How To Use Coils To Repair Your Spleen

• Review Article
• Open Access
• Published: 18 March 2022

Review of proximal splenic avenue embolization in blunt abdominal trauma

CVIR Endovascular volume two, Commodity number:eleven (2019) Cite this article

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Abstract

The spleen is the most commonly injured organ in edgeless abdominal trauma. Unstable patients undergo laparotomy and splenectomy. Stable patients with lower grade injuries are treated conservatively; those stable patients with moderate to severe splenic injuries (grade Three-5) benefit from endovascular splenic artery embolization. Two widely used embolization approaches are proximal and distal splenic avenue embolization. Proximal splenic artery embolization decreases the perfusion pressure in the spleen just allows for viability of the spleen to exist maintained via collateral pathways. Distal embolization tin be used in cases of focal injury. In this commodity we review relevant literature on splenic embolization indication, and technique, comparing and contrasting proximal and distal embolization. Additionally, nosotros review relevant beefcake and discuss collateral perfusion pathways following proximal embolization. Finally, we review potential complications of splenic artery embolization.

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Background

The spleen has many important roles including T-cell proliferation and antibiotic product and phagocytosis of senescent scarlet blood cells (Coccolini et al. 2022; Mebius and Kraal 2005). Therefore, in the setting of splenic trauma, splenectomy is avoided when possible. Avoiding splenectomy precludes the development of overwhelming post-splenectomy sepsis, a potentially fatal infection caused by encapsulated bacteria (Coccolini et al. 2022; Uranus and Pfeifer 2001; Lynch and Kapila 1996; Cullingford et al. 1991; Banerjee et al. 2022).

Trauma protocols are resource and institution dependent. In general, hemodynamically stable with meaning blunt abdominal trauma are imaged with contrast enhanced computed tomography (CT). The abdomen is typically scanned in a portal venous phase (Dreizin and Munera 2022). American Association for the Surgery of Trauma (AAST) splenic laceration grade is based on CT angiography findings (Moore et al. 1994) (see Table 1).

Table one AAST splenic laceration grading by CT. Other findings on CT non included in AAST criteria but important for triaging patients include active extravasation and pseudoaneurysm

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Splenic preservation can exist accomplished via iii routes: ane-bedrest and close monitoring alone (typically for class I or Ii); 2- endovascular splenic artery embolization combined with bedrest and close monitoring (AAST grade 3-V splenic injuries or with CT scans demonstrating pseudoaneurysms, traumatic arteriovenous fistula or extravasation); three-surgical repair (known as splenorrhaphy). Endovascular splenic embolization is constructive; when splenic preservation is washed without adjunctive splenic artery embolization, failure (defined every bit the demand for subsequent splenectomy) is seen in approximately twoscore% of high grade injuries compared to 2% when embolization has been performed (Banerjee et al. 2022; Dreizin and Munera 2022; Moore et al. 1994; Requarth et al. 2022; Ahuja et al. 2022; Scatliff et al. 1975; Albrecht et al. 2002; McIntyre et al. 2005).

Endovascular splenic artery embolization tin can be performed distally or proximally depending on the injury pattern. Distal splenic avenue embolization is preferred in cases of focal vascular injury (eastward.g. vessel truncation, pseudoaneurysm, focal extravasation) (Bessoud and Denys 2004). Distal embolization is often precluded given the predominantly multifocal injury pattern of blunt splenic injury (Scatliff et al. 1975). In cases of multifocal injury or when no focal angiographic abnormality is identified, but CT has demonstrated injury, proximal splenic artery embolization (PSAE) is performed (Imbrogno and Ray 2022).

PSAE works past decreasing the systolic arterial pressure in the spleen, promoting hemostasis and healing inside the splenic parenchyma. Blood flow to the spleen is maintained via collaterals, which non but prevents infarction and abscess formation but also preserves splenic immune function (Imbrogno and Ray 2022; Bessoud and Denys 2004; Zmora et al. 2009). PSAE may also exist performed exterior the setting of trauma such every bit in cases of splenic artery aneurysm/pseudoaneurysm and in post liver transplant splenic artery steal syndrome (Loffroy et al. 2008; Saad 2022; Gu et al. 2022).

