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A systematic review assessing incorporation of prophylactic splenic artery embolisation (pSAE) into trauma guidelines for the management of high-grade splenic injury

CVIR Endovascular volume 6, Article number: 62 (2023) Cite this article

Abstract

Background

Splenic artery embolisation (SAE) has become a vital strategy in the modern landscape of multidisciplinary trauma care, improving splenic salvage rates in patients with high-grade injury. However, due to a lack of prospective data there remains contention amongst stakeholders as to whether SAE should be performed at the time of presentation (prophylactic or pSAE), or whether patients should be observed, and SAE only used only if a patient re-bleeds. This systematic review aimed to assess published practice management guidelines which recommend pSAE, stratified according to their quality.

Methods

The study was registered and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Medline, PubMed, Cochrane, Embase, and Google Scholar were searched by the study authors. Identified guidelines were graded according to the Appraisal of Guidelines Research and Evaluation II (AGREE-II) instrument.

Results

Database and internet searches identified 1006 results. After applying exclusion criteria, 28 guidelines were included. The use of pSAE was recommended in 15 guidelines (54%). This included 6 out of 9 guidelines that were high quality (66.7%), 4 out of 9 guidelines that were moderate quality (44.4%), and 3 out of 10 (30%) guidelines that were low quality, p = 0.275.

Conclusions

This systematic review showed that recommendation of pSAE is more common in guidelines which are of high quality. However, there is vast heterogeneity of recommended practice guidelines, likely based on individual trauma systems rather than the available evidence. This reflects biases with interpretation of data and lack of multidisciplinary system inputs, including from interventional radiologists.

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Background

The spleen is the most frequently injured abdominal organ after blunt trauma [1]. Splenic injury is commonly graded using the American Association for the Surgery of Trauma (AAST) splenic injury scale, where high-grade injury is defined as AAST IV or V injury [2]. Conservative management of high-grade injury has reported re-bleed rates of as high as 75% in adults [3]. As a part of modernisation of multidisciplinary treatment, splenic artery embolisation (SAE) has become a vital treatment strategy in improving the rate of spleen preservation (aka splenic salvage) in patients with high-grade injury [4], and its use is thus increasing [1].

However, due to a lack of prospective data there remains contention amongst stakeholders as to whether SAE should be performed at the time of presentation (prophylactic or pSAE), or whether patients should be observed and SAE or splenectomy used only if a patient re-bleeds, according to haemodynamics and local resources [5, 6]. The only randomised and controlled trial to date comparing pSAE or a strategy of initial observation, showed no difference in mortality between the groups (0% vs 0.8%). However, the authors showed that pSAE resulted in 100% splenic salvage compared to an observation-first approach of 93.7%, where 32.3% of patients required SAE due to re-bleeding. The authors showed that pSAE resulted in shorter median hospital length of stay (9 vs 13 days) and fewer complications (29.2% vs 41.5%) [6]. Based on this and retrospective studies across the globe [7,8,9,10,11,12], splenic salvage of AAST IV and V injury in stable patients should be at least 90% at a major trauma centre as a minimum quality benchmark, and pSAE is an effective treatment to achieve this [1, 6, 13].

It is an accepted management practice that when heterogeneity exists in decision-making, agreeing on a treatment guideline has a role in fostering efficient workflow [14]. In many hospitals, guidelines now exist for almost all procedures. Publication of robust guidelines from major and/or notable organisations has immense value as they provide expert-based guidance (ideally based on high-level evidence) on which individual hospitals can mould their daily practice [15]. However, as evidence is available to all, the basis of major decision-making in guidelines should theoretically be similar [16, 17]. However, many institutions continue to propose management approaches based on their own preferences, team structure, and/or interpretation of the available data [18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42].

This study aimed to systematically review existing published splenic trauma management guidelines and assess whether they recommend pSAE in stable patients with high-grade injury, based on the overall guideline quality.

