Overview of Nonoperative Blunt Splenic Injury Management with Associated Splenic Artery Pseudoaneurysm

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1 Overview of Nonoperative Blunt Splenic Injury Management with Associated Splenic Artery Pseudoaneurysm CHET A. MORRISON, M.D., F.C.C.M., BRIAN W. GROSS, B.S., MATTHEW KAUFFMAN, B.S., KATELYN J. RITTENHOUSE, B.S., FREDERICK B. ROGERS, M.D., M.S. From the Trauma Services, Lancaster General Health, Lancaster, Pennsylvania The delayed development of splenic artery pseudoaneurysm (SAP) can complicate the nonoperative management of splenic injuries. We sought to determine the utility of repeat imaging in diagnosing SAP in patients managed nonoperatively without angioembolization. We hypothesized that a significant rate of SAPs would be found in this population on repeat imaging. Patients undergoing nonoperative splenic injury management from January 2011 to June 2015 were queried from the trauma registry. Rates of repeat imaging, angioembolization, readmission, and SAP development were analyzed. Further, subanalyses investigating the incidence of SAP in patients managed nonoperatively without angioembolization were conducted. A total of 133 patients met inclusion criteria. Repeat imaging rate was 40 per cent, angioembolization rate was 26 per cent, and readmission rate was 6 per cent. Within the study population, nine SAPs were found (8/9 in patients with splenic injury grade III). Of these nine SAPs, three (33%) were identified on initial scans and embolized, whereas six (67%) were found on repeat imaging in patients not initially receiving angioembolization. Splenic injuries are typically managed nonoperatively without serious complications. Our results suggest patients with splenic injuries grade III managed nonoperatively without angioembolization should have repeat imaging within 48 hours to rule out the possibility of SAP. T HE SPLEEN IS the most frequently injured organ in blunt abdominal trauma, 1 and has historically been treated by splenectomy or splenorrhaphy, although recently nonoperative management of splenic trauma has become the accepted approach in hemodynamically stable patients. 2 There is little controversy in the principle that unstable patients with splenic injury merit operative intervention. 3 Management becomes more unclear in the stable patient with splenic injuries, particularly high grade ones, given the evolving role of angiography and embolization, and the increasing experience gained in these techniques. 4 6 Furthermore, splenic injuries are largely diagnosed on the basis of CT scanning with contrast infusion which gives an accurate picture of the spleen at the time of scanning, but does not necessarily predict how the injury will evolve with time. 7 Presented as a QuickShot presentation at the 10th Annual Academic Surgical Congress in Las Vegas, NV, February 3 5, Address correspondence and reprint requests to Frederick B. Rogers, M.D., M.S., Trauma, Lancaster General Hospital, 555 North Duke Street, Lancaster, PA frogers2@lghealth.org. Study design, data analysis, data interpretation, and manuscript preparation by CAM. Study design, data collection, data analysis, data interpretation, and manuscript preparation by BWG. Study design, data collection, and manuscript preparation by MK and KJR. Study design, data interpretation, and editorial oversight by FBR. The Eastern Association for the Surgery of Trauma recently published updated guidelines for the nonoperative management of splenic injuries. 8 Despite an extensive literature review, they were unable to provide firm recommendations for the necessity of repeated imaging, either inhospital or posthospitalization, and specifically cited this as an area requiring further investigation. A recent attempt to achieve consensus on this point by the use of Delphi methods failed, as no consensus was achieved in the use of routine inhospital repeat imaging, with only 46 per cent of experts recommending this. 9 There have, however, been recent reports documenting a significant rate of splenic artery pseudoaneurysm (SAP) in patients who were routinely reimaged. 10, 11 Thus, the value of repeated imaging remains unresolved as the desire to avoid delayed splenic hemorrhage must be weighed against radiation exposure and the cost of scanning on traumatically injured patients. 12, 13 Despite the absence of direct evidence, in 2014 our institution began routinely rescanning patients with splenic injuries above grade III 48 to 72 hours postinjury. Our practice calls for the angioembolization of splenic pseudoaneurysms or active extravasation, but does not mandate intervention for patients without 554

