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I believe with talk to caution here. Hello, everyone Now? Yeah. Okay. Okay. Says that I'm just finding a locational. Tell my camera in a moment. Course. Um, Jimmy, shall we start? Quite a few people just started doing so Hello. Everyone has really joined us. Thank you very much for to me in this Monday evening. My name's you wear on gonna be the host off the session together with May our gym. Who's now the be certain president on Sarah, who's training at Leeds on injure the founder off the IR genius. This is the six session off this year's new initiative Joint Force Off Beast be SIRT and I are juniors out off the verge of Jonah clubs, which were just hopefully sparked some good discussion amount. The latest on what his topics intervention, radiology. So today we're going to talk about the role off splenic artery embolization in the setting of humor on. But I would do a very brief discussion on the topic itself and present the paper on day one. Hand the floor back to the Panelists who are pressing here. We have Mr Morgan Monocle, one of the trauma and vascular surgeons working with London and Island. We've got Professor Hammadi, one off the I R. Consultants at your college on Doctor Kashef, another interventional radiologist based at imperial and trauma. Intervention of leads. Welcome for the audience. You're welcome to submit the questions to the chance, and they will keep that space monitored on were sent out a few back towards the end of session for you to help us improve the syriza's. Well, I'm just going to show you my screen now. It's 8%. Okay. Okay. So I'm one of the radiologist, Specially trained knees. I'm also basically imperial College Healthcare, which is trust just a little bit backgrounds on the trauma service in London, we've got four kind of geographic regions and send marries Hospital of Imperial A Z. You can see the red dots and square covering northwest London. Here's the image that people want to show you is a pad interning a beautiful day. But sometimes I can get really busy, trauma wise, um, splendid injury. If it's suspected, particularly in a police trauma patients on the left, you can see a very busy flow charts. And since how these patients are managed to simplify this, if the patient. Is he not on a P unstable. The trauma team will trigger, sometimes using fast scan, sometimes using CT to triage thie. Degree off injury, I suppose. But if he's really patients really unstable, sometimes the proceeds straight to emergency like possibly, I suppose, that we can talk a bit about that in the discussion session where, as it came down to the stable patients, we have more room to find out what exactly is going on and to what degree off injury that needs to be dealt with with the lower dose. The one Sometimes it's not operated management that would include observation and or embolism. A shin for slightly high grade in May proceed, so intervention you may proceed to surgery and the grading system really help us is displayed on the right. It's a great 1 to 5. It's really use quite universally across different countries on different societies. Stopped them quite in a similar manner. Teo put it simply, Great 1 to 3. The difference is the degree of laceration, the interpreting, um, a hematoma and the subcapital, a human once more addition, more like small modification to that is, if there is large hemoperitoneum That's in a great three trauma excitedly upgraded. It's only because it might. It just means that the subject capsule a hematoma, is so large that has ruptured and may have stopped in the meat. A time of scanning and great four and five basically means a degree off the vascular ization from segmental to told a little bit on the ambulance station technique. Eso spanning artery is not an end artery. Has some of the, you know, sort of first year medical school on atomical sort of diagram may have misled to to that concept in fact, the three collateral pathways by the splitting violent omentum and find the left gastric vessels. And therefore there are two schools of thoughts or two categories of interventions. One is proximal intervention that is to block the the major artery, just this tall to the transfers pancreatic artery. The theory behind that is to reduce the over profusion volume and pressure to the injured splitting. Therefore, reduce the rate of the developing serial and reasons and stop, you know, minor bleeds. Whereas the distal embolization is more to target specific, truncated or injured vessels. The idea is to stop the bleeding Therefore, a lot of different materials can be used for that sort of and segmental arteries. And this is a key differentiation which come back to okay. A. Fortunately, the management of different grades off splint injury. It's not very well, you know, it's not a lot of evidence around it. Apart from case control, studies on some retrospect reviews on Pier Sean are two reasons and large volume studies done Australia and Europe until this study comes out, which is published in JAMA surgery in 2000 and 20. It discussed the effect of prophylactic embolization in patients with blunt splint. Injury off Great Three Plus on here. We're gonna talk about this more details. Eso It's prospective friend of my Lantus Center study in front had between 2014 and 17 patients selection wise. They're many adults, they're human America. We stable and they present within two days off. The initial injury incidents off the grading off the injury were splendid. Eso the great three injury with a two least with large hemoperitoneum I great three plus on or associative at lesions that produce a new injury, civility score or 15, and we'll come back to that score bit later and great four and five. Devascularize splits bank injury and approximately 100 40 patient waiting rolls and randomized into two aunts. One arm is prophylactic spent artery embolization. The next one is surveillance and then and allies. I watch for weight