Highlights from AAST - splenic injury and embolization

This paper states that angio and embolization may be necessary in severe splenic injury, even in the absence of a blush on CT.

AT FIRST BLUSH: ABSENCE OF CT CONTRAST EXTRAVASATION IN GRADE IV-V ADULT BLUNT SPLENIC TRAUMA SHOULD NOT PRECLUDE ANGIOEMBOLIZATION Indermeet Bhullar, Eric Frykberg*, M.D., Joseph J. Tepas, III*, M.D., Daniel Siragusa, Andrew J. Kerwin*, M.D., University of Florida, Jacksonville Invited Discussant: Andrew Peitzman Introduction: In order to clarify the role, indications and outcomes for angioembolization (AE) of nonoperatively managed (NOM) splenic trauma, the implications of absent contrast blush (CB) on computed tomography (CT) of high grade (IV-V) blunt splenic trauma (BST) in adults was analyzed. Methods: All BST patients presenting at a single institution from July 2000 to December 2011 were retrospectively reviewed. Grade of injury (AAST scale), CB on initial CT, numbers nonoperatively managed and undergoing AE, and failures of NOM were analyzed. Statistical analysis was performed using Chi Square. Results: Of 1,056 total BST patients, 864 (82%) underwent CT evaluation and 556 (64%) were hemodynamically stable and eligible for NOM. 95 NOM patients (17%) had CB. AE was done in 88 of these, with angiographic extravasation found in 86 (97.7%), and 3 of these 88 (3.4%) failed NOM. The remaining 7 CB were observed without AE, of which 5 (71.4%) failed NOM (p=0.0004). 53 of all 556 NOM patients (9.5%) had high grade injuries without CB; 19 of these (36%) underwent AE, 17 (89.4%) had angiographic extravasation, and there were no NOM failures in this group. The other 34 high grade injuries without CB or AE had 32% failure of NOM (p=0.03). Conclusion: The strong correlation of CB with active bleeding on angiogram mandates AE for CB in all BST undergoing NOM. However, the absence of CB in high grade BST does not reliably exclude active bleeding. This may be the reason for the high reported failure rates of NOM in high grade BST, as AE is not typically performed in the absence of CB. These data suggest that all hemodynamically stable high grade BST in adults should undergo AE regardless of CB in order to optimize the success and safety of NOM.