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BackTable / VI / Podcast / Transcript #270
Podcast Transcript: Treatment Algorithms for Splenic Artery Embolizations
with Dr. Chris Grilli
In this episode, Dr. Aaron Fritts interviews Dr. Chris Grilli of Christiana Health about his treatment algorithms and procedural tips for splenic embolization as a treatment for splenic trauma, hypersplenism, and splenic artery aneurysm. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Splenic Trauma Presentation: Grading and Management
(2) Splenic Trauma Management: IR or OR? Embolization vs Surgery
(3) Splenic Embolization in Trauma: Techniques and Tools
(4) Splenic Embolization Procedure: Proximal, Distal & Choosing the Embolization Device
(5) Optimizing Splenic Trauma Procedure Time
(6) Splenic Embolization Procedure: Liquid Embolics and Closure Devices
(7) Non-Emergent Splenic Embolizations for Hypersplenism
(8) Non-Emergent Splenic Embolization for Aneurysm
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[Aaron Fritts MD]
Hello everyone, and welcome to the BackTable podcast. Your source for all things interventional and endovascular. You can find all previous episodes of our podcast on iTunes, Spotify, and on backtable.com.
Today we've got a very special episode. We're going to discuss treatment algorithms for splenic artery embolization. We're going to talk a little bit about, mostly probably about trauma, because that's usually the most common reason why we're doing this. Also, a little bit, we'll talk a little bit about Hyper Leninism a little bit at the end.
I'm very pleased to introduce our guest, Chris Grilli MD Grilli, coming from Christiana Health Interventional Radiology Group. Welcome Chris to the show.
[Chris Grilli MD]
Aaron, thanks so much for having me. This is a lot of fun and I really appreciate the invite.
[Aaron Fritts MD]
Yes. I understand you’re the Assistant Program Director of the IR program there. Is that right?
[Chris Grilli MD]
Yes, the Assistant Program Director. We have the integrated pathway as well as the independent pathway. Then I have the fund duty of also being the Assistant Program Director of the DR program at Christiana.
[Aaron Fritts MD]
Well, for the IR audience, we do have some med student listeners. Could you tell us a little bit about what cases your trainees see and a little bit about the program?
[Chris Grilli MD]
Yes. Christiana Care is based in Delaware. We have three hospitals in the system. We, as IRs work mainly out of the main hospital, which is well over 1,000 beds. It's a very big institution. It has a really large catchment area. We cover most of Delaware as well as a large part of Southern Pennsylvania, Eastern Maryland, and also Western New Jersey. We do see a wide variety of cases. As far as the IR department is concerned, there's seven attendings there as well as on top of that four neuro-interventional attendings, and then two attending that pretty much just do CT guided interventions all day long.
They're interventional radiologists at our institution - body guys. Like I said, we have a very, very broad caseload. I would say we're a bit vascular-heavy arterial and venous interventions, which is really great because that's sometimes tough to find nowadays. We also do a fair amount of oncology, UAEs, trauma. We're a level one trauma center, which of course we'll get into today, We do PAEs and all the bread-and-butter cases that you'd expect to see at a place like that. We take one integrated resident per year and one independent resident per year. In the past we have the direct pathway, which many of you may not know, but that was the precursor to the integrated pathway.
That's the type of resident I was. I actually trained at Christiana and then stayed on and we've rolled that over into the integrated pathway. We're really used to having medical students right out of medical school enroll in our program. Then we also have the integrated or independent, which is a one-year program, and as well as ESIR in the DR section.
[Aaron Fritts MD]
Yes. Thank you for sharing that. Having done residency, I did residency at Pennsylvania Hospital up in Philly. I got to work with Dave Ball, and then Sam Putnam. Sam was one of your former colleagues. Those guys definitely inspired and influenced me to go into IR and I like keeping in touch with those guys. How long ago did Sam leave?
[Chris Grilli MD]
Oh, he left a few years ago now. He's now in Memphis, Tennessee at a OBL doing arteries all day long. Both of them, I like to say, and this is true, I taught them really everything they know (Dave Paul and Sam Putnam). They owe me a great deal of gratitude.
[Aaron Fritts MD]
We got that on record.
[Chris Grilli MD]
Yes, that's on record and I want that in the final podcast. I'll send that to them, but they know. They're legends in the Philly area. It was my honor to work with Sam and to know Dave and he's doing some great stuff down there in Memphis.
(1) Splenic Trauma Presentation: Grading and Management
[Aaron Fritts MD]
Well, let's jump into the meat of splenic trauma, the topic for today. How do these patients typically present in your practice?
