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Splenic Embolization Procedure

Author Sai Govindu covers Splenic Embolization Procedure on BackTable VI

Sai Govindu • Jun 16, 2023 • 452 hits

Splenic embolization procedure for trauma management, particularly of grade-three severity, demands proficient techniques and the appropriate tools for effective management. Interventional radiologists Dr. Chris Grilli and Dr. Aaron Fritts provide a comprehensive overview of splenic embolization procedure approaches, informed by preoperative CT scans and tailored to the unique needs of each patient, with factors like obesity or arterial disease influencing the appropriate choices. Knowing the advantages of different embolic agents, the shift in strategies upon viewing angiograms, and the impact of arterial tortuosity on device selection can improve the success and efficiency of the splenic embolization procedure. Understanding proximal and distal embolization, the benefits of the latest coil technology, and the feasibility of liquid embolic and glue can further broaden the scope of minimally invasive treatment options for splenic trauma.

This article features excerpts from the BackTable Vascular & Interventional Podcast. We've provided the highlights here, and you can listen to the full episode below.

The BackTable Brief

• Preoperative CT scans inform the initial plan for the splenic embolization procedure and choice of embolic agent. Options for embolic agents include coils, gel foam, Amplatzer plugs, Terumo plugs, and an endovascular occlusion device. Extravasation in a specific segmental branch of the splenic artery may necessitate distal embolization using a microcatheter and coils.

• In situations where the splenic artery is large or tortuous, coil embolization offers more flexibility compared to plugs. Coils also provide a more immediate effect than plugs, which can require a wait period to see flow reduction. The Embold coil, a newer product, offers a balance between fiber and non-fiber coils, providing formability and the advantages of fiber with a fully detachable system, according to Dr. Chris Grilli.

• Gel foam slurry can be introduced behind the plug during a splenic embolization procedure to hasten the angiographic result. Gel foam has been used successfully for the embolization of specific spleen segments but is usually used in conjunction with proximal coiling or plugging.

• Liquid embolic agents like glue or Onyx may be utilized in non-trauma situations for splenic embolization. Vascular closure devices are often employed to hasten room turnover, including passive devices like the MynxGrip, or active ones like the Angio-Seal or Celt.

Splenic Embolization Procedure Techniques, Tools & Efficiency

Table of Contents

(1) Splenic Embolization in Trauma: Techniques and Tools

(2) Splenic Embolization Procedure: Proximal, Distal & Choosing the Embolization Device

(3) Splenic Embolization Procedure: Liquid Embolics and Closure Devices

Splenic Embolization in Trauma: Techniques and Tools

Dr. Chris Grilli offers a deep dive into the process of handling a hypothetical grade-three splenic trauma that requires embolization. Based on the preoperative CT scan, he typically plans to use a femoral approach, although radial access is also employed in certain cases. The choice of embolic agent is dictated by the nature of the injury and could include coils, gel foam, Amplatzer plugs, Terumo plugs, or an endovascular occlusion device. However, the initial plan can often change once the angiogram is taken. For splenic artery embolization, catheters such as C2 or Sarah are used, with the choice influenced by patient-specific factors such as obesity or arterial disease. Dr. Grilli also discusses his method for handling extravasation in a specific segmental branch of the splenic artery, emphasizing that both proximal and distal embolization have similar salvage rates. Furthermore, the use of various embolization devices is influenced by the tortuosity of the splenic artery.

[Aaron Fritts MD]
Let's take a hypothetical from here. It’s Monday, it's 4:00 PM and the trauma surgeon runs in and says, ''Hey, we got a grade three trauma, splenic trauma, splenic laceration. Can you embolize it?” Can you walk through what you're doing for the audience at that point?

[Chris Grilli MD]
Oh, absolutely. Most of these cases. we're going femoral, although I do radial as well and then it depends on what the preoperative CT looks like. In general, we're talking about ephemeral access using a five-French sheath going up into the splenic artery with a primary curve such as a C2. You can also use a reverse curve catheter. There's nothing wrong with that. I like to track it out in the case of the C2 into the splenic artery as best I can to actually get a nice picture, stabilize my access and then do a couple of runs.

Depending on what I see, I'm deciding whether or not to just do a distal, do a proximal, do both maybe and also deciding what my embolic agent is going to be. There's a lot of options out there now, which is fun. We use everything from coils to gel foam to obviously Amplatzer plugs. There's also some Terumo plugs out there and the endovascular occlusion device. There's a lot of really neat options and it's a really good chance, especially for trainees to get their hands on some different types of embolics and learn how to use them.