2 No. 6 BLUNT SPLENIC INJURY MANAGEMENT AND PSEUDOANEURYSM? Morrison et al. 555 these findings on repeat CT scan. The aim of the present study was to retrospectively review splenic injury patients managed nonoperatively at our mature trauma center to determine whether repeat imaging of the stable trauma patient proved useful in this era of radiation concern and cost-consciousness. It was hypothesized that a significant rate of pseudoaneurysms would be found in nonoperative patients managed without angioembolization repeat imaging. Methods After review and approval by the Institutional Review Board of Lancaster General Health, the trauma registry of the only Level II trauma center in Lancaster, Pennsylvania, was retrospectively queried for all patients undergoing nonoperative blunt splenic injury management from January 2011 to June Patients undergoing operative splenic injury management (splenectomy/splenorrhaphy) and/or presenting with splenic injuries resulting from penetrating trauma were excluded from analysis. Nonoperative treatment was defined as splenic injury management involving observation and/or angioembolization. Collected variables included age, gender, Injury Severity Score (ISS), admission systolic blood pressure, splenic injury grade (I V), repeat imaging, angioembolization, readmission, and presence of SAP. Splenic injuries were classified using American Association for the Surgery of Trauma guidelines by attending radiologist and/or senior trauma surgeon. Patients readmitted for other complications unrelated to their splenic injuries were not considered readmissions for this study. Continuous variables were represented as means and standard deviations and categorical variablesascountsandpercentages. To investigate rates of SAP development, the total study population was separated into observation and angioembolization subgroups. Categorizations were determined based on the patient s initial treatment approach, meaning a patient initially managed with observation who subsequently underwent angioembolization would be assigned to the observation subgroup. Following this division, rates of SAP, repeat imaging, and readmission were analyzed within each subgroup to evaluate trends in nonoperatively managed patients, particularly those in the observation subgroup who did not undergo angioembolization. To determine the impact of splenic injury severity on rates of repeat imaging, readmission, and SAP development, subanalyses evaluating these variables within splenic injury grade categories (minor: grade I II; moderate: grade III; and Severe: grade IV V) were conducted. Additionally, to determine the utility of repeat imaging in the diagnosis of SAP, a query of individual medical records was conducted to determine whether the SAPs found in this study were identified on initial or repeat scan. Unadjusted odds ratios were calculated using regression analysis for all demographic and injury severity variables analyzed within this study to determine whether any significant predictors of pseudoaneurysm development could be identified in patients managed nonoperatively without angioembolization. Statistical significance was defined as P < Results A total of 178 patients presented with splenic injuries fromjanuary2011tojune2015,ofwhich41patients (23%) underwent operative intervention and 4 (2%) sustained penetrating injury causing them to be excluded from analysis. Of the remaining 133 patients comprising the total nonoperative study population, 34 (26%) were initially managed with angioembolization and 99 (74%) with observation only. Although the use of angioembolization was at the discretion of the attending trauma surgeon, the majority of patients who underwent embolization presented with a splenic injury grade $III (32/34, 94%). Additionally, a large percentage of these patients were found to have active extravasation on abdominal CT scan (15/34; 44%). A complete breakdown of nonoperative study population demographics as well as splenic injury grades are presented in Table 1. Within the total study population, nine SAPs were found (7% nonoperative SAP rate). The majority of SAPs occurred in patients with moderate to severe splenic injuries (grade $III: 8/9; 89%). Of the nine SAPs, three (33%) were diagnosed on initial scan and embolized, whereas six (67%) were observed on repeat imaging in patients not initially undergoing angioembolization (6% SAP rate on repeat imaging; Table 2). Of the six SAPs identified on repeat imaging, three were large (>3 cm). All of these large pseudoaneurysms were found in patients with a splenic injury grade of III. Compared with the observation subgroup, patients initially receiving angioembolization presented with significantly higher ISS scores (22.9 ± 10.4 vs 18.5 ± 11.3; P ), and more severe splenic injuries [grade $III: 32/34 (94%) vs 36/99 (36%); P < 0.001]. Within the total nonoperative study population, the repeat imaging rate was 40 per cent (53/133). A total of eight patients were readmitted for splenic injury progression, of which 50 per cent (4/8) were initially managed with angioembolization and 50 per cent with observation only. Of the eight readmitted patients, seven (88%) were rescanned on readmission, one of which was rescanned and proceeded to undergo splenectomy. None of the readmitted patients were found to have SAPs.

