www.elsevier.com/locate/jpedsurg

Journal of Pediatric Surgery (2011) 46, 933–937

The significance of pseudoaneurysms in the nonoperativemanagement of pediatric blunt splenic traumaKathryn Martin, Lisa VanHouwelingen, Andreana Bütter⁎

Division of Pediatric Surgery, Children's Hospital, London Health Sciences Center, London, Ontario, Canada

Received 4 February 2011; accepted 11 February 2011

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Key words:Pediatric;Blunt splenic trauma;Pseudoaneurysm;Nonoperativemanagement

AbstractPurpose: Nonoperative management is the standard of care for hemodynamically stable pediatric andadult blunt splenic injuries. In adults, most centers follow a well-defined protocol involving repeatedimaging at 24 to 48 hours, with embolization of splenic pseudoaneurysms (SAPs). In children, thesignificance of radiologically detected SAP has yet to be clarified.Methods: A systematic review of the medical literature was conducted to analyze the outcomes ofdocumented posttraumatic SAP in the pediatric population.Results: Sixteen articles, including 1 prospective study, 4 retrospective reviews, and 11 case reportswere reviewed. Forty-five SAPs were reported. Ninety-six percent of children were reported as stable.Yet, 82% underwent splenectomy, splenorrhaphy, or embolization. The fear of delayed complicationsowing to SAP was often cited as the reason for intervention in otherwise stable children. Only one childwith a documented pseudoaneurysm experienced a delayed splenic rupture while under observation. Nodeaths were reported.Conclusions: There is no evidence to support or dispute the routine use of follow-up imaging andembolization of posttraumatic SAP in the pediatric population. At present, the decision to treat SAP instable children is at the discretion of the treating physician. A prospective study is needed to clarifythis issue.© 2011 Elsevier Inc. All rights reserved.

Nonoperative management (NOM) is the standard of carefor hemodynamically stable pediatric blunt splenic injuries,with a success rate of more than 90% [1-5]. A fearedcomplication of NOM is delayed splenic rupture. In adults,delayed rupture is seen in 5% to 6% of blunt splenic traumaand is often attributed to the rupture of a posttraumaticsplenic pseudoaneurysm (SAP) [5]. A study by Schurr et al

⁎ Corresponding author. Division of Pediatric Surgery, Children'sospital of Western Ontario, London, Ontario, Canada N6A 4G5. Tel.: +119 685 8401; fax: +1 519 685 8421.E-mail address: andreana.butter@lhsc.on.ca (A. Bütter).

022-3468/$ – see front matter © 2011 Elsevier Inc. All rights reserved.oi:10.1016/j.jpedsurg.2011.02.031

demonstrated SAP in 67% of adults who failed NOM [6].This relationship between failed NOM and posttraumaticpseudoaneurysms in adults has lead to the practice ofrepeated imaging 24 to 48 hours after trauma andangiographic embolization of SAP if detected [7-12].

The significance of posttraumatic SAP in the pediatricsplenic trauma population is less well defined. Splenicpseudoaneurysm in this population is rare, and their presencealone has not been shown to predict delayed splenic bleedingor failure of NOM [1,3,5,13-15]. In children, SAP is thoughtto self-tamponade and resolve spontaneously [1-3,5]. Theapparent healing of SAP in children and the success of NOM

934 K. Martin et al.

is attributed to children's thicker, more fibrous spleniccapsule and denser, more elastic parenchyma [1,10].However, the fear of delayed rupture persists, leading someauthors to suggest routine follow-up imaging and emboliza-tion [2,16-18]. Others are willing to follow these lesionsclinically, given the high success of NOM and the risks ofembolization [1,14,19]. The American Pediatric SurgicalAssociation does not endorse the routine use of follow-upimaging because the appearance of the spleen on imaging hasnot been shown to correlate with splenic integrity or affectpatient outcome [4,20].

A systematic review of the available medical literaturewas conducted to analyze the outcomes of documentedposttraumatic SAP in the pediatric population. We hypoth-esized that the embolization of radiologically detectedposttraumatic SAP is not superior to clinical observation.Furthermore, we reviewed trends in grade, imaging, andoutcomes of SAP in an effort to guide the future managementof incidentally detected posttraumatic SAP.

