Splenic artery embolization versus surgery for blunt splenic injuries: a systematic review, meta-analysis and trial sequential analysis stratified by hemodynamic status.

BACKGROUND: Surgical management of blunt splenic injuries is associated with long hospital stays and high risk of postoperative infections and thromboembolism. Splenic artery embolization (SAE) has emerged as a valuable alternative to preserve the spleen and limit complications in hemodynamically stable patients with moderate and severe injuries. However, how SAE compares to surgery in both hemodynamically stable and unstable populations is still debated, as international trauma guidelines advocate for primary open surgery in unstable cohorts. Therefore, we conducted a systematic review and meta-analysis to evaluate the role of endovascular management across hemodynamic statuses.

METHODS: We searched PubMed, Embase and Cochrane for randomized and nonrandomized studies comparing surgical management to SAE in adult patients with blunt splenic injuries. Risk ratios and mean differences with 95% confidence intervals were calculated for categorical and continuous outcomes, respectively. We conducted a trial sequential analysis to confirm the robustness of our findings.

RESULTS: We analyzed 33 148 patients, of which 9593 were initially treated with SAE. Compared to surgery, SAE was associated with significantly lower mortality (RR: 0.43; 95% CI: 0.25-0.72; p = 0.004). SAE also reduced the length of stay in the hospital and in the intensive care unit (MD: -3.1; p = 0.015 and MD: -4; p = 0.024, respectively). The risk of thromboembolism was significantly reduced following SAE (RR: 0.58; 95% CI: 0.47-0.70; p = 0.0008). There was no difference between groups in terms of additional complications. In a subgroup analysis of hemodynamically unstable patients, SAE maintained a significant survival benefit (RR: 0.47; 95% CI: 0.29-0.75; p = 0.014). Trial sequential analysis confirmed the robustness of our findings in terms of mortality.

CONCLUSION: Our study is limited by potential confounding by indication, heterogeneous populations, and inclusion of observational studies. However, mortality findings remained stable following sensitivity and trial sequential analysis. Therefore, SAE appears to be a valuable alternative to surgery in adult patients with blunt splenic injuries, irrespective of hemodynamic status. This study provides a rationale for expanding the use of SAE in daily practice and may help inform upcoming clinical guidelines.