Methods

Registration

The study was registered on the PROSPERO database (record number CRD42023440729) and is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

Data identification and collection

Medline, PubMed, Cochrane, Embase, and Google Scholar were searched by the study authors based against the PICO format (patient, intervention, comparator, outcome), using the following MeSH terms: “Embolization, Therapeutic/methods”[MeSH], “Abdominal Injuries/therapy”[MeSH], “wounds and injuries [MeSH]”, “Embolization, Therapeutic”[MeSH], “splenic artery” [MeSH], “spleen” [MeSH]. The following additional keywords were searched: trauma, embolization, embolisation, angioembolization, angioembolisation, guideline, protocol, pathway, nonoperative, NOM.

Inclusion and exclusion criteria

Enrolled publications included practice management guidelines from any organisation, for example societies, colleges, government bodies, and hospitals. This included publications where splenic treatment guidelines were presented even if the intention of the study was not specifically to discuss the guideline. All studies within the last 20 years were included (1 January 2003 to 1 January 2023). Duplicate studies were excluded. Studies in the paediatric population were excluded given evidence on trauma management in this context is not comparable to adult populations [43]. Studies were also excluded when they were not in English (n = 3), or when the full text could not be obtained (n = 1).

Guideline quality

The Appraisal of Guidelines for Research and Evaluation II (AGREE-II) instrument has been formulated specifically to assist with development and appraisal of guidelines to ensure that clinicians can measure a guideline’s quality before implementing it in daily use [15]. Guidelines were independently evaluated by 2 study investigators (WC and ML) using the 2017 update of the AGREE-II instrument [44] and included grading against 6 different domains. Studies were then graded for quality as high, moderate, or low. Studies were graded as high when they scored greater than or equal to 60% of the maximum score in 3 or more domains, including domain 3 (rigour of development). Studies were graded moderate when they scored greater than or equal to 60% of the maximum score in 3 or more domains, but not including domain 3. Studies were scored as low when they scored less than 60% in 2 or more domains and less than 50% in domain 3. This determination was according to precedent from previous similar studies which have used this tool [43, 45].

Outcomes

The primary outcome was to assess whether the study recommended the use of pSAE after high grade splenic trauma in stable patients, defined as embolisation (either proximal or distal) for splenic injury of AAST grade IV or V, regardless of the presence of a vascular lesion (active bleeding, arteriovenous fistula, or pseudoaneurysm), in stable patients. Secondary outcomes included stratification of the guideline quality and recommendations according to the type of institution authoring the guideline as well as the region of origin.

Statistical analysis

Numerical data were presented as percentage when calculated using the AGREE-II instrument, or number (percentage). Where relevant, assessment for differences of proportion between high, moderate, and low-quality guidelines was performed using the Chi Square test in Stata (Version 17.0-BE, StataCorp, Texas, USA). Probability values of less than 0.05 were deemed statistically significant.

Results

Search results were identified from the initial query including 951 from databases plus an additional 55 from Google Scholar. After applying exclusion criteria, a total of 28 published guidelines were included in the analysis as shown in Fig. 1. This included 5 guidelines from medical societies, 1 from a government institution, and 22 from individual hospital networks. The majority of the guidelines were from Europe and Asia (9 each, 32%), followed by North America (8, 29%) and Australia (2, 7%).

Fig. 1
figure 1

Flow diagram of study selection

Full size image

Table 1 shows the assessment of guideline quality, where 9 studies were of high quality, 9 studies of moderate quality, and 10 of low quality. As shown in Table 2, 27 out of 28 studies recommended the use of SAE in the management of splenic trauma, the only exception being the study from Koca et al. which did not mention embolisation in their flow chart or text, however, did allude to the concept elsewhere in the document without it being specifically mentioned [36]. In terms of the primary study endpoint, 15 guidelines (54%) recommended pSAE for high-grade injury. This included 6 out of 9 guidelines that were high quality (66.7%), 4 out of 9 guidelines that were moderate quality (44.4%), and 3 out of 10 (30%) guidelines that were low quality, p = 0.275.

