NONOPERATIVE SALVAGE OF COMPUTED TOMOGRAPHY-DIAGNOSED SPLENIC INJURIES - UTILIZATION OF ANGIOGRAPHY FOR TRIAGE AND EMBOLIZATION FOR HEMOSTASIS

Objectives: The aims of this study were to determine if angiographic f indings can be used to predict successful nonoperative therapy of sple nic injury and to determine if coil embolization of the proximal splen ic artery provides effective hemostasis. Methods: Splenic injuries det ected by diagnostic imaging between 1981 and 1993 at a level I trauma center were prospectively collected and retrospectively reviewed after management by protocol that used diagnostic peritoneal lavage, comput ed tomography (CT), angiography, transcatheter embolization, and lapar otomy. Computed tomography was performed initially or after positive d iagnostic peritoneal lavage, Angiography was performed urgently in sta bilized patients with CT-diagnosed splenic injuries. Patients without angiographic extravasation were treated by bed rest alone; those with angiographic extravasation underwent coil embolization of the proximal splenic artery followed by bed rest. Results: Patients (172) with blu nt splenic injury are the subject of this study. Twenty-two patients w ere initially managed operatively because of associated injuries or di sease (11 patients) or because the surgeon was unwilling to attempt no noperative therapy (11 patients) and underwent splenectomy (17 patient s) or splenorrhaphy (5 patients), One hundred fifty of 172 consecutive patients (87%) with CT-diagnosed splenic injury were stable enough to be considered for nonoperative management, Eighty-seven of the 90 pat ients managed by bed rest alone, and 56 of 60 patients treated by sple nic artery occlusion and bed rest had a successful outcome, Overall sp lenic salvage was 88%. It was 97% among those managed nonoperatively, including 61 grade III and grade IV splenic injuries, Sixty percent of patients received no blood transfusions, Three of 150 patients treate d nonoperatively underwent delayed splenectomy for infarction (one pat ient) or splenic infection (two patients). Conclusions: (1) Hemodynami cally stable patients with splenic injuries of all grades and no other indications for laparotomy can often be managed nonoperatively, espec ially when the injury is further characterized by arteriography, (2) T he absence of contrast extravasation on splenic arteriography seems to be a reliable predictor of successful nonoperative management, We sug gest its use to triage CT-diagnosed splenic injuries to bed rest or in tervention, (3) Coil embolization of the proximal splenic artery is an effective method of hemostasis in stabilized patients with splenic in jury, It expands the number of patients who can be managed nonoperativ ely.