[Aaron Fritts MD]
Just to back up one minute. I want to ask you, I'm sure you're reviewing the CT before they wheel them in although I'm sure it's always a rush deal. They're already at the door, but you're reviewing the CT. Do you already have an idea based off of looking at that CT if you're going to embolize proximally or distally and then what type of embolization device you're going to use? Or is it like you wait and see and see what you get when you're in there?

[Chris Grilli MD]
Yes, I always have a plan going into the case of what I think I'm going to do. Now, how often that plan gets turned on its head the second I take my first angiogram? It's probably 50/50. Often, I'll have a plug pulled and waiting to go and then I just throw it away, and we're doing something completely different. I do review the CT. I do try to make a plan, but intraoperatively things change all the time.

[Aaron Fritts MD]
Do you ever go radial access?

[Chris Grilli MD]
Yes, I do radial. I would say for the minority of patients, I do radial. But I definitely do a fair number of them. It's very nice to do, especially if they have a lot of disease or if it's a very obese patient and you don't want to go stick in the groin, it's super quick, easy to get down. Catheter of choice for that is the Sarah catheter. It tends to work great for spleens, but you could also just use a standard primary curve catheter or just an old reverse curve of any type but the Sarah is definitely my favorite. It's really nice to do radial. It tends to be just as quick, you could use the same number of devices. The sheath size I use is the same. I use a five, although I do usually use a slender, so it's a four French access and those cases go really well.

[Aaron Fritts MD]
For the straightforward CLAC - and we're going to talk about challenging CLAC anatomy here in a minute but for the straightforward CLAC anatomy - where you get your C2 right into that splenic, are you then putting a microcatheter through that? Do you ever embolize even if you're able to get your C2 out pretty far, do you ever just embolize through that just because it's fast and quick?

[Chris Grilli MD]
Yes, I do. I would say the majority of cases go like this. I do the runs with the C2. I see laceration, maybe some areas that look like some parenchymal blush, but it's not definitive. It's certainly nothing I would call extra or anything like that. I would say, “Oh, I'm just going to do a proximal,” I have the C2 in the proximal splenic and I deploy a plug or three five coils right through the C2. That type of case is a very, very quick 10-minute case. That's mostly straightforward. Now let's say I see something on my first run, like frank extrav or something I'm really concerned about in a specific segmental branch of the splenic.

I will put a micro through that and go after that and do a distal embolization on that particular branch. Usually through a micro, usually using coils most often detachable coils because we have a bunch of them at my institution and that's what I like to use, but you can use non-detachable as well. They're distal arteries. There's no problem with that. Also in those situations, even if I do distal, I usually leave a proximal embolic on the way out. The data's mixed on this. They've looked at this proximal versus distal and it seems like they had similar salvage rates. There's one study out there that shows if you do both you do have increased complications and poorer outcomes.

However, I do suspect that's due to the fact that people who had both done were sicker patients. In reading the study it looks like they didn't tease that out. I think you just have to make a judgment call at the time as to what exactly you're going to imply based on the data at hand.

[Aaron Fritts MD]
As we commonly will see the splenic artery can be pretty torturous. Does that also help you decide what embolization device to use? Let's say torturous versus non-torturous splenic artery?

[Chris Grilli MD]
Yes, absolutely. I think even tortuous, I'm trying to get my parent catheter out there. However, if a few seconds of trying it's not going or it's kicking out because just extreme tortuosity is not going to go, no matter what wire and catheter combo I'm using, I ditch that right away. I'll just park a reverse curve at the origin and then just go through the splenic with a microcatheter. Time is of the essence in these cases. I generally don't like to keep trying something that's not working. Then in that case you're using coils, which is great. There's so many options out there now, there's even the penumbra pod device which is coils that act like a plug.

There's still a bunch of options out there and certainly the cases go just as quick, and if not even quicker because the one thing we know with the Amplatzer plug if you use that, you have to wait for that thing to shut down. Sometimes it takes a while whereas coils generally go a little quicker.