Table 1 Assessment of guideline quality according to the AGREE-II instrument. All scores shown as a percentage of the maximum score
Full size table
Table 2 Summary of the guideline contents including inclusion of prophylactic splenic artery embolisation
Full size table

Table 3 shows the demographics of high-quality guidelines and compares them to moderate and low-quality guidelines. High quality guidelines were more commonly published by societies (44.4% vs 0% vs 10%) while both moderate and low-quality guidelines were more likely to be published by hospitals (55.6% vs 88.9% vs 90.0%), p = 0.074. In addition, high-quality guidelines were more likely to arise from the North American continent (66.7% vs 0% vs 20%) while both moderate and low-quality guidelines were more likely to arise from Europe (22.2% vs 33.3% vs 40%) or Asia (11.1% vs 44.4% vs 40%), p = 0.030. High, moderate, and low-quality guidelines were of similar likelihood to be published in the last 5 years (55.6% vs 55.6% vs 30%, p = 0.430).

Table 3 Demographics of splenic artery embolisation guidelines according to quality
Full size table

Discussion

This systematic review identified 28 guidelines on the treatment of blunt splenic injury in adults and of these, only 9 were of high quality according to the AGREE-II instrument. The incorporation of pSAE was seen in 54% which is modest, despite the available evidence [6,7,8,9,10,11,12].

In terms of the primary outcome, high-quality guidelines had a higher incorporation of pSAE (66.7%) and while the difference between high, moderate, and low-quality was not statistically significant, it is likely due to a type 2 error from a small sample. High-quality guidelines were also more likely to be written by societies while moderate and low-quality guidelines were more likely written by individual hospitals. Societies may be more likely to consider the value of their brand endorsement, and thus likely to consider the importance of stakeholder engagement and input during development. High-quality guidelines were also likely to arise from North America, however this may be confounded as this was also the location of many leading trauma societies, and the origin of the AGREE-II Enterprise. This may reflect the matured systems of trauma within a continent where trauma has a high prevalence. The authors strongly recommend that anyone who develops or updates a clinical practice guideline considers the AGREE-II instrument, or other similarly validated tools, to ensure that the standard of their recommendations are transparent and robust. From the results of this study, it is felt unlikely that any of the guidelines have specifically used such tools.

Only 5 societies worldwide have chosen to publish a guideline, and some are well overdue for modernisation. An example is the guideline from the Cardiovascular and Interventional Society of Europe (CIRSE), the largest IR society in the world. The current guideline is now over 10 years old and devoid of robust evidence, detail, clarity, and applicability [41], not in keeping with the quality usually seen from such an influential organisation. The low overall uptake of pSAE will be improved if IRs and IR societies such as CIRSE and the Society of Interventional Radiology (SIR), take a larger role in the governance of trauma, integrating themselves in trauma networks, and aligning themselves with local IR and trauma societies in different regions. It is also recommended that societies with sufficient infrastructure consider developing and regularly updating guidelines to remain relevant with constantly changing literature.

In general, most guidelines performed poorest in describing their stakeholder engagement (even those which were high quality), rarely involving a patient advocate, and often missing input from a wider multidisciplinary team. This opens the guideline to bias with reader interpretation and thus implementation of the recommendations. While this may have been acceptable in the early days of trauma which was typically run by surgical specialties, modern trauma management involves centralised, co-ordinated, tertiary care and involves a range of key stakeholders including emergency, surgery, interventional radiology, diagnostic radiology, anaesthetics, intensive care, and many others. In general, guidelines also performed generally poorly on applicability, often presenting an ideal pathway, but omitting measures to ensure that it is feasible, ways to overcome challenges to feasibility, costs, and auditing. It should be acknowledged that some studies presenting a guideline as a smaller component of a wider clinical investigation may not have felt the need to describe their guideline development in detail, and they were still included in this analysis. However, the robust development of a guideline has direct relevance on the downstream utility and it should be encouraged that authors present this vital data moving forward.

