and ultrasound-Doppler follow-up.   J Trauma. 2007;62(6):1481-1486. doi:10.1097/TA.0b013e318047dfb8 PubMedGoogle ScholarCrossref
37.
Margari  S , Garozzo Velloni  F , Tonolini  M ,  et al.  Emergency CT for assessment and management of blunt traumatic splenic injuries at a level 1 trauma center: 13-year study.   Emerg Radiol. 2018;25(5):489-497. doi:10.1007/s10140-018-1607-x PubMedGoogle ScholarCrossref
38.
Harmon  L , Bilow  R , Shanmuganathan  K ,  et al.  Delayed splenic hemorrhage: myth or mystery? a Western Trauma Association multicenter study.   Am J Surg. 2019;218(3):579-583. doi:10.1016/j.amjsurg.2019.06.025 PubMedGoogle ScholarCrossref
39.
Adibi  A , Ferasat  F , Baradaran Mahdavi  MM , Kazemi  K , Sadeghian  S .  Assessment of blunt splenic trauma: which imaging scoring system is superior?   J Res Med Sci. 2018;23:29. doi:10.4103/jrms.JRMS_875_17 PubMedGoogle ScholarCrossref
40.
Crooker  KG , Howard  JM , Alvarado  AR ,  et al.  Splenic embolization after trauma: an opportunity to improve best immunization practices.   J Surg Res. 2018;232:293-297. doi:10.1016/j.jss.2018.06.036 PubMedGoogle ScholarCrossref
41.
Quencer  KB , Smith  TA .  Review of proximal splenic artery embolization in blunt abdominal trauma.   CVIR Endovasc. 2019;2(1):11. doi:10.1186/s42155-019-0055-3 PubMedGoogle ScholarCrossref
42.
Frandon  J , Rodière  M , Arvieux  C ,  et al.  Blunt splenic injury: outcomes of proximal versus distal and combined splenic artery embolization.   Diagn Interv Imaging. 2014;95(9):825-831. doi:10.1016/j.diii.2014.03.009 PubMedGoogle ScholarCrossref
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
Close
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close