Splenorrhaphy can exist used for splenic preservation involves suturing splenic defects and/or applying hemostatic agents to the areas of splenic injury. Information technology is nearly helpful in cases of polytrauma where non-operative management is not possible or preferrable, and has been shown to be an constructive method for splenic preservation (Tsaroucha et al. 2005). Splenic preservation is but a secondary goal in the direction of trauma patients; unstable patients should undergo splenectomy. In patients with poly-intestinal trauma, treatment decisions are based on patients' overall clinical picture.

In this review, we discuss the use of splenic avenue embolization as office of not-operative management for splenic injuries acquired by blunt abdominal trauma. Nosotros compare and dissimilarity proximal and distal embolization. Nosotros review relevant beefcake focusing on where to perform proximal embolization and routes of collateral perfusion post-obit proximal embolization. Additionally, we provide procedural tips and tricks and review potential complications from splenic avenue embolization.

Study choice

Relevant articles pertaining to splenic trauma, role, beefcake, and splenic embolization using PubMed (US National Library of Medicine, Bethesda, MD) were reviewed. No studies were excluded based on year of publication. Selected studies were evaluated and assigned a level of evidence grade based on adaptations from existing guidelines (Table 2). Search terms included splenic embolization, splenic trauma, blunt abdominal trauma, splenic laceration, splenic collateral circulation, spleen preserving distal pancreatectomy.

Table 2 Summary table of primal studies on splenic embolization with a level of evidence designation. Levels of evidence are defined using the grading system adapted from the American Society of Plastic Surgeons and Johns Hopkins nursing bear witness-based practice: Models and Guidelines (Burns et al. 2022; Dang and Dearholt 2022) - (see Table 5)

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Splenic embolization-procedure

Relevant anatomy

Along with the left gastric and mutual hepatic arteries, the splenic artery is i of three branches of the celiac trunk. The splenic artery supplies not only the spleen but too the body and tail of the pancreas and portions of the stomach. The get-go large branch of the splenic artery is typically the dorsal pancreatic avenue, also known every bit the posterior pancreatic artery. This vessel nearly commonly arises from the proximal splenic artery (40–51% of cases; Fig. ane), but may also arise from the celiac trunk (3–28% of cases; Fig. 2), common hepatic artery (17–22% of cases; Fig. 3) or superior mesenteric artery (15–46% of cases) (Baranski et al. 2022; Bertelli et al. 1998; Okahara et al. 2010). The dorsal pancreatic artery bifurcates into left and correct branches; the left co-operative continues as the transverse pancreatic artery, which runs parallel to the splenic artery. The 2d large branch of the splenic artery is the great pancreatic avenue, which is also referred to every bit the arteria pancreatica magna and the greater pancreatic artery. This vessel typically arises from the mid portion of the splenic artery (see Figs. i, 2, and 3). The caudal pancreatic artery is the most distal pancreatic branch, arising from the distal splenic artery in approximately 70% of cases or the inferior polar artery in the remaining xxx% (Macchi et al. 2022) (Fig. four). When performnig PSAE, the platonic placement of plugs/coils is between the dorsal pancreatic artery and great pancreatic artery.

Fig. one

Celiac angiogram (a) in a 22 yo female person status mail rollover motor vehicle accident with grade III splenic laceration shows the dorsal pancreatic artery (curved black pointer) arising from the proximal splenic artery. The dorsal pancreatic artery arises from the proximal splenic artery in approximately 50% of cases. Selective splenic angiogram (b) shows the keen pancreatic artery (curved white pointer) arising from the mid splenic avenue. Note the multifocal areas of dissimilarity pooling within the splenic parenchyma consistent with multifocal traumatic injury

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Fig. two

65 year old female undergoing celiac angiogram for upper gastrointestinal bleed. Celiac DSA showing the dorsal pancreatic artery (thin arrows) arising direct from the celiac torso (dotted blackness pointer), which occurs in ~ xv% of cases. The nifty pancreatic artery (curved black arrow) arises from the mid portion of the splenic artery. Ideal placement of coils/plugs in proximal splenic artery embolization is between these 2 vessels. Transverse pancreatic artery (thick blackness arrow)