1. Methods

London Health Sciences Center librarians conductedsystematic searches of PREMEDLINE, MEDLINE, andEMBASE databases from 1996 to January 2010. Studieswere limited to those published in the English language andinvolving patients younger than 18 years. Separate searchstrategies were formulated for each database using database-specific subject terms, syntax, and free-text forms. Queriesincluded a combination of exploded and nonexplodedsubject headings including the following: splenic artery,spleen, splenectomy, splenic rupture, and aneurysm false.Free-text terms included the following: spleen, splenic,splenectomy, pseudoaneurysm, false aneurysm, injury,trauma, and post-trauma. Editorials and letters wereexcluded. The references of all relevant articles were furtherscreened to identify any remaining pertinent articles.

A single investigator (KM) reviewed all retrievedcitations' titles and abstracts to eliminate those that clearlydid not meet inclusion and exclusion criteria. Twoindependent reviewers (KM and LV) reviewed the remainingarticles in their entirety for final selection. Selected articleswere hand-searched to identify any further relevant articles.

Two independent reviewers analyzed all selected articlesfor quality assessment and data extraction. Data were thenpooled, and discrepancies were dealt with through re-reviewand discussion between investigators until consensus wasobtained. Article quality was determined by study designincluding considerations of randomization, allocation, con-trol groups, outcomes, and follow-up. A standardized dataextraction form was used by investigators. Extracted dataincluded variables involved in the discovery and manage-ment of pediatric blunt splenic injuries with associated SAPsas determined by a review of current literature and expertopinion. Data were then summarized and compared with the

overall trends noted. Direct statistical comparisons betweengroups were not made because studies were too heteroge-neous with regard to methodology and outcome measures forthis to be statistically valid.

2. Results

The literature search retrieved 555 articles. Initial reviewof titles and abstracts eliminated 254 articles based on failureto meet inclusion and exclusion criteria. The remaining 301articles were reviewed in their entirety by both investigatorsfor final selection. Sixteen articles met inclusion andexclusion criteria; however, 2 case reports duplicated thesame case, and thus, the later publication was excluded,leaving 15 articles for analysis. A thorough review of thereferences from these selected articles produced an additional33 articles, one of which met our criteria and was included inour study. Therefore, a total of 16 articles were used for dataextraction: 1 prospective study, 4 retrospective reviews, and11 case reports.

Larger series in our review suggested an incidence ofposttraumatic SAPs between 2% to 27% [1,10,16,21,22]. Intotal, 45 patients with posttraumatic SAP were reported(Table 1). Five SAP were associated with traumaticarteriovenous fistulas (AVFs) in hemodynamically stablechildren. One AVF was observed with serial ultrasounds andresolved without complication [21]. The remaining 4 AVFunderwent intervention: 3 had uncomplicated embolizationsand 1 underwent splenectomy [7,17,24,26]. Two patientswere found to have multiple pseudoaneurysms [18,19]. Onepatient with 2 pseudoaneurysms required splenectomy for aninfected hematoma [18]. The other child with 3 pseudoa-neurysms was managed nonoperatively with radiologicevidence of resolution by post-trauma day 12 [19].

Most the 45 children with SAP underwent intervention(Fig. 1). Thirty-four had embolizations, whereas 2 wentstraight to the operating room. A third child with an SAPdetected on post-trauma day 5 was initially observed until hebecame unstable 2 days later and underwent splenorrhaphywith no long-term sequelae [23]. Three of the 34 emboliza-tions failed because of ongoing bleeding or an inability toplace coils. All 3 of these children subsequently underwentsplenectomy [10]. Twenty-six of the 34 embolizationsoccurred in the series of Mayglothling et al [10]. Shereported 6 splenic infarctions postembolization, all ofwhich resolved without further intervention. There wereno deaths reported.