The domain of clarity of presentation had a somewhat dichotomous result. Those that published a clear and relevant flow chart and/or used an executive summary at the beginning generally scored highly. However, those that described their treatment without a specific chart scored lower. In addition, editorial independence was generally transparent through mandated reporting standards in journals. Those that did not publish their guideline in a journal often did not choose to voluntarily report any potential conflicts of interest.

A major component of the interpretation bias of guidelines is the failure for treatment pathways to adequately consider splenic function and instead place a weighted focus on mortality as the only endpoint [4]. This is also in part because it is difficult to measure treatment success in trauma and most studies in this context are retrospective with several inherent biases, leading to scepticism of results and lack of applicability of approaches where trauma systems aren’t replicable [6, 8]. In addition to these challenges, interventional radiology is still a young specialty, and as such training and governance structures vary significantly between different hospitals, regions, and countries [5]. This means that access to expert skills with appropriate training is also not universal.

Given SAE was mentioned in all guidelines, trauma networks should endeavour to include a sustainable IR service to be involved in the management of major trauma. This should involve expansion of the current IR workforce so that smaller hospitals have timely IR services available, or for patients to be sent to a centre with resources to prioritise splenic salvage in addition to mortality prevention. The benefits of salvage are vast and include the avoidance of a laparotomy with associated morbidity, prevention of overwhelming post-splenectomy infection (OPSI), reduced need for future vaccinations, reduced need for future prophylactic antibiotics, and cost savings to the individual and society [46,47,48,49].

The authors acknowledge that this study is limited by the interpretation and assessment of guideline quality and while this is an objective validated tool, still requires individual interpretation. In addition, guidelines published within a clinical cohort study may not have provided the full breadth of information to allow for their interpretation as discussed earlier. However, the authors chose to present all guidelines rather than limit the analysis to purely those from major societies given the very small sample. The statistical analysis in Table 3 is also based on a small sample. The guidelines also cross the 2018 update to the AAST injury grading criteria [2] and this may theoretically affect management decisions moving forward for those with an earlier guideline based on the 1994 AAST definitions. There is also variation in how stakeholders may view and define “prophylactic embolisation” with differing opinions on the relative importance of parenchymal injury and vascular lesions.

Conclusions

This systematic review showed that recommendation of pSAE is more common in guidelines which are of high quality. However, there is vast heterogeneity of recommended practice guidelines, likely based on individual trauma systems. This reflects biases with interpretation of data, and lack of multidisciplinary system inputs from IRs. More societies should publish guidelines, ensuring they are high-quality by conforming to existing validated reporting standards. Centres or countries which do not have the infrastructure to support pSAE are encouraged to embed IR within their trauma governance structure and overcome barriers to implementation to improve quality of care, rather than using a self-generated treatment algorithm which may not provide their patients with the established short- and long-term benefits of splenic salvage.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available but are available from the corresponding author on reasonable request. Please contact the corresponding author for additional information.

Abbreviations

IR:

Interventional radiology

AAST:

American association for the surgery of trauma

SAE:

Splenic artery embolisation

pSAE:

Prophylactic splenic artery embolisation

OR:

Odds ratio

AGREE-II:

Appraisal of guidelines for research and evaluation II

PRISMA:

Preferred reporting items for systematic reviews and meta-analyses

PICO:

Patient, intervention, comparator, outcome

CIRSE:

Cardiovascular and interventional society of europe

SIR:

Society of interventional radiology

OPSI:

Overwhelming post-splenectomy infection

References

  1. Clements W, Joseph T, Koukounaras J, Goh GS, Moriarty HK, Mathew J, Phan TD. SPLEnic salvage and complications after splenic artery EmbolizatioN for blunt abdomINal trauma: the SPLEEN-IN study. CVIR Endovasc. 2020;3(1):1–9.

    Article  Google Scholar 

  2. Kozar RA, Crandall M, Shanmuganathan K, Zarzaur BL, Coburn M, Cribari C, Kaups K, Schuster K, Tominaga GT. AAST patient assessment committee. Organ injury scaling 2018 update: spleen, liver, and kidney. Journal of trauma and acute care. Surgery. 2018;85(6):1119–22.