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Fig. three

32 year erstwhile male person in a snowmobile verses truck accident. a Celiac DSA afterwards proximal splenic artery embolization with an AMPLATZER™ Plug (black star). Note the dorsal pancreatic artery (sparse straight black arrow) originates from the mutual hepatic artery, a variation that occurs in approximately twenty% of cases. Blood from the dorsal pancreatic artery so travels left along the transverse pancreatic artery (thick blackness arrows). Claret and so flows retrograde up the great pancreatic avenue (curved black arrow) reconstituting the mid/distal splenic artery (thick white arrow). b Subsequent epitome shows reconstituted menstruum in the mid/distal splenic artery (thick white pointer) with opacification of splenic artery branches (thin white arrows)

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Fig. 4

52 yo male status post motor vehicle blow with course 3 splenic injury. Afterwards coils were mistakenly placed distal to the origin of the great pancreatic artery (thin white arrowa, b), splenic artery DSA shows at that place is reconstitution of the distal splenic avenue (thin black arrowsb-d) via a cracking pancreatic artery to transverse pancreatic avenue (thick white pointerb) to caudal pancreatic avenue (curved white arrowb) pathway. The caudal pancreatic avenue arises from the distal third of the splenic artery (lxx% of cases) or an inferior polar co-operative of the splenic avenue (30% of cases)

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Embolization technique

Splenic avenue embolization is typically performed via a trans-femoral approach. The celiac trunk is engaged using a 5 Fr reverse bend catheter, such equally a Cobra, Sos or Simmons catheter. Celiac angiogram using digital subtraction angiography is so done, with a catamenia rate of five–7 mL/second for a total volume of xx–28 mL. Images are evalutated for splenic artery patency, tortuosity, size, and blueprint of injury. Mutual angiographic findings of splenic injury in blunt abdominal splenic trauma include arteriovenous fistula (directly connections betwixt arteries and veins), pseudoaneurysm (focal outpouching of a vessel), vasospasum/truncation (abrubt vessel cutoff) (Madoff et al. 2005). Frank extravasation of dissimilarity (extravascular contrast which diffuses from site of injury) tin be seen, but is rare (Madoff et al. 2005). The origin, patency and class of other branches of the celiac trunk such every bit the left gastric artery, the gastroduodenal artery and the right gastroepiploic avenue are evaluated as these branches are of import in supplying collateral perfusion to the spleen. A catheter is then advanced selectively into the splenic avenue and angiogram is so done with farther evaluation of splenic artery diameter (typically betwixt 5 and nine mm in diameter) and splenic parenchymal injury. The origins of pancreatic branches such as the dorsal pancreatic artery and the great pancreatic avenue are noted. Typical flow rates for selective splenic avenue angiogram are five–vi mL/second for a total volume of 15–xviii mL.

Proximal versus distal splenic artery embolization

PSAE is performed in cases of multifocal injury, whereas distal embolization is reserved for cases of focal vascular injury (Table iii). There is no significant difference in efficacy of splenic salve between proximal and distal embolization (Schnuriger et al. 2022). There is, however, a higher rate of small splenic infarctions with distal splenic embolization (Imbrogno and Ray 2022; Schnuriger et al. 2022; Killeen et al. 2001). Another reward of PSAE over distal embolization is faster process times, which is important in trauma patients whose hemodynamic stability can change chop-chop. A quicker procedure also allows for timely treatment of other injuries, and information technology helps reduce radiation dose (Imbrogno and Ray 2022). A theoretical disadvantage of PSAE is rebleeding distal to the coils/plugs; endovascular re-intervention would necessitate navigation through collaterals to perform subsequent distal embolization (Imbrogno and Ray 2022). This has not occurred in any published series to date. In cases where splenic injury is present just the angiography is negative, PSAE is preferred (Imbrogno and Ray 2022).

Table 3 Proximal vs Distal Splenic Embolization in Trauma Patients (Ahuja et al. 2022; Imbrogno and Ray 2022; Schnuriger et al. 2022; Killeen et al. 2001)

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Distal embolization

To perform distal embolization, a microcatheter and microwire are advanced to the site of the vessel injury causing the extravasation, pseudoaneurysm or arterio-venous fistula. Once in proper position, embolization with particles, mucilage (such as Due north-butyl cyanoacrylate), gelfoam and/or coils is performed. Embolization using glue is an effective technique that can be used in patients with coagulopathy, however due to rapid polymerization of glue fabric, there is a small risk of embolization too proximal to the desired expanse of handling (Loffroy et al. 2008). Completion selective so proximal splenic angiograms are done after distal embolization to ensure desired occlusion of the injured vessel.

