Presentation on theme: "Jamaica Hospital Trauma Conference July 21st, 2014 Greg Eckenrode"— Presentation transcript:
1Jamaica Hospital Trauma Conference July 21st, 2014 Greg Eckenrode Role of Arterial Embolization in Non-Operative Management of Splenic InjuriesJamaica Hospital Trauma ConferenceJuly 21st, 2014Greg EckenrodeADVANCING SCIENCE, ENHANCING LIFE
2Management of Traumatic Spleen Injuries Historically, nearly all splenic injuries were managed operativelyNon-operative management developed in the pediatic population in the late 1960sIncreasing prevalence in adult population since the 1980sCurrently 50-70% of splenic injuriesStein DM, Scalea TM J Intensive Care Med. 2006;21(5):296.
3Operative ManagementHemodynamically unstable patients with evidence of abdominal bleedingPositive FAST or DPA/DPLPatients requiring abdominal exploration for other injuriesIntraperitoneal free airSigns of peritonitis
4Operative Management Hemodynamically stable patients CT findings of contrast extravasation or vascular blushHigh grade injuries (generally IV-V)Age > 55Unable to safely observe patient
5Conventional Non-Operative Management Admit to monitored care settingBed rest, NPOSerial Hgb/Hct every 6 hours for 24 hoursFrequent vital signs, serial abdominal exams
6Splenic Angiography and Embolization First applied to traumatic splenic injuries in 1995Multiple techniquesDistal selectiveProximalBothIntended to improve success of non-operative management
7Clinical QuestionsDoes splenic artery angiography and embolization improve non-operative management outcomes?Which patients should undergo angiography and embolization?
8Western Trauma Association 4 L1 trauma centers in the United States155 patients who underwent angiography and embolization for pseudoaneurysm, active bleeding on CT, significant hemopertoneum, and high grade injuriesCompared against the results of the Eastern Trauma Association study, which used conventional observation
9Comparison ResultsHaan, et al; J Trauma Mar;56(3):542-7.
10Ullevaal University Hospital: 2006 In 2002, implemented policy that all patients with splenic injury Grades III-V or ongoing bleeding underwent arterial embolizationCompared to all splenic injuries from , when arterial embolization was no performed at the hospitalGaardner, C, et al; J Trauma Jul;61(1):192-8
13Multicenter Variation: 2010 Compared 4 L1 trauma centers with variation in rates of splenic artery embolization in non-operative managementRates ranged from 19% to 1%Compared rates of splenic salvage and non-operative failureBannerjee, et al; J Trauma Acute Care Surg Jul;75(1):69-74
14Population Comparison Bannerjee, et al; J Trauma Acute Care Surg Jul;75(1):69-74
15Management Comparison Bannerjee, et al; J Trauma Acute Care Surg Jul;75(1):69-74
16Splenic Salvage RateBannerjee, et al; J Trauma Acute Care Surg Jul;75(1):69-74
17Wake Forest - 2014 Single site L1 Trauma Center Prior to 2010, angiography and embolization performed for CT contrast blushStarting in 2010, prospectively performed angiography and embolization on all Grade III-IV splenic injuriesCompared non-operative failure rates against recent historical controls from periodMiller, et al; J Am Coll Surg Apr;218(4):644-8
18Study Group Comparison Miller, et al; J Am Coll Surg Apr;218(4):644-8
19Study Results 2010-2012: Non-operative failure rate of 5% Failure rate of 25% in 16 protocol deviations (p=0.02): Non-operative failure rate of 15% (p=0.04)
20ConclusionsIn historical comparisons, patients with splenic injuries who are candidates for non-operative management have better outcomes when SAE is utilizedCenters which perform a higher rate of SAE have higher rates of spelic salvage and lower rates of non-operative management failure
21ConclusionsCenters which implement a standard protocol mandating SAE for non-operative splenic injuries experience decreased rates of of non-operative failure and increased rates of splenic salvage
22Future DirectionsNo prospective, head-to-head randomized clinical trial of SAE in non-operative splenic injuriesLimited data with respect to cost effectiveness
23Splenic Injury Grading Grade I:Hematoma: Subcapsular, < 10% of surface areaLaceration: Capsular tear < 1 cm depthGrade IIHematoma: Subcapsular, % of surface areaLaceration: Capsular tear cm depth not involving trebecular vessel
24Splenic Injury Grading Grade IIIHematomaSubcapsular, > 50% of surface areaSubcapsular, expandingRuptured subcapsular or parenchymalIntraparenchymal > 5cmLaceration> 3cm depthInvolving trabecular vessel
25Splenic Injury Grading Grade IVLaceration: segmental or hilar vessels with > 25% devascularizationGrade VHematoma: shattered spleenLaceration: total devascularization