    Google Scholar 

  3. Olthof DC, Van der Vlies CH, Goslings JC. Evidence-based management and controversies in blunt splenic trauma. Curr Trauma Rep. 2017;3:32–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Clements W, Moriarty HK, Koukounaras J. Splenic artery embolisation in trauma: it is time to stand alone as its own treatment. Cardiovasc Intervent Radiol. 2020;43(11):1720–1.

    Article  PubMed  Google Scholar 

  5. Hughes J, Scrimshire A, Steinberg L, Yiannoullou P, Newton K, Hall C, Pearce L, Macdonald A. Interventional radiology service provision and practice for the management of traumatic splenic injury across the regional trauma networks of England. Injury. 2017;48(5):1031–4.

    Article  PubMed  Google Scholar 

  6. Arvieux C, Frandon J, Tidadini F, Monnin-Bares V, Foote A, Dubuisson V, Lermite E, David JS, Douane F, Tresallet C, Lemoine MC. Effect of prophylactic embolization on patients with blunt trauma at high risk of splenectomy: a randomized clinical trial. JAMA Surg. 2020;155(12):1102–11.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Banerjee A, Duane TM, Wilson SP, Haney S, O’Neill PJ, Evans HL, Como JJ, Claridge JA. Trauma center variation in splenic artery embolization and spleen salvage: a multicenter analysis. J Trauma Acute Care Surg. 2013;75(1):69–75.

    Article  PubMed  Google Scholar 

  8. Schnüriger B, Martens F, Eberle BM, Renzulli P, Seiler CA, Candinas D. Treatment practice in patients with isolated blunt splenic injuries: a survey of Swiss traumatologists. Unfallchirurg. 2013;116:47–52.

    Article  PubMed  Google Scholar 

  9. Capecci LM, Jeremitsky E, Smith RS, Philp F. Trauma centers with higher rates of angiography have a lesser incidence of splenectomy in the management of blunt splenic injury. Surgery. 2015;158(4):1020–6.

    Article  PubMed  Google Scholar 

  10. Lavanchy JL, Delafontaine L, Haltmeier T, Bednarski P, Schnüriger B, Registry ST. Increased hospital treatment volume of splenic injury predicts higher rates of successful non-operative management and reduces hospital length of stay: a Swiss trauma Registry analysis. Eur J Trauma Emerg Surg. 2022;1:1–8.

    Google Scholar 

  11. Harbrecht BG, Ko SH, Watson GA, Forsythe RM, Rosengart MR, Peitzman AB. Angiography for blunt splenic trauma does not improve the success rate of nonoperative management. J Trauma Acute Care Surg. 2007;63(1):44–9.

    Article  Google Scholar 

  12. Chastang L, Bège T, Prudhomme M, Simonnet AC, Herrero A, Guillon F, Bono D, Nini E, Buisson T, Carbonnel G, Passebois L. Is non-operative management of severe blunt splenic injury safer than embolization or surgery? Results from a French prospective multicenter study. J Visc Surg. 2015;152(2):85–91.

    Article  CAS  PubMed  Google Scholar 

  13. Rong JJ, Liu D, Liang M, Wang QH, Sun JY, Zhang QY, Peng CF, Xuan FQ, Zhao LJ, Tian XX, Han YL. The impacts of different embolization techniques on splenic artery embolization for blunt splenic injury: a systematic review and meta-analysis. Mil Med Res. 2017;4:1–2.

    Google Scholar 

  14. Schaekermann M, Beaton G, Habib M, Lim A, Larson K, Law E. Understanding expert disagreement in medical data analysis through structured adjudication. Proc ACM Human-Comput Interact. 2019;3:1–23.

    Article  Google Scholar 

  15. Dans AL, Dans LF. Appraising a tool for guideline appraisal (the AGREE II instrument). J Clin Epidemiol. 2010;63(12):1281–2.