Eighty-seven percent of the reported cases had repeatedimaging as part of a trauma pathway or to document healingbefore return to normal activity (Table 1). Only 4 of the 45cases had imaging because of new symptoms, whichincluded pain, fever, and shortness of breath [1,7,18].Splenic pseudoaneurysms were detected using ultrasound,computed tomography, magnetic resonance imaging, andangiography. More than one imaging modality was often

Table 1 Reports of posttraumatic SAPs

Reference Age (y) Injurygrade

Injury Timedetected

Imaging Reason forrepeatedimaging

Clinicalstatus

Treatment Outcome

Hiraideet al [23]

12 NOS PA D 5 US, CT, MRI Document healing Stable Observed Becameunstable witha delayedrupture.Underwentsplenorrhaphy.

Fitoz et al [18] 12 NOS PA ×2 Wk 2 US, CT Pain + fever NOS Splenectomy Found infectedhematoma.Uneventfulrecovery.

Engelke et al [3] 15 II PA Wk 3 US, CT Document healing Stable Embolized ResolutionNagar et al [19] 7 I PA ×3 D 2 US Document healing Stable Observed ResolutionMaloo et al [24] 14 III PA/AVF D 14 US Document healing Stable Embolized ResolutionOguz et al [17] 12 IV PA/AVF D 15 US, CT Document healing Stable Embolized ResolutionYardeni et al [2] 10 III PA Wk 6 CT Trauma pathway Stable Embolized Residual

splenic cystJames et al [25] 5 NOS PA D 4 US Document healing Stable Embolized ResolutionOguzkurtet al [26]

13 NOS PA/AVF M 4 US Document healing Stable Splenectomy Resolution

Gow et al [14] 6 IV PA D 5 US NOS Stable Observed Resolution8 NOS PA D 6 US NOS Stable Observed Resolution

Raghavanet al [7]

8 III PA/AVF D 5 US, Angio Tachypnea + Pain Stable Observed Resolution12 NOS PA NOS US, Angio Symptomatic Stable Observed Resolution

Dobremezet al [16]

7 II PA D 5 US Document healing Stable Embolized Resolution14 III PA D 5 US Stable Embolized Resolution

Mayglothlinget al [10]

13-17 Mean III 26 PA H 48-96 CT, Angio Trauma pathway 26 stable 26 embolized 3 failed →splenectomy;6 infarctions

Frumientoet al [1]

3 III PA D 14 CT Pre-discharge Stable Observed Resolution14 IV PA D 14 CT Pain Stable Observed Resolution

Minariket al [21]

NOS NOS PA/AVF Wk 6 US Trauma pathway Stable Observed Resolution

Mehallet al [22]

NOS III PA Wk 6 US Trauma pathway Stable Embolized Resolution

NOS indicates not otherwise specified; PA, pseudoaneurysm; US, ultrasound; CT, computer tomography; MRI, magnetic resonance imaging;Angio, angiogram.

935Significance of pseudoaneurysms in blunt splenic trauma

used to confirm the diagnosis. Posttraumatic pseudoaneurysmswere detected as early as post-trauma day 2 and as late as 4months after the initial trauma [10,19,26]. Splenic pseudoa-neurysm was documented in all grades of splenic injury.

Fig. 1 Management and outcomes of posttr

3. Discussion

Controversy exists over the optimal management ofposttraumatic SAP in children. Our literature review found a

aumatic SAPs after blunt splenic injury.

936 K. Martin et al.

2% to 27% incidence of pediatric SAP after blunt splenictrauma [1,10,16,21,22]. A separate series of studies designedto document healing by computed tomographic scan andultrasound detected no SAP in a group of 307 patients [1].This discrepancy may be owing to a reporting bias in ourpopulation or a failure to detect pseudoaneurysms in theseother studies.

Of the 45 posttraumatic SAP reported in our review, 9were observed, of which 8 resolved spontaneously. Theremaining child in the observed group became unstableand required urgent splenorrhaphy [23]. The majority(76%) of the detected SAP underwent embolization (Fig.1). All of these patients were in stable condition at thetime of SAP detection and treatment (Table 1). The fearof delayed splenic rupture and other late complications ofposttraumatic SAP, such as AVF formation, were oftencited as the reason for intervention in otherwise stablechildren [3,7,16,17,26]. Interestingly, Davies et al [27]reported a case of a boy, aged 15 years, who died ofdelayed splenic bleeding 23 days after his initial injury.This patient had follow-up imaging before hospitaldischarge that had ruled out SAP, raising the possibilityof other mechanisms of delayed splenic rupture inchildren [27].

