title: Prospective trial of angiography and embolization for all grade III to V blunt splenic injuries: nonoperative management success rate is significantly improved.
abstract: 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.
  
  
  METHODS
  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.
authors.affiliation: Department of Surgery, Wake Forest University, Winston-Salem, NC. Electronic address: pmiller@wakehealth.edu.
authors.forename: Preston R
authors.initials: PR
authors.lastname: Miller
authors.affiliation: Department of Surgery, Wake Forest University, Winston-Salem, NC.
authors.forename: Michael C
authors.initials: MC
authors.lastname: Chang
authors.affiliation: Department of Surgery, Wake Forest University, Winston-Salem, NC.
authors.forename: J Jason
authors.initials: JJ
authors.lastname: Hoth
authors.affiliation: Department of Surgery, Wake Forest University, Winston-Salem, NC.
authors.forename: Nathan T
authors.initials: NT
authors.lastname: Mowery
authors.affiliation: Department of Surgery, Wake Forest University, Winston-Salem, NC.
authors.forename: Amy N
authors.initials: AN
authors.lastname: Hildreth
authors.affiliation: Department of Surgery, Wake Forest University, Winston-Salem, NC.
authors.forename: R Shayn
authors.initials: RS
authors.lastname: Martin
authors.affiliation: Department of Surgery, Wake Forest University, Winston-Salem, NC.
authors.forename: James H
authors.initials: JH
authors.lastname: Holmes
authors.affiliation: Department of Surgery, Wake Forest University, Winston-Salem, NC.
authors.forename: J Wayne
authors.initials: JW
authors.lastname: Meredith
authors.affiliation: Department of Radiology, Wake Forest University, Winston-Salem, NC.
authors.forename: Jay A
authors.initials: JA
authors.lastname: Requarth
mesh_terms: D000328:Adult; D000792:Angiography; D002985:Clinical Protocols; D004621:Embolization, Therapeutic / Q000379:methods*; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D015641:Radiography, Interventional; D013154:Spleen / Q000098:blood supply / Q000000981:diagnostic imaging / Q000293:injuries*; D013157:Splenic Artery / Q000000981:diagnostic imaging*; D014057:Tomography, X-Ray Computed; D014193:Trauma Centers; D017211:Treatment Failure; D016896:Treatment Outcome; D014949:Wounds, Nonpenetrating / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*