Splenic Trauma Where to Occlude and with what

Transcription

1 Splenic Trauma Where to Occlude and with what Trauma session, Thurday May 5, 2016 Pierre GOFFETTE St-Luc University Hospital Brussels

2 Pierre Goffette, M.D. Consultant/Advisory Board: Covidien (Neuro) and Terumo

3 EAST Practice management guidelines 2012 J Trauma 2012, 73: S NOM of BSI: Treatment modality of choice Success 86-97% (Raikhlin A et al. Can J Surg 2008) Hemodynamiccally stable/stabilized patients Irrespective to the grade of injury Angio-embolization: important adjunct to NOM of splenic #

4 Spleen # New CT-based grading system 2006 To predict the need for intervention Devascularization/laceration involving 50% or more of the splenic parenchyma CB > 1 cm in diameter active extravasation pseudoaneurysm AAST 1994 Large Hemoperitoneum (Diffuse, 3 or more areas) Sensitivity 100% Specificity 88% Accuracy 93% Marmery H, AJR 2007, 189: Thompson BE, J Trauma 2006, 60:

5 Splenic embolization in trauma 3 main indications in stable/stabilized Pts A. Active bleeding on CT B. Vascular injury (false-aneurysm, AVF) C. AAST Grade III-V injury to prevent rebleeding and secondary rupture (Grade IV-V for Miller, J Am Coll Surg 2014) Situation A-B: Focal lesion with normal parenchyma in the vincinity Situation C: Multiple/deep lesions involving multiples branches

6 Level of embolization? No Consensus Proximally in main splenic artery Distally and selectively Combination of both techniques High grade + bleedings Large hemoperitoneum + bleedings

7 Proximal SAE: Rationale Drop of intra-splenic arterial pressure (47% Bessoud) allowing spontaneous thrombosis of injured vessels Splenic perfusion preseved by collateral flow from left gastric branches gastroepiploic arcades pancreatic posterior arcades Theorical increased risk of secondary bleeding because arterial injuries left untreated Limited risk of major splenic infarction (minor in 63%) - No abscess requiring intervention

8 Proximal splenic artery occlusion Indications Diffuse bleeding High grade injuries Tortuous vessels Unstable patients Technics Optimize collateral flow: embo Distal to dorsal pancreatic art. Proximal to main Pancreatica Magna Balloon occlusion test Variability of pressure drop (collat.) (Requarth, J trauma 2010) Coils versus Plugs

9 Proximal splenic artery occlusion High flow vessel: Risk of Embo agent migration MacroCoils Nester,Tornado (Cook) Scaffold technique Ancor technique Detachable 2D/3D coils Interlock (Boston) Concerto (Covidien) Azur (Terumo) framing, hydrogel Retracta (Cook) Plug (AVP II, AVP IV) Straight segment 20-40% oversizing Additional coils, gelfoam

10 24-yr old male, road-traffic accident Grade III splenic #, large hemoperitoneum Blunt trauma in 14 Pts AVP 4 / 7mm (occl in5 min) (Wildus et al. JVIR 2008, 19: ) Proximal splenic art. embo with AVP I (8-12 mm) 5-6 F guiding catheter Occlusion in 10 min. Additional coils in 3 Pts 2 subsequent splenectomy (instability, false aneurysm)

11 NGE: 8Pts, Grade IV(4x), V(4x) 3 proximal, 5 combined embo AVP 4, 5fr catheter, upsizing 30% Time to occlusion: 4,5 min (2,1-10) Delayed arterial patency 100% 4 mo fup: spleen salvage 100% JVIR 2012, 27:

12 Adavantages of AVP for proximal SAE Precise occlusion Delivery through diagnostic catheter (AVP 4) Retrievable and repositionable Quick vascular occlusion <10 min No risk of device migration Prevent migration of additional coils if needed Minimal Artifact on CT, no recanalization Less radiation Wildus DM, JVIR 2008, 19: Zhu X, CVIR 2011, 34: Ng E, JVIR 2012, 27:

13 Distal splenic artery embolization Selective embolization (multiple sites in Gr IV/V) Sometimes tricky in cases of unstable hemodynamic condition BUT Does not reduces arterial pressure Bleeding vessels overloocked because spasm or mass effect by hematoma.delayed rebleeding More or less extended infarction in most cases Denys A, GEST May2011, Paris

14 Gr III BSI + active bleeding + false-aneurysm 3 µnester coils 3mm

15 Distal splenic artery embolization Indications Focal bleeding Low/high grade # Straight forward access Stable patients Technics Coaxial guiding/µkt As selective as possible µcoils, glue, gelfoam slurry PVA for multiple subcapsular bleedings (?)

16 Stable polytraumatized 43 year male (motocycle crash) Glue embolization Day 6 Control CT

17 Gr V BSI + Large Hemopritoneum Distal + Proximal SAE

18 Embolization technique: success rate Haan J, J Trauma 2005, 58: Nb of Pts CT grade Failure% Re-embo Infarct% Main coil Selective distal Combined Frandon J, Diag and intervent imaging 2014, 95: Nb of Pts CT grade Failure% Re-embo Infarct% Main coil na 6 Selective distal na 9 Combined na 0

19 Outcome of Proximal versus Distal Splenic Artery Embolization after splenic trauma Systematic Review and Meta-Analysis (479 Pts -15 series) 15/147 studies met criteria for meta-analysis: injury grade, indication for SAE, level of SAE, detailed complications All retrospective n= 497 pts Schnüriger B et al. J Trauma 2011, 70,1:252-60

20 Outcome of Proximal versus Distal Splenic Artery Embolization Systematic Review and Meta-Analysis (479 Pts -15 series) Schnüriger B et al. J Trauma 2011, 70,1:252-60

21 J Trauma 2011, 70,1:252-60

22 What is the best technique? Proximal (n=107) Distal (n=63) P value Major rebleeding 4.7% 6.3% NS Major infarction 0% 1.6% NS Major infection 1.9% 0% NS Minor rebleeding 2.2% 4.2% NS Minor infarction 0.8-4% 13-19% S Both techniques: equivalent major infarction and infection rates Minor infarction (no splenectomy): distal >> proximal embo clinical relevance questionnable! Schnuriger B et al. J Trauma 2011, 70,1: Denys A, GEST May 2011, Paris

23 Splenic Immune function after SAE Is it a concern? Lausanne experience (Bessoud, J Trauma 2007, 62:1481-6) Thrombocytes: 312 +/- 75 G/L AbPneu T19F/T14F 20% Low Ab values against pneumocoque Similar to overall population No need for antiaggregative treatment No need for standardized vaccination

24 SAE should reduce immunological complication of spleen # Distal embolization may maintain better function

25 Injury 2016, 47: studies (both adults and children) NO OPSS reported (vaccination??) All but 2 studies: preserved splenic function Lack of single parameter or test to demonstrate preserved splenic function

26 Take Home points Proximal or Distal or both SAE after BSI?? Only minor differences Physician expertise High-grade # & active bleeding: Combined techniques Plug are promising alternative to coil Splenic function not altered RcT still needed