Prospective trial of angiography and embolization for all grade III to V blunt splenic injuries: nonoperative management success rate is significantly improved

J Am Coll Surg. 2014 Apr;218(4):644-8. doi: 10.1016/j.jamcollsurg.2014.01.040. Epub 2014 Jan 28.


Background: Nonoperative management (NOM) of blunt splenic injury is well accepted. Substantial failure rates in higher injury grades remain common, with one large study reporting rates of 19.6%, 33.3%, and 75% for grades III, IV, and V, respectively. Retrospective data show angiography and embolization can increase salvage rates in these severe injuries. We developed a protocol requiring referral of all blunt splenic injuries, grades III to V, without indication for immediate operation for angiography and embolization. We hypothesized that angiography and embolization of high-grade blunt splenic injury would reduce NOM failure rates in this population.

Study design: This was a prospective study at our Level I trauma center as part of a performance-improvement project. Demographics, injury characteristics, and outcomes were compared with historic controls. The protocol required all stable patients with grade III to V splenic injuries be referred for angiography and embolization. In historic controls, referral was based on surgeon preference.

Results: From January 1, 2010 to December 31, 2012, there were 168 patients with grades III to V spleen injuries admitted; NOM was undertaken in 113 (67%) patients. The protocol was followed in 97 patients, with a failure rate of 5%. Failure rate in the 16 protocol deviations was 25% (p = 0.02). Historic controls from January 1, 2007 to December 31, 2009 were compared with the protocol group. One hundred and fifty-three patients with grade III to V injuries were admitted during this period, 80 (52%) patients underwent attempted NOM. Failure rate was significantly higher than for the protocol group (15%, p = 0.04).

Conclusions: Use of a protocol requiring angiography and embolization for all high-grade spleen injuries slated for NOM leads to a significantly decreased failure rate. We recommend angiography and embolization as an adjunct to NOM for all grade III to V splenic injuries.

Publication types

  • Clinical Trial
  • Comparative Study

MeSH terms

  • Adult
  • Angiography
  • Clinical Protocols
  • Embolization, Therapeutic / methods*
  • Female
  • Humans
  • Injury Severity Score
  • Male
  • Middle Aged
  • Prospective Studies
  • Radiography, Interventional*
  • Spleen / blood supply
  • Spleen / diagnostic imaging
  • Spleen / injuries*
  • Splenic Artery / diagnostic imaging*
  • Tomography, X-Ray Computed
  • Trauma Centers
  • Treatment Failure
  • Treatment Outcome
  • Wounds, Nonpenetrating / diagnostic imaging
  • Wounds, Nonpenetrating / mortality
  • Wounds, Nonpenetrating / therapy*