Proximal embolization

For PSAE, vascular plugs and/or coils can be used (Table 4). The desired site of embolization for PSAE is betwixt the dorsal pancreatic artery and great pancreatic artery (Widlus et al. 2008; Sclafani et al. 1991). Some operators prefer 0.035″ coils given their greater radial force and wall apposition, which minimizes the run a risk of distal migration in the high flow splenic artery. Coils should be sized to be 20–30% larger and plugs should exist sized 30–50% larger than the target vessel (Vaidya et al. 2008). Some operators prefer using vascular plugs for PSAE as they can be precisely placed (Norotsky et al. 1995). The AMPLATZER™ Family of Vascular Plugs (AVP; Abbott Laboratories, Chicago, IL) is the merely plug big enough for the proximal splenic avenue embolization. These plugs come in three varieties, the AVP, the AVP Two and the AVP-4 (Vaidya et al. 2008). The AVP-iv, which can be delivered through whatsoever catheter that accepts a 0.038″ wire, is infrequently used because the largest diameter they come up in is 8 mm (maximum target vessel bore of  5.5 mm). The AVP 2 comes in a wider variety of diameters. The 10 and 12 mm AVP 2 can exist delivered through a five Fr sheath or a 6 Fr-guiding catheter.

Table four Pearls and Pitfalls of Splenic Avenue Embolization

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Combined proximal and distal embolization

Later on distal embolization, PSAE can be performed. The decision on whether to perform PSAE after distal embolization depends on injury pattern, patient condition, local practice patterns and operator preference. The rationale for performing PSAE subsequently successful distal embolization is that some vascular injuries may not exist visible on initial angiogram and may lead to delayed drain in one case the vasospasm subsides (Nance and Nance 1995; Campbell et al. 1991; Norotsky et al. 1995). This combined approach, however, leads to a higher rate of complications; a recent meta-analysis compairing serious complication rates (defined equally those requiring further intervention, organ dysfunction, need for ICU direction, or death) showed a more than than doubled rate of complications in combined embolization (58.8%) compared to PSAE (18.2%) or distal embolization (28.7%) lonely (Rong et al. 2022).

Collateral routes of perfusion afterward PSAE

The left gastroepiploic artery arises from either the distal splenic artery or an junior polar branch of the splenic artery. Information technology runs along the greater curvature of the stomach and, in ~ 90% of cases, anastomoses directly with the right gastroepiploic artery, a last co-operative of the gastroduodenal artery (Egorov et al. 2022). The short gastric arteries are a group of 2–10 small terminal arteries arising from the distal splenic avenue and its concluding branches (Egorov et al. 2022). They course within the gastrosplenic ligament where they anastomose with branches of the left gastric artery (Gregorczyk et al. 2008).

I collateral pathway to the spleen after PSAE is from the dorsal pancreatic artery to the transverse pancreatic artery to the bully pancreatic avenue which so feeds into the mid/distal splenic artery (Figs. v and six). Intendance must be taken not to embolize distal to the great pancreatic avenue; if embolization is performed distal to this artery, this route will longer be able to provide collateral menstruation to the spleen (Fig. 7). Other routes, such the bully pancreatic artery to the caudal pancreatic avenue may allow for collateral perfusion if embolization is performed distal to the great pancreatic avenue (Fig. 4). Another route of collateral flow is from the right gastroepiploic artery to the left gastroepiploic, which then feeds into the distal splenic artery or an inferior polar branch (Figs. 8 and ix). The left gastric artery supplies an of import collateral route afterwards PSAE. The left gastric avenue anastomoses with the short gastrics in the region of the fundus of the tum, thereby supplying branches of the splenic artery (Fig. 10). These latter 2 pathways are relied upon to maintain splenic viability when distal pancreatectomy with splenic preservation and splenic vessel sacrifice (Warshaw's technique) is performed (Warshaw 1988; Jean-Philippe et al. 2022). Finally, multiple collateral routes of collateral perfusion combining any of the above routes may as well be seen.

