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Natural history of splenic vascular abnormalities after blunt injury

A Western Trauma Association multicenter trial

Zarzaur, Ben L. MD, MPH; Dunn, Julie A. MD; Leininger, Brian MD; Lauerman, Margaret MD; Shanmuganathan, Kathirkamanthan MD; Kaups, Krista MD; Zamary, Kirellos MD; Hartwell, Jennifer L. MD; Bhakta, Ankur DO; Myers, John MD; Gordy, Stephanie MD; Todd, Samuel R. MD; Claridge, Jeffrey A. MD; Teicher, Erik MD; Sperry, Jason MD; Privette, Alicia MD; Allawi, Ahmed MD; Burlew, Clay Cothren MD; Maung, Adrian A. MD; Davis, Kimberly A. MD, MBA; Cogbill, Thomas MD; Bonne, Stephanie MD; Livingston, David H. MD; Coimbra, Raul MD; Kozar, Rosemary A. MD, PhD

Journal of Trauma and Acute Care Surgery: December 2017 - Volume 83 - Issue 6 - p 999–1005
doi: 10.1097/TA.0000000000001597
WTA 2017 Plenary Papers
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BACKGROUND Following blunt splenic injury, there is conflicting evidence regarding the natural history and appropriate management of patients with vascular injuries of the spleen such as pseudoaneurysms or blushes. The purpose of this study was to describe the current management and outcomes of patients with pseudoaneurysm or blush.

METHODS Data were collected on adult (aged ≥18 years) patients with blunt splenic injury and a splenic vascular injury from 17 trauma centers. Demographic, physiologic, radiographic, and injury characteristics were gathered. Management and outcomes were collected. Univariate and multivariable analyses were used to determine factors associated with splenectomy.

RESULTS Two hundred patients with a vascular abnormality on computed tomography scan were enrolled. Of those, 14.5% were managed with early splenectomy. Of the remaining patients, 59% underwent angiography and embolization (ANGIO), and 26.5% were observed. Of those who underwent ANGIO, 5.9% had a repeat ANGIO, and 6.8% had splenectomy. Of those observed, 9.4% had a delayed ANGIO, and 7.6% underwent splenectomy. There were no statistically significant differences between those observed and those who underwent ANGIO. There were 111 computed tomography scans with splenic vascular injuries available for review by an expert trauma radiologist. The concordance between the original classification of the type of vascular abnormality and the expert radiologist’s interpretation was 56.3%. Based on expert review, the presence of an actively bleeding vascular injury was associated with a 40.9% risk of splenectomy. This was significantly higher than those with a nonbleeding vascular injury.

CONCLUSIONS In this series, the vast majority of patients are managed with ANGIO and usually embolization, whereas splenectomy remains a rare event. However, patients with a bleeding vascular injury of the spleen are at high risk of nonoperative failure, no matter the strategy used for management. This group may warrant closer observation or an alternative management strategy.

LEVEL OF EVIDENCE Prognostic study, level III.

From the Department of Surgery (B.L.Z., J.L.H.), Indiana University School of Medicine, Indianapolis, Indiana; Department of Surgery (J.A.D., B.L.), University of Colorado Health, Loveland, Colorado; Shock Trauma Center (M.L., R.A.K.), University of Maryland School of Medicine, Baltimore, Maryland; Department of Diagnostic Radiology and Nuclear Medicine (K.S.), University of Maryland School of Medicine, Baltimore, Maryland; Department of Surgery (K.K., K.Z.), UCSF Fresno, Fresno, California; Department of Surgery (A.B.), Grant Medical Center, Columbus, Ohio; Department of Surgery (J.M.), University of Texas Health Science Center, San Antonio, San Antonio, Texas; Department of Surgery (S.G., S.R.T.), Baylor College of Medicine, Houston, Texas; Department of Surgery (J.A.C.), Metro Health, Cleveland, Ohio; Department of Surgery (E.T.), INOVA Hospital, Falls Church, Virginia; Department of Surgery (J.S.), University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Surgery (A.P., A.A.), Medical College of South Carolina, Charleston, South Carolina; Department of Surgery (C.C.B.), Denver Health, Denver, Colorado; Department of Surgery (A.A.M., K.A.D.), Yale School of Medicine, New Haven, Connecticut; Department of Surgery (T.C.), Gunderson Health, La Crosse, Wisconsin; Department of Surgery (S.B., D.H.L.), Rutgers New Jersey Medical School, Newark, New Jersey; Department of Surgery (R.C.), University of California San Diego, San Diego, California.

Submitted: February 15, 2017, Accepted: April 24, 2017, Published online: May 31, 2017.

This work was presented in part at the 47th annual meeting of the Western Trauma Association, March 5 to 10, 2017, Snowbird, Utah.

Address for reprints: Ben L. Zarzaur, MD, MPH, Department of Surgery, Indiana University School of Medicine, 702 Rotary Circle, Room 022B, Indianapolis, IN 46204; email: bzarzaur@iupui.edu.

© 2017 Lippincott Williams & Wilkins, Inc.