Listen to the Full Podcast

Treatment Algorithms for Splenic Artery Embolizations with Dr. Chris Grilli on the BackTable VI Podcast)
Ep 270 Treatment Algorithms for Splenic Artery Embolizations with Dr. Chris Grilli
00:00 / 01:04

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Splenic Embolization Procedure: Proximal, Distal & Choosing the Embolization Device

Splenic embolization procedure normally has the common endpoint of blocking flow in the main splenic artery in a proximal embolization. Dr. Chris Grilli emphasizes the importance of understanding collateral circulation when undertaking proximal embolization and considering the versatility of using coil embolization versus plugs. Given the multiple collateral pathways in the spleen, placing the embolization device distal to the dorsal pancreatic is a general rule of thumb. Choosing splenic embolization devices depends on the vasculature and each type of device varies in versatility and efficiency. For large or tortuous arteries, the flexibility and reliability of coils are important to consider. Using plugs as embolization devices can be beneficial in their one-and-done usage but inaccurate sizing and time to settle are notable limitations. Coils tend to be more versatile and flexible with more options than ever in the market. In particular, the latest generation of coils, like the Embold, strike a balance between traditional fiber coils and non-fiber ones, offering formability, fiber advantages, and a fully detachable system for more control during splenic embolization.

[Aaron Fritts MD]
Let's talk about that. Let's talk about embolization. I do want to talk about the variety of different coils out there, but let's talk about endpoint real quick and then we'll talk about the different coils. What are the pros and cons of each embolization device? What is the endpoint, what are you looking for? Is it full-on stasis or just to slow it down so that you don't see that active bleeding anymore?

[Chris Grilli MD]
The ideal endpoint and we're going to talk about this in the context of a proximal embolization is, I see that my device has blocked flow in the main splenic artery, yet when I do the run and, on the delay, I see the distal splenic artery filling via the collateralization to the spleen. That's my endpoint. If I'm, and I shouldn't be saying this, but if I'm in a rush and I plop in a plug, I don't always wait the 10 minutes or so for that thing to go down if I'm confident it's going to go down. So I just get out of dodge.

However, ideally you want your final run to show that whatever device you have in there has obstructed flow in the main and now you're getting collateralization. Maybe it's worth quickly talking about it. The collateralization of the spleen is really robust. You're getting a ton via the left gastric through the short gastrics. You're getting a lot through the epiploic the right to the left, and then to the spleen. Then of course, what everybody always talks about is if you do use a plug or embolic device, put it distal to the dorsal pancreatic which will then go to the greater pancreatic and then fill up the spleen.

I don't kill myself in looking for the dorsal pancreatic or where to put the plug. Honestly, even if I put the plug right over or coils right over the dorsal pancreatic that spleen's not going anywhere because of the multiple, multiple, collateral pathways out there. Although an ideal location is just right after that dorsal pancreatic branch.

[Aaron Fritts MD]
Great. You mentioned the advantage of placing a plug which is one and done, but that the downside and I've seen this too, is having to sit there and wait to see that flow slow down. Whereas for coils, you can pop them in and I would say just as quickly. I think it has a more immediate effect, but tell our audience your experience and the variety of different coils that you use when you're doing these.

[Chris Grilli MD]
That's exactly right. The plug does take a while to set down. Also sizing the plug can be difficult, because if it's a large splenic artery and you have gen four plugs going up to 8 millimeters, and if it's too large, you're not going to get a plug to fit. Certainly, I had a case with a fellow put in a plug. It looked okay, took our next run and the plug was slowly chugging out to the distal splenic artery, and you're kicking yourself going “Oh, come on.” You really have to oversize those plugs like crazy. 20% to even 40% in some situations. I like those oversized, really oversized.

Whereas coils give you a lot more flexibility. Obviously, you have much larger sizes. I do like a fiber coil if I can get it. We have all different types of coils at my institution. I tend to see them shut down quicker with fibers, but certainly the options out there now are huge. We have really long coils at pretty large millimeter sizes. You can get away with one to two coils, do the case actually cheaper, and quicker, and like you said, often you see the result much quicker. The trick is getting a bite approximately.

It's nice to get to find a branch that you can dig the front end of the coil into and then you're good, or if you can get a turn and get the coil to grip on the turn instead of it traveling out, that helps with getting it in quickly.

[Aaron Fritts MD]
You mentioned there's new ones on the market. For example, we know the sponsor today shows is the Embold. I've yet to use it. Is there any advantage to you to these new ones that are on the market? I know they're fiber but there are other older coils that are fiber as well.

[Chris Grilli MD]
The Embold are the next generation to the interlock. The interlock was great. However, it was a little more difficult to form than a non-fiber coil which was a downside, and also it wasn't completely detachable. I couldn't bring it out and then pull it right back in, and certainly if the catheter sizing was off or if you didn't flush it well, sometimes they'd come detached. The Embold operates in a mechanical mechanism where it's fully detachable. You could put the thing all the way out and pull it back in, and it doesn't really let go until you decide to break the back end of the Embolds deployment device.