[Chris Grilli MD]
Like I mentioned, we are a level one trauma center, so this is something we do plenty of. We have a lot of interactions with the trauma team every day, spleen or otherwise. As we know, most of these are blunt-force traumas. Occasionally, we'll get a penetrating trauma splenic injury that does go to IR. It's definitely a very small minority of patients. Then when thinking about splenic injuries, you could have an acute injury. The patient comes in, they're stable or they're unstable, and they get triaged right away.
Then there's also when it comes to spleens, delayed splenic rupture which we could touch on later, where the spleen's fine initially. Then all of a sudden, you're dealing with a bit of an acute situation for hours, days, or sometimes even longer down the road. We see both of those really at Christiana. Splenic Embol has been going on for a long time, since the seventies when they were using autologous blood clots. This is nothing new. But really, it took a couple of decades for IR to really get involved in the trauma algorithm. In the ‘90s they were already identifying defects in their algorithm.
They were just starting to use more commonly cross-sectional imaging as opposed to just ultrasound or just lavage. Really, we're seeing that if they see blush on CT scans, their fail rate for OBS alone was near 70%. That brings the question of, what do you do with these patients like this? Do you jump all the way to taking their spleens out or are there other options? That's where IR has started to get involved and now is well established as part of their algorithm. For example, at my institution, when the trauma surgeon calls me, it's usually well-siphoned out already. They're not sending me grade ones or on the other spectrum, very unstable patients to evaluate.
They're usually appropriate. We're talking about grade three, four, five lacerations using the AAST guidelines. Usually, although not all the time, those are stable patients. Maybe we should go into this because we do have some medical students probably listening.
[Aaron Fritts MD]
Yes. Let's talk about the grades of splenic injury and the treatments for each.
[Chris Grilli MD]
Knowing these will help dictate the rest of this conversation. If we're using the AAST guidelines, we were talking about five grades, obviously from zero to five, getting worse all the way from grade one, which is just a very small laceration. We've seen these on CTs before. You could barely see the dark laceration. On the scan, it's less than a centimeter. They might have a small hematoma, but it's less than 10% or something small. Then grade two, there’s a little bit more of that but still really nothing large in the parenchymal intraparenchymal really to worry about.
Then you get up to three where now you have either a ruptured subcapsular or a parenchymal hematoma. You have a much deeper laceration - 3 centimeters. Then grades four and five, we're starting to talk about the devascularization of the spleen itself. In grade four, more than 25% of the spleen is devascularized. In grade five, there is a completely shattered spleen, which is completely devascularized. So obviously, it is a higher grade. The initial guidelines didn't even mention hematomas or devascularization, but in 2018, AAST started to notice. If we see involvement of the vasculature, or if we see large hematoma, these patients are doing much worse.
So in 2018, they modified it and added the hematoma sizes. They added the stuff about the devascularized portions of the spleen so as to better triage their patients. Even in the world, there's a world organization of emergency surgery that also has a grading system, which I like even more. It's simpler, which I always prefer. It's only four grading classes. It lumps the lower-grade AAST together into a one. Then as it gets higher, obviously more vascular involvement, but their grade four is just anybody who's unstable which makes sense.
You could have a 1-centimeter laceration, but if the patient's unstable or not doing well, then that's not going to be the same as a patient who has a 1-centimeter laceration and is rock solid. Their grading system brings in more of the clinical side of things a little bit, which I really do like.
(2) Splenic Trauma Management: IR or OR? Embolization vs Surgery
[Aaron Fritts MD]
How's trauma surgery deciding whether or not to send them to IR or take them to the OR? Is it based off of whether stable versus unstable?
[Chris Grilli MD]
In the most simplest form I always tell my residents, if it's a spleen that's unstable, those should be going to the OR. If it's a spleen that's stable, those are the ones that are considered for IR. Now, that's very oversimplified. In fact, there's a UMass study from, I think this year or maybe last year, that they were taking unstables and stables to the IR suite, and the complications and mortality were the same. There are exceptions to that rule. But in general, we're talking about an AAST one, even a two through five. If they're stable, you can do observation. If it's a higher grade, you take them to IR. If they're unstable, they pretty much automatically go to surgery.
Now, have I done unstable patients before in IR? Let's say there's a poor operative candidate or there's some other extenuating circumstance. You have to take each case by itself. Then if you consider, and so I said I'd mentioned this peds patient. For peds patients, it's a little different algorithm. Everything shifts to the left. No matter what their grade is, you're pretty much monitoring them as long as they're stable. It doesn't matter what the size of their hematoma is. Do they have a big peri splenic subcapsular hematoma? It doesn't really matter. You watch those. Only if they start to demonstrate that they're not improving clinically, would you even consider embolization. The criteria is even stricter for those type of patients.
