Imamoto Toshiro, Sawano Makoto, Hirano Takahisa
Department of Emergency Medicine and Critical Care, Saitama Medical Center, Saitama Medical University, Kawagoe, JPN.
Cureus. 2024 Jul 6;16(7):e63986. doi: 10.7759/cureus.63986. eCollection 2024 Jul.
Transcatheter arterial embolization (TAE) has increasingly replaced surgery for treating solid organ injuries, including the spleen, due to its minimally invasive approach. Studies show only a 3% splenectomy rate after TAE, despite a 10% incidence of missed vascular injuries in the American Association for the Surgery of Trauma (AAST) grade III splenic injuries on initial computed tomography (CT) scans. However, there's a lack of high-quality studies recommending specific CT follow-up intervals after non-operative management (NOM) of splenic injuries or guidelines for initiating treatment in cases of pseudoaneurysms or arteriovenous fistulas (AVFs). Here, we discuss the case of a 44-year-old man who presented with a splenic injury due to a motor vehicle accident. The splenic injury was AAST-spleen grade III, but because there was no evidence of extravascular leakage or AVF formation, NOM was selected. CT on the fifth day showed a pseudoaneurysm and an AVF, for which TAE was performed on the seventh day, preserving most of the parenchyma of the spleen with no complications. The indications for NOM as a treatment strategy for splenic injury are expanding, but since the 2018 revision of the AAST grading, the grade changes depending on the presence or absence of vascular injury, but in some cases, it is difficult to determine the presence or absence of active bleeding by CT findings. In fact, it has been reported that more than 25% of vascular lesions do not show up on CT, although CT has good sensitivity in detecting active bleeding, and the rate of NOM failure is higher in AAST grade III and above, so early angiography is likely to be useful. Splenic AVF may present with few symptoms in the early stages but may present with extrahepatic portal hypertension in the late stages, and patients may present to the hospital with symptoms such as abdominal pain and diarrhea. TAE is often the treatment of choice in traumatic cases, and the extent of embolization is important in the balance between preserving splenic function and completing treatment. The shift towards conservative management of splenic trauma may increase the occurrence of splenic AVFs. Transcatheter coil embolization of segmental branches has been effective in treating posttraumatic splenic AVFs, preserving splenic immune function and reducing risks linked to surgery and splenectomy.
经导管动脉栓塞术（TAE）因其微创性，已越来越多地取代手术用于治疗包括脾脏在内的实体器官损伤。研究表明，TAE术后脾切除术的发生率仅为3%，尽管在美国创伤外科学会（AAST）III级脾损伤的初次计算机断层扫描（CT）中，漏诊血管损伤的发生率为10%。然而，缺乏高质量的研究推荐脾损伤非手术治疗（NOM）后的具体CT随访间隔，也缺乏关于假性动脉瘤或动静脉瘘（AVF）病例启动治疗的指南。在此，我们讨论一名44岁男性因机动车事故导致脾损伤的病例。脾损伤为AAST脾脏III级，但由于没有血管外渗漏或AVF形成的证据，选择了NOM。术后第5天的CT显示有一个假性动脉瘤和一个AVF，因此在第7天进行了TAE，保留了脾脏的大部分实质，且无并发症。NOM作为脾损伤治疗策略的适应证正在扩大，但自2018年AAST分级修订以来，分级根据血管损伤的有无而变化，但在某些情况下，很难通过CT表现确定是否存在活动性出血。事实上，尽管CT在检测活动性出血方面具有良好的敏感性，但据报道超过25%的血管病变在CT上未显示，且AAST III级及以上的NOM失败率更高，因此早期血管造影可能会有用。脾AVF在早期可能症状较少，但在后期可能出现肝外门静脉高压，患者可能因腹痛、腹泻等症状入院。TAE通常是创伤病例的首选治疗方法，栓塞范围对于平衡保留脾功能和完成治疗很重要。脾外伤向保守治疗的转变可能会增加脾AVF的发生率。节段性分支的经导管弹簧圈栓塞术在治疗创伤后脾AVF方面已取得成效，可保留脾免疫功能并降低与手术和脾切除术相关的风险。