    Article  PubMed  Google Scholar 

  16. Stassen NA, Bhullar I, Cheng JD, Crandall ML, Friese RS, Guillamondegui OD, Jawa RS, Maung AA, Rohs TJ Jr, Sangosanya A, Schuster KM. Selective nonoperative management of blunt splenic injury: an eastern Association for the Surgery of trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5):S294–300.

    Article  PubMed  Google Scholar 

  17. Rowell SE, Biffl WL, Brasel K, Moore EE, Albrecht RA, DeMoya M, Namias N, Schreiber MA, Cohen MJ, Shatz DV, Karmy-Jones R. Western trauma association critical decisions in trauma: management of adult blunt splenic trauma—2016 updates. J Trauma Acute Care Surg. 2017;82(4):787–93.

    Article  PubMed  Google Scholar 

  18. Coccolini F, Montori G, Catena F, Kluger Y, Biffl W, Moore EE, Reva V, Bing C, Bala M, Fugazzola P, Bahouth H. Splenic trauma: WSES classification and guidelines for adult and pediatric patients. World J Emerg Surg. 2017;12:1–26.

    Google Scholar 

  19. Bhullar IS, Tepas JJ III, Siragusa D, Loper T, Kerwin A, Frykberg ER. To nearly come full circle: nonoperative management of high-grade IV–V blunt splenic trauma is safe using a protocol with routine angioembolization. J Trauma Acute Care Surg. 2017;82(4):657–64.

    Article  PubMed  Google Scholar 

  20. Watson GA, Hoffman MK, Peitzman AB. Nonoperative management of blunt splenic injury: what is new? Eur J Trauma Emerg Surg. 2015;41:219–28.

    Article  CAS  PubMed  Google Scholar 

  21. Hameed M, Butterworth S, Goecke M, Mihailovic A, Robbins N, Wilson H, Hawes H, Evans D. Trauma services British Columbia. Specialist trauma advisory . Clinical practice guideline for the management of Blunt Splenic Injury in adults 16 years of age or older [internet]. 2023. Available from: http://www.phsa.ca/Documents/Trauma-Services/Spleen%2008%20Full%20CPG%20for%20download.pdf. Accessed 14 Sept 2023.

  22. Cheatham ML, Gratzon AC. Algorithm for the evaluation and Management of Blunt Splenic Injury [internet]. 2023. Available from: https://surgicalcriticalcare.net/Guidelines/Blunt%20splenic%20injury%202015.pdf. Accessed 14 Sept 2023.

  23. Lin BC, Wu CH, Wong YC, Chen HW, Fu CJ, Huang CC, Wu CT, Hsieh CH. Splenic artery embolization changes the management of blunt splenic injury: an observational analysis of 680 patients graded by the revised 2018 AAST-OIS. Surg Endosc. 2023;37(1):371–81.

    Article  PubMed  Google Scholar 

  24. Van der Cruyssen F, Manzelli A. Splenic artery embolization: technically feasible but not necessarily advantageous. World J Emerg Surg. 2016;11(1):1–4.

    Google Scholar 

  25. Tugnoli G, Bianchi E, Biscardi A, Coniglio C, Isceri S, Simonetti L, Gordini G, Di Saverio S. Nonoperative management of blunt splenic injury in adults: there is (still) a long way to go. The results of the Bologna-Maggiore hospital trauma center experience and development of a clinical algorithm. Surg Today. 2015;45:1210–7.

    Article  PubMed  Google Scholar 

  26. Gilmore L. Canberra health services guideline: splenic injury management guidelines for adults [internet]. 2023. Available from: https://www.canberrahealthservices.act.gov.au/__data/assets/word_doc/0006/2074623/Splenic-Trauma.docx. Accessed 14 Sept 2023.

  27. Wu SC, Chow KC, Lee KH, Tung CC, Yang AD, Lo CJ. Early selective angioembolization improves success of nonoperative management of blunt splenic injury. Am Surg. 2007;73(9):897–902.

    Article  PubMed  Google Scholar 

  28. Wu SC, Chen RJ, Yang AD, Tung CC, Lee KH. Complications associated with embolization in the treatment of blunt splenic injury. World J Surg. 2008;32:476–82.