[Aaron Fritts MD]
Are the peds patients more likely to go for embolization versus surgery if they're unstable?
[Chris Grilli MD]
They're more likely to do nothing. They're more likely to observe and it's very rare. If they're largely unstable, they're probably going to go to the OR. IR's role gets crunched a little bit in the middle. Again, this is all very institutionally dependent. A lot of studies have looked at this comparing institution versus institution and everybody has a little bit of a different algorithm, but definitely that's the trend that's seen out there. There's plenty of data in the trauma literature telling what we need to do. They have meta-analysis of 10,000 patients looking at grade four and fives and demonstrating a much-improved salvage rate with doing embolization versus just observation.
[Aaron Fritts MD]
In the peds population?
[Chris Grilli MD]
In the adult population. There are smaller studies in the ped population.
(3) Splenic Embolization in Trauma: Techniques and Tools
[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.
(4) Splenic Embolization Procedure: Proximal, Distal & Choosing the Embolization Device
[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.
[Chris Grilli MD]
There's another thing. I wouldn't be an IR without that. I would quit if I lost the advantage wire.
[Aaron Fritts MD]
I'd just walk out if they were on backorder.
[Chris Grilli MD]
Right, that's it, I'm done. I'm going to find a new career. That's just one of those devices that you've come to really love over the years and the Embold really strikes a nice balance and it's exactly like that.
(5) Optimizing Splenic Trauma Procedure Time
[Aaron Fritts MD]
Peder Horner wanted me to ask you, what is on your playlist when you're doing a splenic embolization? Or is there no time for music?
[Chris Grilli MD]
That's an excellent question. I've evolved over the years. My go-to used to be laid-back beach mix on Pandora which brought in a lot of reggae so it was upbeat yet kind of chill, so it kept me in a good place. I went through a Ray Charles phase for a while. Also a same type of vibe. Now we're just touring ‘90s alternative rock.
[Aaron Fritts MD]
Oh, that's my sweet spot.
[Chris Grilli MD]
There’s little bit of Weezer thrown in there. The key is just keep it upbeat, but that's a really important question and I do appreciate it.
[Aaron Fritts MD]
He was hoping it was metal rock but you know.
[Chris Grilli MD]
One of my techs loves metal rock and he'll put it on sometime. I don't know, I can't concentrate on that. I got to get out of the room.
[Aaron Fritts MD]
It's too much. I like the grunge. The ‘90s grunge is - it works out for me.
[Chris Grilli MD]
‘90s grunge, right? That strikes the right balance, it keeps going. Now of course, if something goes wrong and I start to get pissed-off, all the music goes off. It gets quiet and everybody gets uncomfortable.
[Aaron Fritts MD]
Oh, the music is off. Especially, what happens is a lot of times, trauma surgery is in the window staring at every move while you're doing the case. I would say that's like 9 times out of 10.
[Chris Grilli MD]
Oh yes. They're there looking at you.
[Aaron Fritts MD]
The control room is packed with people. You have an audience for this.
[Chris Grilli MD]
Yes, they're watching. I have to constantly remind myself this is not the time to dance along or take a break or harass the fellow too much. When you have good residents and fellows you have that option of taking a break and maybe doing a few dance numbers around the room to keep it light. They don't tend to like that.
[Aaron Fritts MD]
While you're waiting for that plug to…
[Chris Grilli MD]
While you're waiting for that plug you got to do something. It's either that or put in coils behind the plug and got to ....
[Aaron Fritts MD]
Have you ever done that?
[Chris Grilli MD]
No, you know what I do, sometimes is, I hate to admit this, is I'll take a little gel foam slurry and just pump a little in right behind the plug and that gets your beautiful angiographic result without having to wait the 15 minutes.
[Aaron Fritts MD]
I've had to do that too. Have you ever just done gel foam? I guess A, have you ever done that, and B, why? What was the reason for just doing gel foam?
[Chris Grilli MD]
I haven't done gel foam on a whole spleen. I've done gel foam on segments. If I saw a really ugly segment, so a distal embolization, I have done on gel foam. But then again, I am still combining that usually with a proximal coiling or plugging, so it's never been just gel foam. Gel foam is nice to have around.
(6) Splenic Embolization Procedure: Liquid Embolics and Closure Devices
[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.
[Aaron Fritts MD]
Yes, for sure. Anything that we left out on splenic trauma before we move on to these non-emergent splenic embolization cases?
[Chris Grilli MD]
No, I think we hit all the major points. Nothing's striking me right away.