The single delayed splenic rupture reported in ourseries suggests that SAP will rupture in 11% of cases.This represents a significant rate of delayed splenicrupture; however, this number is likely inflated because ofthe number of patients who underwent embolization andthe lack of routine imaging and reporting of SAP byradiologists. Given the success of NOM for blunt splenictrauma and the absence of routine follow-up imaging inmost institutions, it is likely that many posttraumatic SAPstill go undetected and resolve spontaneously without anylong-term sequalae [4,9,13,28]. Delayed splenic rupture isthought to be very rare (b1%) in the pediatric population,with some larger series reporting no ruptures [27-29].Adult data have demonstrated that both contrast blush andSAP predict delayed splenic bleeding and the failure ofNOM [6,8,10]. This has not been convincingly demon-strated in the pediatric population. In fact, there isevidence that contrast blushes in children do not predictfailure of NOM. It is also possible that the same is truefor SAP [30-32].

The American Pediatric Surgery Association's guide-lines, first published in 2000 and subsequently validated byStylianos [4,20], do not recommend routine follow-upimaging of pediatric blunt splenic trauma. This issupported by many other studies including a large reviewby Huebner and Reed [29] who demonstrated that theoutcome of pediatric blunt splenic injures was unaffectedby imaging protocols in 1083 patients. Yet, 91% of theposttraumatic SAP documented in this review was foundduring routine imaging, whereas only 9% were detectedwhile investigating new or persistent symptoms. This hasled some authors to suggest routine imaging of splenic

injuries to look for SAP despite the American PediatricSurgery Association guidelines [2,16,17].

The risks of embolization need to be considered beforeroutine embolization of posttraumatic SAP is undertaken.Twenty-six percent of the embolizations in this series hadcomplications that included splenic infarction, splenicbleeding, and the inability to place coils [10]. Experiencefrom the adult literature has shown that complications canoccur in up to 62% of embolizations and includebleeding, infarction, AVF, splenic rupture, abscessformation, pleural effusion, fever, coil migration, andcontrast-induced renal insufficiency [9,13,33,34]. Nocomplications of femoral artery access were reported inour review, but these are well documented in the pediatricliterature and include bleeding, femoral artery pseudoa-neurysm, femoral AVF, acute limb-threatening ischemia,and chronic leg ischemia presenting as claudication andlimb-length discrepancy [35,36]. All 3 cases of technicalfailure reported in this review went on to splenectomy[10], begging the question: is splenectomy the next step infailed embolization?

The quality of the literature presented in this systematicreview is poor because 11 of 16 articles are case reports. Thelarger retrospective series also represent low-quality studiesthat lack randomization, blinding, and adequate controlgroups. These studies failed to control for confoundersbecause of inconsistent imaging protocols and criteria for thediagnosis of posttraumatic SAP. The only prospective study,by Mehall et al [22], was also limited because its primaryoutcomes were unrelated to the detection and management ofSAP. Therefore, they did not control for important factorssuch as variability among radiologists.

Given the lack of consensus in the literature, Li andYanchar [37] conducted a survey of Canadian pediatricsurgeons to determine their management of pediatric bluntsplenic injury, including their approach to follow-up imagingand SAP. They found that half of the surveyed group wouldmanage posttraumatic SAP seen on follow-up imaging withurgent angiography and embolization irrespective of hemo-dynamic status. Furthermore, pediatric surgeons who hadpreviously managed a case of SAP were twice as likely toorder follow-up imaging to screen for SAP and thrice morelikely to pursue angiography if a SAP was found [37]. Theresults of this survey further demonstrate the currentvariability in screening and treating radiologically detectedposttraumatic SAP.

At present, there is no evidence to support or dispute theroutine use of follow-up imaging and embolization ofposttraumatic SAPs in children with blunt splenic trauma.Previous studies demonstrating the overwhelming successof NOM would suggest that hemodynamic status, and notradiologic findings, should be the guiding force oftreatment [19,22,28,32,38]. Currently, the treatment ofSAP is left to the discretion of the treating physician.Prospective data are needed to clearly define the naturalhistory of posttraumatic SAP.

937Significance of pseudoaneurysms in blunt splenic trauma

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