sort of approach. So for the prophylactic, Advil is a shin. There are two techniques shown at the bottom of the page. It can be proximal embolization only we can be a combined distal and then proximal um, Symbolization on the authors of Stress that that they use the slightly larger coils and avoid my cricoid on Definitely not to use the, you know, firm and bollixed like such a blue include and have a gelatin fragments cetera to avoid infection. And we'll come to that. Why, that's the case. Approximately six patients, 60 patients at the primary, endpoints in both arms. The primary endpoints, quite interestingly said by page there but by the authors is 50% off this planet prank, um, at preservation at one month them several other secondary endpoints, including slightly longer term splenic rescue rates, major complications, etcetera. So first we'll look at the demographics. I think the fights to say that that between the two groups, the baseline characteristics are very well balanced. They're usually young male employees or student groups, and the injuries most frequently occur in traffic. Accidents in studies like this would involve podiatry on patients who might not be conscious or easy to evaluate. The authors also include the table we have not shown here to includes the include the patients that are non valuable clinically on DNA. Come back to the new injury Severe Trees Severity School. The way is calculated in this study is by square the grade off the specific organ, and then you choose the three most serious injured organ and add the mark. Uh, if the example a splint injury is great for the patient already scored 16 and even the minus injury off any other system. For example, chest one point and neck and head the neck. Another point you were already produced. School off 18. So in this study, the N s score the median score for two arms is actually 90 and 20. So bear that in mind. I can't find in the paper or the supplementary material to separate li describe other injuries. That's the thing patient has suffered a particularly those who other organ injuries that may already require intervention with or without a splenic intervention. The primary endpoint splitting Explain it rescue rates at one month. There's no significance this significant difference between the two. The prophylactic arm achieved 19% minus one that when a bit too far in the cross now became the croutons on Do. The other group achieved 93% in the which for weights one a crisis and spring splenectomy at one month, there's a breakdown of different senses. How they of chief, the spent rescue. It's can see that the overall is very high in the nut. In the high nineties, they will come back to that same description on looking at the spending artery embolization as the technique itself. So for the prophylactic group, everyone would have underwent a technically successful and Eliza a shin front on one required additional reimburse Liz a shin a day fine. Whereas the watchful Wait group has got 19 patients at one month eso slightly delayed in total, only two patients for perfect group requires reading to mention, although what I was unclear, which What kind of technique? A, which vessels they went back into for the surveillance group. Overall, about a third patients required some fall off intervention, including one patient required to embolizations the awful complications related to this procedure. It's not very significant different between the two groups. Thie Overall complication as showing here it looks very high, 45% and 52%. But if you if I draw your attention to the table on the right, the authors counts splenic organ specific complications such as a fistula information or pseudoaneurysm formacion. A scar medications, sure, but also hammer. Egemen requires transfusion as complications. I think that's significantly push the number up and organ specific complications. Theo. Only one that jumps out is pseudo aneurysm, in which is really higher in the surveillance and then ambulances a shin Group. Interestingly, none of the groups develop spank abscesses, and there's no other significant complications specific to the spleen. Other voice. The hospital stay is much shorter for the prophylactic group. As you can see on one, my argue that the the shorter stay my also reduced the complication for tic. Yeah, really. In the Kobe roaming world predictors for the surveillance and embolization groups, the one that really comes up is great for injury or about a zit can see 70% actually requires set a form off reintervention, whereas only one in five in degree three or lower on Actually no other characteristics have any predictive value. One thing I noticed that in the secondary I'll calm that author's wish to talk about immune function essay for the patients who underwent embolization but actually have not reported in this particular paper that all other secondary outcomes are are adequately reported. So a quick summary. So the prophylactic group, 100% technical successful early prophylaxis, a prophylactic embolization 3% require and allies it by one month. That's reintervention 8% minor procedure related complications 45 or complications by one month. Overall, 98% splitting rescue the other arm, 12% would develop pseudoaneurysm as would be predicted by the pathophysiology. Yes, I suppose, as with this spilling a fistula on five would 5% would already require splenectomy by day five. A third would require a form off definitive intervention, and great fall on higher injury is the strongest predictor again. Non released, stiffly significant race off procedure or complication between the two groups and overall achieve 93% rescue rates. Quick, this discussion just draw from the paper and some comments in questions. The author draw a conclusion rightly, that there is no difference in the Spanish rescue rates between the two groups. But as we can see, the complicated competition profile, the event timeline and surely the patient experience will defer overall