一个似是而非的困境：我们是否过度诊断和过度治疗创伤性脾实质内假性动脉瘤？
A pseudo-dilemma: Are we over-diagnosing and over-treating traumatic splenic intraparenchymal pseudoaneurysms?
机构信息
From the Department of Surgery (S.R.), Virginia Commonwealth University, Richmond, VA; R Adams Cowley Shock Trauma Center (M.N.H., N.K.D., K.L.H., R.K., J.S.M., J.S.R., D.V.F., R.A.K., T.M.S.), University of Maryland Medical System, Baltimore, Maryland; Department of Surgery (A.K.), Stanford University, Stanford, California; and Department of Surgery (J.J.DB.), University of Texas at Austin, Austin, Texas.
出版信息
J Trauma Acute Care Surg. 2024 Feb 1;96(2):313-318. doi: 10.1097/TA.0000000000004117. Epub 2023 Aug 21.
BACKGROUND
Splenic embolization for traumatic vascular abnormalities in stable patients is a common practice. We hypothesize that modern contrast-enhanced computed tomography (CT) over diagnoses posttraumatic 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 January 2016 to December 2021. Multidisciplinary review was used to compared initial CT findings with 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 postembolization CT at 48 hours to 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
Therapeutic/Care Management; Level IV.
背景
在稳定患者中，脾栓塞治疗创伤性血管异常是一种常见做法。我们假设，现代对比增强计算机断层扫描（CT）过度诊断了创伤性脾血管病变，例如可能不需要栓塞的实质内假性动脉瘤（PSA）。
方法
我们回顾了 2016 年 1 月至 2021 年 12 月期间我们高容量中心对钝性脾损伤的血管内治疗经验。多学科回顾用于比较初始 CT 发现与随后的血管造影，分析确定的血管病变的处理和结果。
结果
在研究期间，853 例脾损伤患者中，255 例（29.9%）在住院期间的任何时候都进行了脾血管造影。58%的初始 CT 发现血管病变；漏出（12.2%）和 PSA（51.0%）。血管造影平均在入院后 22 小时进行，其中 38%在 6 小时内进行。对 90.5%（231 例）的患者进行了栓塞治疗。在初始 CT 发现 PSA 的 130 例患者中，36 例（27.7%）在随后的血管造影中未见明显病变。在 125 例初始 CT 未发现 PSA 的患者中，67 例（54%）在随后的血管造影中发现 PSA。在栓塞后 48 至 72 小时的 CT 上，41.0%（48/117）有 PSA 的患者和 22.2%（2/9）无栓塞的患者仍可见脾 PSA 灌注。在观察未栓塞的 PSA 的 24 例患者中，只有 1 例（4.1%）需要延迟脾切除术，而栓塞组中 6.9%（16/231）的患者在入院后平均 5.5±4 天进行脾切除术。
结论
CT 与脾 PSA 的血管造影识别之间存在很高的不一致率。即使在血管造影中发现并栓塞，近一半的患者在后续影像学检查中仍可见灌注。这些发现质疑对所有脾 PSA 常规进行血管内栓塞治疗的合理性。
证据水平
治疗/护理管理；IV 级。
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