3 556 THE AMERICAN SURGEON June 2017 Vol. 83 TABLE 1. Nonoperative Splenic Injury Population Demographics Total Study Population (n 4 133) Number (%) Age Mean: 38.3 ± 22.3 years <18 20 (15.0) (29.3) (26.3) $50 39 (29.3) Gender Female 55 (41.4) Male 78 (58.7) ISS Mean: 19.7 ± 11.2 <12 38 (28.6) (44.4) >25 36 (27.1) Systolic blood pressure Mean: ± 29.9 mm Hg <90 4 (3.01) (54.9) > (42.1) Splenic injury grade I 35 (26.3) II 30 (22.6) III 45 (33.8) IV 21 (15.8) V 2 (1.50) Repeat imaging Yes 53 (39.9) No 80 (60.2) Readmission Yes 8 (6.02) No 125 (94.0) Angioembolization Yes 34 (25.6) No 99 (74.4) Pseudoaneurysm Yes 9 (6.77) No 124 (93.2) Pseudoaneurysm on repeat scan 6/9 (66.7) Univariate analysis calculating the unadjusted odds ratios of pseudoaneurysm development for patients undergoing nonoperative splenic injury management without angioembolization found no association between age, admission systolic blood pressure, or ISS and SAP; however, a trend toward significance was observed for male trauma patients. Additionally, splenic injury grade $III was found to be predictive of PSA development. Discussion Nonoperative management of stable patients with splenic injuries has been the paradigm for some time, particularly since 1995 when Sclafani et al. 14 reported on their results of angiographic diagnosis and management of patients suffering splenic hemorrhage. Since then, the nuances of this paradigm continue to generate considerable research interest, and there is some controversy regarding exactly who gets angiography, repeat imaging, and when they receive it. In an effort to address these issues, the Eastern Association for the Surgery of Trauma issued management guidelines in and updated them in There were 12 topics that the committee felt deserved further study, and one of them was the necessity of repeated imaging, particularly as it has been shown there is much variability in the practice of nonoperative management. 16 Nor is it clear what the evolution of splenic injuries are over time, given the variability of follow-up imaging reported in the literature. Given these circumstances, it is perhaps not surprising that there is the variability that there is. Weinberg, for example, found a rate of 7.1 per cent SAP in a series of 411 patients with splenic injury treated nonoperatively. 17 Davisfoundasimilarrateof 7.7 per cent in 298 patients who had follow-up CT by day two or three in their institution. 18 Muroya found a rate of 15.4 per cent; and his group rescanned patients in one week (actually once per week while they were in the hospital, depending on physician discretion). 10 One might wonder if this was too long an interval to prevent early rebleeding. Perhaps most remarkably, Leeper et al. 11 found a rate of SAP and arterial extravasation in 6 per cent of patients routinely rescanned during a 12-year period, and advocated routine reimaging of patients regardless of splenic injury grade. Our results that document a 7 per cent (9/133) rate of SAP development in nonoperatively managed patients predominantly presenting with high splenic injury grades, are certainly in keeping with these previously reported results, and in our opinion, argue for the routine reimaging of patients with grade III and above splenic injuries managed without embolization. The fact that 67 per cent (6/9) of the SAPs identified in our nonoperative population were found on repeat scan in patients with $grade III splenic injuries not initially embolized, and 50 per cent (3/6) of these SAPs were large (>3 cm), with a high propensity for rebleeding, further supports this recommendation. Although our institution only implemented the practice of routinely rescanning these at-risk patients in 2014, we still reported low rates of failed nonoperative management within our splenic injury population over the January 2011 to June 2015 study period, with only one of our 133 nonoperatively managed patients requiring delayed splenectomy. This finding is consistent with recent results that show low failure rates of nonoperative therapy. 19 Of note, we had eight patients readmitted for nonspecific pain and concern for infection and rebleeding, which suggests that future work that