    Article  PubMed  Google Scholar 

  29. Girard E, Abba J, Cristiano N, Siebert M, Barbois S, Létoublon C, Arvieux C. Management of splenic and pancreatic trauma. J Visc Surg. 2016;153(4):45–60.

    Article  CAS  PubMed  Google Scholar 

  30. Kanlerd A, Auksornchart K, Boonyasatid P. Non-operative management for abdominal solidorgan injuries: a literature review. Chin J Traumatol. 2022;25(5):249–56.

    Article  PubMed  Google Scholar 

  31. Lee MA, Yu B, Lee J, Choi KK, Park JJ, Park Y, Han A, Gwak J, Lee GJ. Comparison of outcomes before and after establishing a regional trauma center and following a protocol to treat blunt splenic injury in South Korea: a retrospective study. Hong Kong J Emerg Med. 2018;25(6):343–9.

    Article  Google Scholar 

  32. Romeo L, Bagolini F, Ferro S, Chiozza M, Marino S, Resta G, Anania G. Laparoscopic surgery for splenic injuries in the era of non-operative management: current status and future perspectives. Surg Today. 2021;51:1075–84.

    Article  PubMed  Google Scholar 

  33. Mitsusada M, Nakajima Y. Protocol for splenic salvage procedures in this era of non-operative management. Acute Med Surg. 2014;1(4):200–6.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Frandon J, Arvieux C, Thony F. Indications for embolization in a French level 1 trauma center. J Visc Surg. 2016;153(4):25–31.

    Article  CAS  PubMed  Google Scholar 

  35. Singh A, Kumar A, Kumar P, Kumar S, Gamanagatti S. “Beyond saving lives”: current perspectives of interventional radiology in trauma. World J Radiol. 2017;9(4):155.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  36. Koca B, Topgül K, Yürüker SS, Çınar H, Kuru B. Non-operative treatment approach for blunt splenic injury: is grade the unique criterion?. Ulus Travma Acil Cerrahi Derg. 2013;19(4):337–42. https://doi.org/10.5505/tjtes.2013.89411.

  37. Cameron JL, Cameron AM. Current surgical therapy E-book. Elsevier Health Sciences; 2016. 29 Nov 2016. Available from https://books.google.com.au/books?id=FM6fDQAAQBAJ.

  38. Ruscelli P, Buccoliero F, Mazzocato S, Belfiori G, Rabuini C, Sperti P, Rimini M. Blunt hepatic and splenic trauma. A single center experience using a multidisciplinary protocol. Ann Ital Chir. 2017;88(2):129–36.

    Google Scholar 

  39. El-Matbouly M, Jabbour G, El-Menyar A, Peralta R, Abdelrahman H, Zarour A, Al-Hassani A, Al-Thani H. Blunt splenic trauma: assessment, management and outcomes. Surgeon. 2016;14(1):52–8.

    Article  PubMed  Google Scholar 

  40. Brillantino A, Iacobellis F, Robustelli U, Villamaina E, Maglione F, Colletti O, De Palma M, Paladino F, Noschese G. Non operative management of blunt splenic trauma: a prospective evaluation of a standardized treatment protocol. Eur J Trauma Emerg Surg. 2016;42:593–8.

    Article  CAS  PubMed  Google Scholar 

  41. Chakraverty S, Flood K, Kessel D, McPherson S, Nicholson T, Ray CE, Robertson I, van Delden OM. CIRSE guidelines: quality improvement guidelines for endovascular treatment of traumatic hemorrhage. Cardiovasc Intervent Radiol. 2012;35:472–82.

    Article  PubMed  Google Scholar 

  42. University of Colorado School of Medicine. Guideline for Management of Spleen Trauma [internet]. 2023. Available from: https://medschool.cuanschutz.edu/docs/librariesprovider74/traumaand-acute-care-surgery-pdfs/trauma-protocols/spleen-trauma-2018.pdf?sfvrsn=e32141b9_2. Accessed 14 Sept 2023.

