Proximal Splenic Artery Embolization: Strategies for Successful Splenic Salvage in Unstable Trauma

Splenic artery embolization (SAE) in hemodynamically (HD) unstable trauma remains controversial. We demonstrate the efficacy of proximal embolization and optimization strategies including target arterial segment and embolization material selection {1}.

Materials and Methods:

A retrospective study was performed including 182 patients (Table 1 for characteristics), who underwent proximal SAE at a Level 1 trauma center from 9/1/2015 to 9/1/2024. HD unstable defined as pre-intervention systolic pressure < 90 mmHg. Polytrauma was defined by Abbreviated Injury Score >3 of concurrent non-abdominal trauma {2}. Primary endpoints include adverse events (infarction, bleeding), re-intervention, and mortality. Hypothesis testing performed using Student’s t-test, Chi-Squared test, and Analysis of Variance (ANOVA).

Proximal SAE sites: Type I (proximal to dorsal pancreatic arteries [DPA]), Type II (distal to DPA, proximal to great pancreatic artery [GPA]), Type III (distal to GPA) {3}.

Results:

Patients presented with HD instability in 30% (n=55) of cases. Overall mean Injury Severity Score {4} was 30.6 (SD 12). High-risk factors include 83% (n=151) American Association for Surgery of Trauma (AAST) Grade IV-V splenic injury {5}, 66% (n=119) polytrauma, and 31% (n=57) coagulopathy (INR >1.4). Splenic salvage was achieved in 95% (n=172) of patients, 2.7% (n=5) underwent splenectomy, with 2.7% (n=6) mortality (80% non-splenic cause).

Type II proximal SAE (n=136, 75%) was associated with fewer complications (p=0.008), compared to Type I (18%, n=33) and Type III (7%, n=13). Combination proximal and distal embolization (16%, n=30) did not differ in complication rate from proximal SAE alone (p=0.79). 

Embolization with coils (49%, n=89), vascular plug (43%, n=79), or gelfoam + coils/plug (8%, n=14), did not differ significantly in adverse event rates (p=0.18).

Non-visualization of collateral flow to spleen after embolization was the only factor predictive of complication (13.8% vs. 2.7% with visible collaterals, p=0.012), which was associated with Type I and III SAE (p< 0.001).

Conclusion:

Proximal SAE is safe and effective even in unstable polytrauma, with AAST IV-V splenic injury, achieving rates of splenic salvage comparable to previous studies on stable AAST III-IV splenic injury (92-95%) {6}. Outcomes were improved with Type II SAE and the use of detachable coils/plugs to confirm collateral flow prior to deployment.