I've used it quite a bit now. I really like that coil. I think it strikes a nice balance between having a fiber coil which may be more difficult to form with the fact that there's less fibers on this. The front end of it's not fiber, so it really goes in first like a non-fiber coil, like a ruby, and like a bolt. Something like that where it forms very, very nicely. The fibers come later so you get the benefit of a fiber coil but with the deployability of a non-fiber coil. So far at my institution I think I could speak for most of my colleagues, that's been the workhorse of late of our coils. We really, really like them and they seem to strike a nice balance.

[Aaron Fritts MD]
That reminds you of the glide advantage wire. You got the hydrophilic front with the stiff back which I love.

Splenic Embolization Procedure: Liquid Embolics and Closure Devices

Non-trauma situations for splenic embolization procedure offer an application for liquid embolic agents, given cost is a limiting factor. Onyx is a popular option but is pricey and thus limited to non-trauma cases. Regarding sheath removal post-procedure, Dr. Grilli often pulls the sheath unless told otherwise. Standard vascular closure devices for splenic embolization include mynxGrip, Angio-Seal and the Celt.

[Aaron Fritts MD]
I have another question from Peder Horner. He wanted to know: would you ever consider a liquid embolic? Is there ever a case for a liquid embolic? Probably not in trauma.

[Chris Grilli MD]
People do use these, yes. That brings us more into other reasons to do splenic embolization, which I don't know if you want to go to into yet, but yes people do a lot of different things. There’s glue. There's obviously that which goes in gel form, but glue is definitely brought into it. People use Onyx for it. I haven't used it. I could see where that may be useful. To make it cost-effective, you have to find really cheap glue to use. Glue can be quick, but if you're doing a bunch of segmentals, it tends to not be that quick. There's an Onyx study just out of Jefferson right down the road from me that looked at using Onyx for these devascularization cases, and they found less side effects.

I’m not sure why they had less side effects, but they did report that. It seems like Onyx is another usable option, but again, really, really pricey. It's something to consider. So not for trauma.


[Aaron Fritts MD]
Not for trauma. In a minute I want to jump into the non-emergent splenic embolization. But real quick, for example, you achieve stasis and vital signs, stabilize, and everybody's high-fiving. Are you leaving your sheath in for when the patient goes up to the ICU or are you pulling, and are you doing closure device or are you having somebody hold pressure? How do you handle the sheath afterwards?

[Chris Grilli MD]
Most of the time we're pulling the sheath. Now if the trauma team is there and they say, "Can you leave the sheath?" We're more than happy to do that, as long as we make it clear to them that it's their job to pull now in a few days whenever they're done with it. Most of the time we're pulling it. The vast majority of times at Christiana, we do use a closure device just to free up the room quicker. Our problem is more room time turnover rather than the cost of case. We have a bunch of different closure devices. We have passive closure devices like the MynxGrip.

We also have active closure devices like the Angio-Seal and the Celt more recently, which is really great for these five French cases because they do have a five French device that the patient is pretty much sealed instantly. You just have to watch it under ultrasound. But yes, the vast majority of time is using a closure device to close.

[Aaron Fritts MD]
Yes, that's a great point because these are not scheduled cases. They're often times brought in, in the middle of your day and then everything's getting pushed back of course, and room turnover is key, like you mentioned. You want to get them closed up and get them onto--

[Chris Grilli MD]
Whenever I walk out of a room and say to my coordinator that we're holding pressure, I get an eye roll and a fist shaking at me. We got to keep things moving.

Podcast Contributors

Dr. Chris Grilli discusses Treatment Algorithms for Splenic Artery Embolizations on the BackTable 270 Podcast

Dr. Chris Grilli

Dr. Christopher Grilli is a practicing interventional radiologist with the ChristianCare Interventional Radiology Group in Delaware.

Dr. Aaron Fritts discusses Treatment Algorithms for Splenic Artery Embolizations on the BackTable 270 Podcast

Dr. Aaron Fritts

Dr. Aaron Fritts is a Co-Founder of BackTable and a practicing interventional radiologist in Dallas, Texas.

Cite This Podcast

BackTable, LLC (Producer). (2022, December 9). Ep. 270 – Treatment Algorithms for Splenic Artery Embolizations [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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