second point overall, very high splaying rescue rates compared to historic data that paleness 100% correct. In fact, historic data shows approximately 60 know operated, manage patient would eventually need spend extra. Me. This data was from early two thousands, and based on that assumption to pay the paper, the study is probably under powered because they over assume the difference off the two groups. But the point is, ah, choice or 50% splenic mask preservation. What I think is very meaningful or is it perhaps more meaningful? Been splenectomy rate, which can splenectomy can happen as a result off over ambulances Asian. I suppose. The study actually did a lot of immune function studies, but they have not published it. It may help us to find a more precise percentage that, you know, is a functions. Spleen a spring can't can still being function. For example, if it's set at 20% then the embolization may or can be more aggressive. Fourth point in the selection of, you know, dramatically stable, poorly trauma patients. A sign really alluded to a lot of this patient coming in the police trauma set up setting on. It would be quite good to know whether any of these patient underwent intervention for others organs or even a squash chin where there were cysts to woods prophylactically, amble eyes, somebody's splitting if they're human. Definitely unstable, for example, for honest liver laceration as a co existing injury. Further points. Expert availability in clinical trial context short. I mean, there will always be diagnostic discrepancies, technical variability and limitations in the real world. Who we possibly achieve facing the real world's I'm not sure are impatient Reassessments. How patient Follow up, you know, different pathway is definitely require different labor intensity, either for the trauma of surgical team or even for the prophylactic group. You would front load the pressure on to the I R services has there being a medical, if normative calculations year on what with the outcome be on wood. A patient choice mean anything here, particularly for these kind of patients who are quite severely injured in really. In reality, I'm not sure what's the percentage off lost to follow up, which I presume it's quite high and with different strategies which result in different timelines effect of the overall come and equity just there for are some thoughts and questions out there. But I'm going to hand the floor back to the catalyst form or food for thought. Thank you. Rice. Um, so height of to cut shirt from, like, Teo comment. Oh, well, thank you very much for the for. The summary on your presentation was very good and very own points in particular. Like the beginning. Intrasection well, actually wanted to sort of. Maybe we could open up the discussion because, obviously, um, this is a randomized trial on we don't have many of those in trauma, and the reason for that is because it's just so difficult to randomized urine trauma under many factors, where I felt are important to consider which were excluded, and I think it's very difficult to simplify the reason we don't run the most for most because it's very difficult to sort of categorize and compartmentalize. And I think this trial attempted to do that. Which is why the numbers were so small. But I'd be interested to hear both more bins on most opinions on it before I, you know, go on extreme on the on the paper. Um, I'll come in there. You Thanks. I think you actually look towards I'm out. First of all, thank you for a very comprehensive one through the paper and quite rightly as adequate pointed out. It's it's very difficult controlled. Let's get any really high quality. And, um, I've controlled trials. And if you really wanted to look at does prophylactic splenic amble eyes, age really work compared to trauma, you have to cut all the hemodynamically stable patients as well. That's never gonna happen. You're never gonna get after approval or never mind financial pages for that. So straightaway, you're dealing with a slightly separate bunch. Um, off patients. I give you my my take on a surgeon on gyno in Imperial. Absolutely spoil it. And with the intervention scout, because Aleka on mold and that sort of people will come in and we'll embolize screens whenever and That's not the case around the country on the rest of the Western world. So absolutely spoils imperial. But when I see it, it's from my point. Her gyn. Obviously, if your patients chemo examine on well, I don't like using the word stable hemodynamically on. Well, you get surgery because not just because the spleen is leading rapidly. The patient may die because what her things are probably bleeding a swell. Then you got the court a patient or human dynamically. Well, as far as I'm concerned, if there is an arterial side to us, whether you want to call up Exposition Bush or pseudo aneurysm or a small lady fistula, then I think am blessing makes true defense absolutely does, because what it does it it improves your chances off successful nonoperative manage, but the vast majority of strength meeting still use. But if you see an arterial side, if by ambulance and yes, your hemodynamically well patient, it improves your chances of having a successful known operative out. The bulk of the data out there when you go through it as a bit of a mind field is those embolization make a difference. If you don't have an arterial side on my intuition is, it probably doesn't and this paper kind of kind of agrees of thoughts. But the good news is, it's also known inferior, so there's no right or wrong answers. If you choose to embolize all your spleen's. Is that the wrong thing to do? Probably not. If you choose to nonoperative valid, all the speed's I have. No, I have not sure. Is that wrong? Probably not. So in many ways, this paper, like all good research, probably asked, opposes more questions than actually answers just before I am medical. Um oh, come in there. Everything I'll say is the grade of splenic injury. Why, that's useful to talk a common language. Why it's very useful for research. It wasn't really any more. Inform us off what to do next. Really? And I know there are many institutions. Great. 