A Pseudo-Dilemma: Are We Over-Diagnosing and Over-Treating Traumatic Splenic Intraparenchymal Pseudoaneurysms?

Abstract

Introduction Splenic embolization for traumatic vascular abnormalities in stable patients is a common practice. We hypothesize that modern contrast-enhanced CT over diagnoses post-traumatic splenic vascular lesions such as intraparenchymal pseudoaneurysms (PSA) that may not require embolization. Methods We reviewed the experience at our high-volume center with endovascular management of blunt splenic injuries from Jan 2016-Dec 2021. Multidisciplinary review was used to compared initial CT findings to subsequent angiography, analyzing management and outcomes of identified vascular lesions. Results Of 853 splenic injuries managed overall during the study period, 255 (29.9%) underwent angiography of the spleen at any point during hospitalization. Vascular lesions were identified on 58% of initial CTs; extravasation (12.2%) and PSA (51.0%). Angiography was performed a mean of 22 hours after admission, with 38% done within 6 hours. Embolization was performed for 90.5% (231) of patients. Among the 130 patients with PSA on initial CT, 36 (27.7%) had no visible lesion on subsequent angiogram. From the 125 individuals who did not have a PSA identified on their initial CT, 67 (54%) had a PSA seen on subsequent angiography. On post-embolization CT at 48-72 hours, persistently perfused splenic PSAs were seen in 41.0% (48/117) of those with and 22.2% (2/9) without embolization. Only one of 24 (4.1%) patients with PSA on angiography observed without embolization required delayed splenectomy, whereas 6.9% (16/231) in the embolized group had splenectomy at a mean of 5.5 + 4 days after admission. Conclusion There is a high rate of discordance between CT and angiographic identification of splenic PSAs. Even when identified at angiogram and embolized, close to half will remain perfused on follow-up imaging. These findings question the use of routine angioembolization for all splenic PSAs. Level of Evidence IV Study Type Therapeutic/care management

Response to the letter to the editor for our article entitled “A pseudo-dilemma: Are we over-diagnosing and over-treating traumatic splenic intraparenchymal pseudoaneurysms?”

“…W e greatly appreciate Dr. Hoffer's perspective in his letter to the editor regarding our article on management of splenic pseudoaneurysms (PSAs) after blunt injury. 1 He points out that lack of visualization of a splenic PSA on angiography does not indicate the absence of injury and persistent visualization of splenic PSA on computed tomography angiography 3days after splenic angioembolization (SAE) is not an indication of failure of embolization. Hence, he argues, these findings cannot be used to make the case that we are overtreating splenic PSAs.…”

“…2,5 The authors report a high success rate for nonoperative management, with a 6.7% delayed splenectomy rate (2.6% hemorrhage related, 0.9% due to enlargement of PSA) -which was less than half that expected based on historic controls with the reported injury grade. 1,2,5 In a population where 90.5% of patients had proximal splenic artery embolization, it is difficult to conclude that AE was not beneficial for the population as a whole or for the 77% that had PSA identified. 1 The case for overdiagnosis or overtreatment has not been made.…”

“…1,2,5 In a population where 90.5% of patients had proximal splenic artery embolization, it is difficult to conclude that AE was not beneficial for the population as a whole or for the 77% that had PSA identified. 1 The case for overdiagnosis or overtreatment has not been made. The findings of inconstant imaging evidence of PSA and persistent opacification after SAE do not support more restrictive indications for SAE.…”

What is the optimal management for pseudoaneurysm in splenic injury?

“…With respect to the first question, it is reported that the authors' group at the Shock Trauma Center typically performs proximal or midsplenic artery embolization using coils or plug devices to prevent post-embolization splenic complications. 1 Interestingly, a systematic review with meta-analysis demonstrated that, compared with proximal SAE, distal SAE had a lower rate of splenic infarction and infectious complications requiring delayed splenectomy. 2 At our institution (Maebashi Red Cross Hospital in Maebashi, Japan), we primarily perform selective distal SAE with gelatin particles.…”

“…for their thoughtful review of our article on management of splenic pseudoaneurysms (PSAs) after blunt trauma. 1 They have highlighted several important questions that we would like to address. First and foremost is the question of optimal approach to splenic angioembolization (SAE) and whether a proximal, selective, or superselective approach will be more effective at preventing the progression of a splenic injury while also reducing the chance of splenic ischemia-associated…”