Angiography hasn't lowered splenectomy rates after blunt splenic injury

Last Updated: 2017-04-10

By Will Boggs MD

NEW YORK (Reuters Health) - Increasing usage of angiography and embolization in the management of high-grade blunt splenic injury in recent years has not reduced overall splenectomy rates, according to new findings.

"Using angiography in an indiscriminate way for high-grade spleen injury will not likely change the overall splenectomy rate at a particular center,” Dr. Ben L. Zarzaur from Indiana University School of Medicine in Indianapolis told Reuters Health by email. “Patient selection is key.”

When angiography was introduced in the management of blunt splenic injury, the rate of successful nonoperative management was already increasing across institutions. A recent study using data from the National Trauma Data Bank (NTDB) found significant variability in the use of urgent splenectomy in this setting.

Dr. Zarzaur’s team used NTDB data from 2008 to 2014 to investigate nationwide trends in angiography usage and splenectomy rates among more than 53,000 adults with Grade III or higher blunt splenic injury.

The rate of angiography at centers that used it increased by 16% per year for all high-grade blunt splenic injury, with overall increases from 5.7% in 2008 to 14.1% in 2014, the researchers report in the Annals of Surgery, online March 27.

During the same interval, the overall splenectomy rate remained stable at centers that used angiography, with rates of 24.1% in 2008 and 23.5% in 2014. In contrast, overall splenectomy rates decreased from 27.0% in 2008 to 20.7% in 2014 at centers that did not use angiography.

Early-splenectomy rates were stable over time at all centers; rates of late splenectomy were significantly reduced over time at centers with and without angiography, although there was a faster decline in late splenectomy rates at non-angiography centers than at angiography centers.

Mortality rates decreased to a similar extent at centers with and without angiography (from 5.4% to 4.1% and from 6.0% to 3.3%, respectively) between 2008 and 2014.

“There are likely subsets of patients who will benefit from angiography,” Dr. Zarzaur said. “It is hard to justify its use as a screening tool given the high cost and high rate of complications without the potential benefit.”

“So,” he concluded, “I would recommend that centers optimize their use of early splenectomy for patients with hemodynamic instability, focus on high-yield use of angiography for patients with pseudoaneurysm or blush on screening CT scan, and monitor for hemodynamic instability or dropping hematocrit for 3-5 days after injury, particularly for high-grade injuries.”

SOURCE: http://bit.ly/2nTy29j

Ann Surg 2017.