Fig. v

Schematic for the dorsal pancreatic (thin white arrow) to transverse pancreatic (thick white arrow) to great pancreatic avenue (curved white pointer). Short black arrows announce the management of menses. (Blackness star-coils in proximal splenic artery)

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Fig. 6

Transradial splenic angiogram post-obit splenic trauma. Later proximal splenic artery embolization using coils (black star), flow from the proximal splenic avenue (straight white arrow) to the distal splenic avenue (curved white pointer) is maintained via dorsal pancreatic (straight sparse black pointer) to transverse pancreatic (directly thick blackness arrow) to great pancreatic artery (curved black arrow) pathway

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Fig. vii

85 year former male with pancreatic cancer status postal service iatrogenic trauma following drain placement for a perisplenic abscess. Splenic artery DSA afterwards embolization shows that the AMPLATZER™ Plug (white pointer) has mistakenly been placed distal to the great pancreatic artery (curved black arrow). This excludes collateral perfusion of the spleen via the dorsal pancreatic avenue (straight sparse black pointer) to transverse pancreatic (thick blackness arrows) to great pancreatic artery pathway

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Fig. 8

Schematic representation of collateral pathway of right gastroepiploic (thick curved blackness pointer) to left gastroepiploic avenue (thin curved black pointer). The right gastroepiploic avenue is a terminal branch of the gastrodoudenal avenue (GDA; straight white arrow). Information technology courses within the greater omentum forth the greater curvature of the stomach. The left gastroepiploic artery may ascend from the distal splenic or an inferior polar artery

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Fig. 9

56 year old female, history of alcoholism, fall from standing height. Celiac artery angiogram later on proximal splenic artery embolization with an AMPLATZERTM Plug (star a). This shows collateral perfusion to the spleen and distal splenic artery (straight black arrowsb-d) via GDA (thin straight white arrow b, c) → right gastroepiploic (curved white arrow b-d) → left gastroepiploic pathway (curved black arrowb-d). Annotation that the parenchymal opacification of the spleen is markedly delayed compared to the liver, an expected finding after PSAE (d). Corkscrew intrahepatic arteries and the recannalized periumbilical vein with hepatopedal flow (thick white arrow b, c) are consistent with the patient's known history of booze cirrhosis and portal hypertension

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Fig. x

a Schematic of collateral splenic perfusion via the left gastric (star) to short gastric pathway (curved arrows). Annotation that the normal management of flow is reversed in the short gastric arteries. b 39 yr one-time female with history of splenic laceration caused by motor vehicle blow 11 years prior which was treated with a subtotal splenectomy too equally splenic artery and vein ligation. Left gastric artery angiogram done for bleeding gastric varices demonstrates the left gastric to short gastric to spleen collateral pathway

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Post procedure

Antibiotic therapy

Based on our literature review, at that place are no current antibody treatment guidelines for splenic avenue embolization in the setting of trauma. At our establishment, we routinely give 1 g of Cefazolin immediately prior to splenic artery embolization (Level V, come across Table 5). Following PSAE, if the post embolization DSA shows good flow to the spleen we do not routinely use go along antibiotic therapy. If, nevertheless there is poor menses to the spleen on post procedure DSA, nosotros give amoxicillin/clavulanic acid for 7 days to encompass enteric flora. Following distal embolization, if a large territory was embolized we requite five days of amoxicillin/clavulanic acid.

Tabular array 5 Levels of Evidence Adapted from the American Lodge of Plastic Surgeons and Johns Hopkins nursing evidence-based practice: Models and Guidelines (Burns et al. 2022; Dang and Dearholt 2022)

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Splenic office afterward embolization

Splenic function is preserved afterwards splenic embolization (Bessoud et al. 2007; Olthof et al. 2022). Preserved phagocytosis is confirmed by the absence of Howell-Jolly bodies (abdormal bsophilic nuclear remnants withing ruby-red blood cells due to scarce phagocytosis) after splenic embolization (Olthof et al. 2022; Pirasteh et al. 2022). Splenic dependent T-cell immunity is preserved after splenic embolization. The levels of 2 subpopulations of CD4+ T cells (CD4 + CD45RA+ and CD4 + CD45RO+), which are essential in antigen induced T-cell proliferation, are markedly diminished in asplenic patients but are normal after splenic embolization (Malhotra et al. 2010). Finally, antibody response to pneumococcal polysaccharide vaccine is preserved later splenic embolization but is blunted in asplenic patients (Olthof et al. 2022). Routine encapsulated organism antibiotics after splenic embolization is non needed.