  43. Yanchar N, Tardif PA, Freire G, Bérubé M, Stelfox HT, Beaudin M, Stang A, Beno S, Weiss M, Labrosse M, Zemek R. Clinical practice guideline recommendations for pediatric solid organ injury care: a systematic review. J Trauma Acute Care Surg. 2023;95(3):442–50.

    Article  PubMed  Google Scholar 

  44. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 2010;182(18):E839–42.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Johnston A, Kelly SE, Hsieh SC, Skidmore B, Wells GA. Systematic reviews of clinical practice guidelines: a methodological guide. J Clin Epidemiol. 2019;108:64–76.

    Article  PubMed  Google Scholar 

  46. Clements W, Mathew J, Fitzgerald MC, Koukounaras J. Splenic artery embolization after delayed splenic rupture following blunt trauma: is nonoperative management still an option in this cohort? J Vasc Interv Radiol. 2021;32(4):586–92.

    Article  PubMed  Google Scholar 

  47. Yip H, Skelley A, Morphett L, Mathew J, Clements W. The cost to perform splenic artery embolisation following blunt trauma: analysis from a level 1 Australian trauma Centre. Injury. 2021;52(2):243–7.

    Article  PubMed  Google Scholar 

  48. Slater SJ, Lukies M, Kavnoudias H, Zia A, Lee R, Bosco JJ, Joseph T, Clements W. Immune function and the role of vaccination after splenic artery embolization for blunt splenic injury. Injury. 2022;53(1):112–5.

    Article  PubMed  Google Scholar 

  49. Lukies M, Zia A, Kavnoudias H, Bosco JJ, Narita C, Lee R, Joseph T, Clements W. Immune function after splenic artery embolization for blunt trauma: long-term assessment of CD27+ IgM B-cell levels. J Vasc Interv Radiol. 2022;33(5):505–9.

    Article  PubMed  Google Scholar 

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Acknowledgements

The authors acknowledge all staff in the Department of Radiology, Department of Trauma, and the National Trauma Research Institute.

Funding

This study was not supported by any funding.

Author information

Authors and Affiliations

  1. Department of Radiology, Alfred Hospital, 55 Commercial Rd, Melbourne, VIC, 3004, Australia

    Warren Clements & Matthew W. Lukies

  2. Department of Surgery, Monash University Central Clinical School, Melbourne, Australia

    Warren Clements, Mark Fitzgerald, Joseph Mathew, Christopher Groombridge & Matthew W. Lukies

  3. National Trauma Research Institute, Melbourne, Australia

    Warren Clements, Mark Fitzgerald, Joseph Mathew, Christopher Groombridge, Ee Jun Ban & Matthew W. Lukies

  4. Department of Trauma, Alfred Health, Melbourne, Australia

    Mark Fitzgerald, Joseph Mathew & Christopher Groombridge

  5. Discipline of Child and Adolescent Health, Sydney Medical School, Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia

    S. Murthy Chennapragada

  6. Department of Medical Imaging, The Children’s Hospital at Westmead, Sydney, NSW, Australia

    S. Murthy Chennapragada

  7. Acute General Surgical Unit, Alfred Health, Melbourne, Australia

    Ee Jun Ban

Authors
  1. Warren Clements
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  2. Mark Fitzgerald
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  3. S. Murthy Chennapragada
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  4. Joseph Mathew
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  5. Christopher Groombridge
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  6. Ee Jun Ban
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  7. Matthew W. Lukies
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Contributions

WC and ML (2 authors) were involved in study design, data analysis, and writing. MF, SMC, JM, CG, and EJB (5 authors) were involved in study design, data analysis and editing of the manuscript.

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Correspondence to Warren Clements.

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Clements, W., Fitzgerald, M., Chennapragada, S.M. et al. A systematic review assessing incorporation of prophylactic splenic artery embolisation (pSAE) into trauma guidelines for the management of high-grade splenic injury. CVIR Endovasc 6, 62 (2023). https://doi.org/10.1186/s42155-023-00414-6

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