Splenic Embolization Procedure

[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.

[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.