Complications

A multi-institutional trial assessing complexity from splenic artery embolization establish a major complication rate of 20%, and a pocket-sized complication rate of 23% (Ahuja et al. 2022; Haan et al. 2004). There is statistically no meaning departure in the rate of major complications such as infection, infarction, or rebleeding requiring splenectomy when comparing proximal or distal splenic artery embolization (Schnuriger et al. 2022). The but complication discrepancy betwixt PSAE and distal embolization is splenic infarct, with ~3x college charge per unit of infarct in distal embolizations (i.6% - iii.viii% rate of major splenic infarctions in distal embolization; 0.0–0.5% for PSAE) (Schnuriger et al. 2022; Bessoud et al. 2007). Signs and symptoms of infarction include left upper quadrant pain and tenderness, fever, leukocytosis, nausea and vomiting, and an elevated serum lactate dehydrogenase (Lawrence et al. 2010). Splenic abscess (Fig. 11) frequently presents with persistent fever despite antibiotic coverage, left sided pleural effusion, and left upper quadrant pain (Lee et al. 2004).

Fig. 11

37 year old male with an AAST grade Three splenic injury following high speed motor vehicle crash. a Splenic artery DSA with a catheter in the splenic artery (blackness pointer) demonstrating a focal pseudoaneurysm (white arrows). b A base of operations catheter in the splenic artery (small white arrow), with a v F microcatheter fed through a tortuous splenic artery (big white arrow). The tortuosity and distance of this pseudoaneurysm precludes the use of traditional covered stents in this area. c Post coil embolization DSA showing a treated pseudoaneurysm. d I calendar week after embolization, an axial contrast enhanced CT through the spleen demonstrates distal embolization coils (small white pointer), an area of focal infarction (modest black arrow), and a splenic abscess (large blackness arrow). A partially visualized drain is present within the infected collection (big white pointer)

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Conclusion

The spleen is commonly injured in blunt trauma. In hemodynamically stable patients, attempts are made at splenic preservation in order to sustain its immune role thereby preventing overwhelming postal service-splenectomy infection. PSAE plays an of import role in non-operative management of splenic trauma. It works past decreasing perfusion pressure inside the splenic parenchyma. At the aforementioned time, collateral menstruation keeps the splenic tissue feasible, preserving its function and preventing infarction and abscess formation. Distal embolization tin be performed in cases of focal vascular injury.

Abbreviations

AAST:

American Association for the Surgery of Trauma

APV:

AMPLATZER™ Vascular Plug

CT:

Computed tomography

DSA:

Digital subtraction angiogram

PSA:

Pseudoaneurysm

PSAE:

Proximal splenic avenue embolization

RTC:

Randomized Controlled Trial

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1. Segmentation of Interventional Radiology, University of Utah Section of Radiology, 30 N. 1900 E., Salt Lake City, UT, 84132, USA

   Keith Bertram Quencer & Tyler Andrew Smith

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KQ, TS participated in article selection, draft creation, response to revisions, and editing. KQ obtained and labeled imaging. All authors read and canonical the final manuscript.

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Correspondence to Tyler Andrew Smith.

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Quencer, Thou.B., Smith, T.A. Review of proximal splenic artery embolization in edgeless intestinal trauma. CVIR Endovasc 2, 11 (2019). https://doi.org/ten.1186/s42155-019-0055-3

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• Received: 15 January 2022

• Accepted: 07 March 2022

• Published: 18 March 2022

• DOI : https://doi.org/10.1186/s42155-019-0055-three

Keywords

• Splenic embolization
• Blunt intestinal trauma
• Proximal splenic embolization
• Splenic salve
• Splenic anatomy

How To Use Coils To Repair Your Spleen,

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