45. We'll all get embolized. I'm again. I'm not saying that's wrong. I'm just saying that maybe outcomes aren't that different of those who we choose to manners. No, not really. From the outset, you do not have an arterial problems to this panic injury, and I'd be delighted to hear at a cat Most I thought from that. Sorry that I'm really starting detector. So joining us also in the panel is Dr Sean Drooling. Dariush India. Apologies closer. Hi. Hi. Sorry about us. So Hello. Hi. Thank you for joining us on. Doctor Delusion Year is informational. Really? Gist practising in Atlanta on university off Emory. Welcome. Thank you. Yeah, it's a It's a, uh, first when I say it was a great overview. Um, great overview of the paper. Um uh, and I I I would echo. Um What, um, uh, doctor McMonagle had mentioned previously this This this paper definitely opens up more questions than that. Those answers, um, you know it from from our spit perspective. Um, we typically follow the the East guidelines, which is the Eastern Association for Surgical Trauma Guidelines. And most, um um and patients with anything greater in the great to splenic laceration. Um, you've bought a angiography, at least in angiography. We haven't really set a protocol for prophylactic for prophylactic embolization. Usually it's it's only embolized if you see a blush, but, um, this could definitely with this paper. It could definitely change your practice paradigm in some way. Um, you know that there are forgiven Dargan. It could definitely be made for for, um prophylactically embolize ing just just to from a quality perspective and for, um, you know, affecting length of stay. Um, you know, the only you know. But the authors did mention, and I think this is needs to be further. It evaluated, you know, you're you're trading length of stay for the cost of the procedure. So which is not? It's not, um, it's not insignificant least in United States. That's a That's an interesting point because, obviously, as you say, I mean that there is no right around in the sense that no one's found a consensus kind of internationally. I think, from our perspective, up to Grade three. Obviously, I'm very much against this particular ization, cause I think you have to look at the patient and there's always more to it. If you never you can get to spell it isolates panic injuries, but there's always more to it on has more consistent, like the degree of trauma. Everything else as well as the spleen is such a key component of what you do to the patient, and I'm like more, but I don't like the word stable on stable. The patient in the physiological supporter they don't on. I think we've always kind of up to Grade three with It was non operative, and then we discussed a great three. But that's sort of the retrospective date. Is is that if there's no blush on the CT, your identity or identification of blush is lower on an angio. So the question is, Do we just embolize those groups? And I think from my perspective, I do look at the clinical scenario whether the hematocrit slow if the patient about elderly, if this other trauma was is the capsule in tax? Is the hilum involved? Until we use those factors to go for reduce produce perfusion pressure and obviously we do targeted for when the actual bleeding and we stopped the active bleeding. So our practice are slightly different Yours, But it's interesting to see your aspect so you would do an angio, but not necessarily the embolization component. Is that correct? Correct. Yeah, is basically ah um, and you're right here that with CT, you know, there's there's a high correlation of of with with bleeding on CT that with a swell a zillion. Oh, since they're, ah, bleeding on angiography, I think they're thought Is that you know they want They want to make sure that we're not missing any potential. For, you know, visualization of student aneurysms are, um that that may be missed on the phase of the CT. Um, it made the phase of the CT. May not have gotten it. And that's the angiography is kind of more specific, you know, more specific. Um, test findings. So busy. Busy. Busy calls for you, huh? Yeah, yeah. Yes. Course. Every everything. The way they're red, you know, there's a lot of variability, and then the interpretations of these, uh, of absence of ct graded injuries. Um, so yeah, we are. We tend to be pretty busy. Um, it can I, uh, comment. Ah, on the paper. Okay. Amy? Yes, please. So I'll take you back slightly to the paper. I think the and you did mention that Ah, the the to find. Ah, our CT in trauma is not coming. And it is quite interesting. And they should be congratulated for the, uh, this attempt. Ah, to study the splenic laceration. Now, the I must say the setting off the trial. Ah, it's obvious that the authors did their best to, uh, maximize Ah, and standardized the protocol of the procedure and try So the imaging assessment, the way they mentioned how they acquired the images quite good. And the, um, all the conduct off the off the trial, it seems fair. And ah was well done. The my issue with it is 30 when it starts to ah analyze the results. Now, one thing in this paper that the yes, it is under my storms. But the analysis was based on intention to treat patients without really commenting or taking into account the crossover. So patients with the surveillance arm going to embolization and the successful immunization with success goes to the surveillance. So because its intention to treat that's my interpretation of it Ah, the the other thing and they did not comment. So overall, yes, they achieved quite good results in in saving speeds, both arms, but one third of them ah underwent embolization from the surveillance on. So this one third is significant, and I was a bit surprised they did not mention that in the