Splenic Embolization Complications
Overview
Splenic artery embolization (SAE) is associated with major complication rates of 3.7-28.5% and minor complication rates of 23-61%, but remains significantly safer than operative management, particularly splenectomy, which carries a 32% infectious complication rate compared to 4.2% with embolization. 1
Major Complications (3.7-28.5% incidence)
Life-Threatening Complications
- Re-bleeding: Occurs when embolization fails to control hemorrhage, requiring repeat intervention or surgery 1
- Total or subtotal splenic infarction: Extensive tissue death that may necessitate splenectomy 1, 2
- Splenic abscess: Infected necrotic tissue requiring antibiotics and possible drainage or splenectomy 1, 2
- Acute renal insufficiency: Contrast-induced nephropathy from the procedure 1, 2
- Splenic cysts: Post-traumatic fluid collections that may become symptomatic 1, 2
- Puncture-related complications: Access site bleeding, pseudoaneurysm, or arterial dissection 1
Critical Risk Factor
Distal embolization carries significantly higher major complication rates (24%) compared to proximal embolization alone (6%, p=0.02). 2 Three-fourths of patients with major complications underwent distal embolization 2
Minor Complications (23-61% incidence)
Common Self-Limited Issues
- Fever: Part of post-embolization syndrome 1
- Left-sided pleural effusion: Occurs in 9% of cases, typically resolves spontaneously 1, 2
- Coil migration: Occurs in 4.5% of cases, usually clinically insignificant 1, 2
- Partial splenic infarction: Limited tissue necrosis that heals without intervention 1, 2
Post-Embolization Syndrome (PES)
In pediatric patients, PES occurs in 90% of cases, consisting of abdominal pain, nausea, ileus, and fever. 1 This syndrome is self-limited and resolves spontaneously in 6-9 days 1
Management of PES
- Supportive care with pain control 3
- Antibiotic prophylaxis to prevent infectious complications 3
- Reassurance that symptoms will resolve without intervention 1
Infectious Complications
Pneumonia
Long-Term Infection Risk
Patients require vaccination against encapsulated bacteria (S. pneumoniae, H. influenzae, N. meningitidis) starting no sooner than 14 days post-embolization. 1 If discharge occurs before 15 days and vaccination compliance is uncertain, vaccinate before discharge 1
- Seasonal influenza vaccination recommended for patients over 6 months 1
- Antibiotic therapy strongly considered for any unexplained fever, malaise, or chills 1
- Primary care providers must be informed of the embolization 1
Comparative Morbidity: Embolization vs. Surgery
Operative management carries significantly higher complication rates than embolization across all studies except one. 1
Complication Rate Comparison
- Observation alone: 4.8% infectious complications 1
- Angioembolization: 4.2% infectious complications 1
- Splenorrhaphy: 10.5% infectious complications 1
- Splenectomy: 32.0% infectious complications (p=0.001) 1
Additional surgical complications include increased death rates, pleural drainage requirements, acute renal failure, and pancreatitis 1
Management of Complications
When to Abandon Embolization
Proceed to splenectomy when NOM with embolization fails and the patient remains hemodynamically unstable, shows significant hematocrit drop, or requires continuous transfusions. 1
Monitoring Protocol
- Intensive care admission for at least 24 hours post-embolization 4
- Serial hemoglobin and vital sign monitoring 4
- Intra-abdominal pressure monitoring to detect compartment syndrome 4
- Doppler ultrasound or contrast-enhanced ultrasound for follow-up of vascular complications 1
Pseudoaneurysm Management
The risk of post-traumatic pseudoaneurysm is low and most resolve spontaneously, but embolization should be considered when pseudoaneurysms are identified. 1 In pediatric patients under 15 years, perform contrast-enhanced ultrasound prior to discharge; if pseudoaneurysm persists, consider embolization 1
Critical Pitfalls to Avoid
Technical Considerations
- Avoid distal embolization when possible: Use proximal embolization for diffuse injuries or multiple vascular abnormalities to minimize major complications 1, 2
- Prefer coils over temporary agents: Permanent embolic materials provide more durable hemostasis 1
- Confirm pancreatic vascular anatomy: Ensure adequate collateral circulation before proximal embolization 1
Patient Selection Errors
- Do not perform embolization in hemodynamically unstable patients: These patients require immediate operative management 1
- Recognize facility limitations: Centers without rapid angiography access or intensive monitoring should proceed directly to surgery for moderate-severe injuries 1
Post-Procedure Management
- Start thromboprophylaxis early: Mechanical prophylaxis is safe immediately; LMWH-based prophylaxis should begin as soon as possible in selected patients 1, 4
- Do not discharge too early: Minimum 3-5 day hospital stay for high-grade injuries 4
- Ensure vaccination compliance: Critical for preventing overwhelming post-splenectomy infection (OPSI) 1
Splenic Function Preservation
Embolization does not totally compromise splenic function; no significant differences in immunoglobulin titers exist between embolized patients and controls despite elevated leukocyte and platelet counts. 1 The spleen's intense vascularization maintains sufficient blood flow for immunological function through collateral pathways 1