[Aaron Fritts MD]
Let's talk about, I don't know what's more common, hypersplenism or aneurysm? Probably aneurysms are more common wouldn’t you say?
[Chris Grilli MD]
We do a little bit of both.
[Aaron Fritts MD]
It's a choice.
[Chris Grilli MD]
Yes, we could start with hypersplenism.
(7) Non-Emergent Splenic Embolizations for Hypersplenism
[Aaron Fritts MD]
Yes. That's good. Hypersplenism, I guess we could let our audience know why these patients are presenting and what the work-up is.
[Chris Grilli MD]
There are a number of reasons why we might embolize a spleen other than trauma hypersplenism being one of the major causes, either in a cirrhotic patient: someone with lymphoma and leukemia, somebody on chemotherapy or somebody with a hematologic disorder. We get a lot of these consults from our cancer center and our oncologists.
When I first started at Christiana, they weren't sending a lot of these, to be honest. Then I happened to have a discussion with an oncologist and with a low platelet patient who was not able to resume chemotherapy.
I told them about this and they seemed shocked and amazed that this was doable. They sent a patient who had a very robust response in their platelets and since then we've gotten quite a few more consults for these. This is a completely different reason than our trauma and a completely different way we do these cases. At the most basic level in the hypersplenism's platelet sequestration type case, we're looking to embolize and kill off part of the spleen rather than just slow flow into it. They did look at doing proximal embolizations and see if it had any effect on platelets. There were a couple of studies showing a little bump but I don't really believe them.
In general, the rule is a proximal embolization is not really going to have any effect on the size of the spleen or the platelet sequestration. Now we're talking about actually going into the segmental branches and taking out flow to certain portions of the spleen. The classic teaching is, well you take out about 40% to 70% of the spleen and that will give you a safe bump in your platelets, a reliable bump in your platelets, and even in your white blood cell count a little bit as well without having a ton of complications or not having very high complications.
This procedure is actually a pretty morbid procedure and I don't think people appreciate how dangerous this procedure can be. Certainly, when I get a consult for the oncologist, I want to see that patient in my IR clinic before I schedule them for the case because they need to know, the oncologist isn't telling them. They're telling the patient “they're going to do a noninvasive procedure, it's going to be fine, your platelets are going to bump up and then we're going to resume chemotherapy.” I need to talk to them seriously about the morbidity and mortality even with this procedure in the office.
I also explain to them that, "Hey, it's not going to be a smooth, smooth road. You'll probably be in the hospital a few days after the procedure. You might be in a lot of pain even though I'm going to give you a ton of pain medications. You're going to be nauseous. You're going to have this post-embolization syndrome and even after you get discharged, you're going to feel pretty beat up for a little bit.” It's not a procedure to be taken lightly as some of the referrers seem to think of it.
[Aaron Fritts MD]
You said about 40%, right? Is the target percentage roughly?
[Chris Grilli MD]
Yes, 40 to 70% depending on what you read.
[Aaron Fritts MD]
You're in the middle of your procedure. How do you determine percentage in? Do you use cone beam CT when you're looking for? Then you do like an injection and look for roughly calculating that percentage based off of enhancement? How do you determine that?
[Chris Grilli MD]
I would say the majority of the time I'm not using cone beam CT. However, it is definitely a good thing to use. I just tend to be inpatient and want to get out of the room as fast as possible. A lot of people do use cone beam CT to really get an accurate depiction of how much spleen you're actually taking out. I'm doing runs and trying sometimes different obliquities because you can get tripped out on a single view. I’m trying to estimate based on the runs, how much of the spleen roughly I'm taking on. I know it's not dead-on accurate and I have used cone beam in the past, but it gives me a general idea.
There's actually a really crazy study out of Japan where they actually looked into this and they measured the feeding artery and were able to accurately predict how much of the spleen they were devascularizing from taking out that feeding artery. That would be pretty cool to do, although you'd have to start measuring every artery and doing calculations along the side. Although it's neat, I don't see a ton of people doing that. The risk is you can go from and certainly I've been in this situation where I was at 40% and I'm like, "I want a little more, so I'll take one." Then boom, you're at 80% with the next embolization. It can go from too little to too much very quickly, so you got to be careful with that.
[Aaron Fritts MD]
Sounds like maybe a neat AI project if somebody could create an algorithm. I don't know if there’s really a product market fit there or like the need for it, but there's definitely a market fit. But I don't know if it is with the number of hypersplenism cases being done in the United States.
[Chris Grilli MD]
Probably be a little low.
[Aaron Fritts MD]
Stuff like that could be applied.