4 No. 6 BLUNT SPLENIC INJURY MANAGEMENT AND PSEUDOANEURYSM? Morrison et al. 557 TABLE 2. Splenic Injury Characteristics by Grade Categorization Minor (Grade I II) (n 4 65) Moderate (Grade III) (n 4 45) Severe (Grade IV V) (n 4 23) Number Number (%) Repeat imaging (n 4 53) 19 (29.2) 26 (57.8) 8 (34.8) Readmission (n 4 8) 2 (3.07) 3 (6.67) 3 (13.0) Embolization (n 4 34) 2 (3.07) 15 (33.3) 17 (73.9) Pseudoaneurysm (n 4 9) 1 (1.54) 7 (15.6) 1 (4.35) Pseudoaneurysm on Repeat scan (n 4 6/9) 0/1 (0.00) 5/7 (71.4) 1/1 (100.0) attempts to quantify the benefits of nonoperative therapy take readmission rates into account. Frequency and timing of angiography and repeat imaging remains an issue. Not all of our patients who were treated with angiography underwent transcatheter arterial embolization (TAE), although there was an increasing feeling among the practice during the study interval that patients with high-grade injuries should undergo TAE, and of course these patients were not routinely reimaged. This is currently an unsettled issue, although there seems to be emerging evidence that early TAE, particularly for high-grade (grades IV and V) splenic injuries can decrease the need for splenectomy. 20, 21 Clearly, the grade of the splenic injury plays a major role in how these injuries are managed. We noted that we did not routinely reimage our low-grade splenic injuries; this is in part because it had been shown by Haan et al. 22 that follow-up abdominal CT was not necessary in low-grade splenic injury. This has also been found in the pediatric population. 23 There is thus the possibility that small SAPs could have been missed in our patient population, but we do not think this would have measurably impacted the results, particularly since many of these small SAPs would be expected to occlude. 24 It should be quite obvious that the ultimate goal of all this effort to work out the timing of repeat imaging and the place of TAE in patients offered nonoperative management is the prevention of delayed bleeding and subsequent operation. In our series, 41/178 (23%) patients needed operative intervention, which reflects a somewhat conservative approach to the management of splenic trauma, and may explain why our delayed bleeding rate was so low. Left unresolved is the issue of whether every SAP discovered on routine imaging requires angiography, with its expense, radiation exposure, and contrast dye exposure. Muroya found that approximately one half to the SAPs that were found spontaneously occluded, but did not relate that to SAP size. 10 Intuitively, one would expect that a large SAP would be much less likely to occlude and more likely to rebleed, and thus most physicians would treat this by TAE if discovered. This alone might make it worthwhile for repeat imaging to be done, although further research to better define the risk/benefit ratio, taking costs, and radiation exposure into account would be helpful. Limitations of this study include the fact that this was a small single institutional study, and given the numbers, meaningful comparisons with other patient series would be difficult; accordingly, we refrained from making direct comparisons with other patient populations managed a different way, and are cautious about being overconfident in our patient management practice in terms of recommending best practices for management of patients with splenic injuries. Also there may have been possible lack of complete followup, as patients might have presented somewhere else for delayed bleeding episodes, although it is less likely that patients would go elsewhere as we represent the only trauma center in our county, and patients who present at other area hospitals with traumatic injury are routinely rather promptly referred here. It is also possible we may have under or overcalled borderline grade lesions in splenic injury, such that there are patients who might have benefitted from repeat imaging that we missed, or had it despite a low propensity for delayed SAP. We doubt however that this would have significantly changed the incidence of SAP or the need for reimaging. Conclusion In summary, we attempted to assess rates of SAP development in patients with splenic injuries managed nonoperatively who did not have angioembolization. In review of our data, we found a rate of SAP on repeat scan that was not trivial, which we feel supports the early rescanning of patients with splenic injuries $grade III managed nonoperatively without embolization, to avoid delayed hemorrhage. We certainly intend to continue this practice in our facility following the results of this investigation, and believe that future studies can further clarify the role of intervention and timing in the treatment of splenic injury.

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