[Chris Grilli MD]
My gosh, totally. You could do a run. It can map out the arteries. You do a spin once in the beginning and then estimate based on what you've taken out. I could see that happening, measuring how much spleen you're taking out per branch. That'll be down the road. Just like in trauma, there's also a different number of devices we could use for this. We touched on this already. Going from gel foam, you could use coils, glue, and particles which are probably the most common.
I've used quite a few different things. I have used particles, 3 to 500 most often, and then sometimes 5 and 700 if we're talking a range micron for the branch, and goes very well. I think it's quick. I've also used a lot of coils. I really like using coils for this. It gives me very, very precise control. I can get into specific branches and I can even do tiger striping where I do a branch, I skip a branch, I do a branch etc. so that you don't have one large area of necrosis because certainly, the big fear is abscess and sepsis after this peritonitis and all the things that go with that.
The theory is you don't create one large necrotic area. Potentially you're going to get around that potential adverse event. Coils are also very, very good for this. They've done studies looking at this. Again, a lot of this is in the Japanese-Asian literature, but they've looked at coils versus gel and found that the complications were the same and the platelet increase was also the same. It really leaves a lot of options for the IR to decide what they want to use.
(8) Non-Emergent Splenic Embolization for Aneurysm
[Aaron Fritts MD]
We got a few minutes left here to just briefly talk about aneurysms, which I would imagine you'd only really use coils. You can't really use plugs. Really coils would be the only thing you would use for aneurysms. How often are you guys treating those in your practice?
[Chris Grilli MD]
We get a few of those a year. For whatever reason in our practice, we get a lot more hypersplenism than we do aneurysms, but we do see a fair number of aneurysms. You're exactly right. We're using coils to do those - generally long packing coils. The longer the better, depending on the aneurysm size. We have also used covered stents in cases where we try to maintain flow to the spleen and just to try something different to be honest. We use a cover stent to cover it up, especially if there's a short neck and you feel like you can't seed a bunch of coils on the inside.
Also, another thing we've used is just coil, distal coil proximal, and don't coil the sack itself because as we've discussed already. Depending on where the aneurysm is, you're not going to kill the spleen by just coiling that small segment out. There's going to be robust collateral flow so you're good where you don't even have to pack the aneurysm sac. There are plenty of options when it comes to aneurysms and they can be a lot of fun to do. My favorite is just packing the sac though because it's fun to do and it's cool to do.
[Aaron Fritts MD]
What I've seen people do, is put a framing coil in there and then just pack it with fillers after that for the most part, but all detachables.
[Chris Grilli MD]
Detachables.
[Aaron Fritts MD]
Have you ever had an issue where a little end of a coil sticks out and you got to decide what to do? You try and snare it or just leave it as is because again, it's the spleen. It's not really going to shut down flow to the spleen. What do you do in those kinds of scenarios?
[Chris Grilli MD]
Oh, sure. That happens all the time. That's another thing you’d see with your GDAs and stuff like that where you just have a little tail sticking up. It's always on the last quail. You're always like, I think I'm done, but I'm going to put one more in and then that. It's always that one. When talking about the spleen, it's not a big deal. I would just leave it. Honest to God, even if a whole coil flicked off and fell into a segmental branch, you're not going to really worry about that. You're going to cause more damage, more radiation, more time, mucking around trying to get the thing out. Although it doesn't look pretty on your run or on your pictures, you have to put it all into perspective when deciding how to chase things like that.
[Aaron Fritts MD]
Splenic artery embolizations don’t always look pretty anyway. That’s trauma care.
[Chris Grilli MD]
Exactly. It looked like a mess no matter what.
[Aaron Fritts MD]
Exactly. I think that pretty much covers it. Anything else that we left behind, Chris, that would be useful to the audience when it comes to splenic artery embolization?
[Chris Grilli MD]
No, I don't think so. I mentioned they're going to be hospitalized for a couple of days. I do put these patients on PCAs often with or without a steroid bolster and then Toradol is also very useful to use. Sometimes I get this question often from the patient: do I need vaccinations? The data suggests you don't because you still do have remaining splenic parenchyma, which will eventually start to hypertrophy as well, which is sometimes why you need to do repeat procedures. You don't need to be vaccinated as long as you're leaving some spleen behind which is a common question. I think that covers it.
[Aaron Fritts MD]
Well, Chris, thank you so much for coming on. We really appreciate it. To our audience, if you have any questions or want to look up any of the resources that we mentioned, for example, the grading scale from 2018 AAST, we'll put those in the show notes so that you can have them ready and handy. Thanks, everybody for listening.
Podcast Contributors
Dr. Chris Grilli
Dr. Christopher Grilli is a practicing interventional radiologist with the ChristianCare Interventional Radiology Group in Delaware.
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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