conclusion or make ah alluded to Italy conclusion um uh, the Because if you have one third in the surveillance undergoing sort off emergent embolization, that's not good for surveillance. Ah, the what? I mean, 26 I think out of 60 or something like that. It's just quite high and the length of stay on, I think Ah, our guests from states mentioned that length of stay it is important and even if it is not in UK, were on a ah, the public health system. Ah, but if the pressure on beds is massive so if we managed to discharge patient earlier four days, I think this was the difference. More or less, it's it's significant. So and and the other thing is the great four and five, the majority off very intervention or three. The crossover was in the great for, um five. I would probably ah felt more comfortable if they said that there is a difference. But in the higher grades and then we can't prove it stood Stickley. And we need more studies that that was to me, that would be a good ah come out conclusion from from this study. But overall, I mean, if we go to our practice, I mean, I can't replicate what? Ah, Erica saying And Morgan, because we're practice in the same place and we're we're sort of the same sort of school off thought, yes, high grade I personally have, and I think the rest of it we'll have low threshold to to intervene with embolization. I agree with Morgan that if the patient has multiple injuries, I mean, it's not only spleen, we need to look at the overall patients, but I decided it with one minor point. I think if you have another injury that does not justify, you go and deal with the spleen openly because you cannot do split or a fee properly. And, ah, successfully and most of the time and the idea of savings, spleen and civilized, the patient and then patient goes to theater. To me, it's ah, it's a good thing because you save spleen, you prove Yes, we we haven't yet approved the immune function of the spleen on. I don't think we will be able to do that for foreseeable future, but I think it is something that is welcome to feel if we save us being so I'm taking too much. I know I agree. I agree with you. I think, um, the options off, I I think for me delay bleeding is the thing I want to prevent, because if someone is on one undergoes theater. But if you're going to look, you can't stop and geography and embolization in a hemodynamically unsupported patient and just take this being out on. I think we're definitely moved away from just we embolize. I think we've become more selective. Honorable is a shins and aspirin ectomy is and we'll plant the pattern, especially with the pediatric population, which took an area on its own. You can push the screen a lot before you have to do anything to it. So I think we're kind of less aggressive than we used to be said 10 years ago, and we started at the trauma center. But I think I actually think if there's any kind of extra out of us and extraditable bleeding reverence of a ruptured spleen on the patient's one isolated injury, there is definitely scope of reducing perfect perfusion pressure. But if there's more than two or three quarts of blood and the patient is ongoing, support needed and there's going to be other things on this means ruptured. Obviously, that's a different argument. But I agree that I think if what I don't want happening is people moving to was a little delayed bleeding thing and kind of not embolize in high grade. And then we're going to come back two days later and they rupture on. Most of these used to sing two weeks was the late leading, but now we find the 1st 72 hours is where the data shows the delay bleeding will happen on. No one knows who gets the delayed pseudoaneurysm and who doesn't have looked a great of injury. We've looked at the the the a SST. We've looked at the SSI, and there is no indication. And obviously the only thing that pattern would found this the higher the severity of the index of injury severity, a higher the risk of embolize a patient. But that's kind of hand in hand anyway. So so we haven't yet found out watch which patients we don't even have. The blood supply of the screen is much simpler than the blood supply of the liver. We still haven't figured out the pattern on all this literature supports the fact that we don't know which ones will be bleeding. Which ones won't on symptoms? Just one. Just the great of injury is not enough to predict that. Yeah, I'll come in there. I I agree with everything I like a said there, Um, it's suppose one way to try and answer some of those questions will be just a super select. All those patients who did have an arterial complication you were embolized. I'm look at the rates off the bleeding and slacked me later on. Because the signal is not. There will be a group of patients who will still continue to believe from the venous side. But you would hope that that number is mitigated for em by taking care of the inflow and one thing just take more upon taking up on. But you mentioned about the length staying that is very relevant because it was quite a significant difference between about 13 days, nine days between those who were just surveyed versus those who had an intervention on I. I would like to see a super selective study done maybe from the same data. Looking out what was the length of state for those patients who went to the theater and under spleen's out. I'm in particular those isolated standing injury know under significant abdominal injuries. What was their land of state? Because if it's the same or worse than those reading intervention that we know interventions clearly a good thing to do on a Most said, If you could preserve a span, then operate that may be a good thing is, Well, if you had a high bridge and type of burning space, do you think I I put out to do it through the panel is where radiologist or interact adventurous is. Maybe this. Maybe this paper will inform future practice from the point of view that if you are going to intervene for traumatized clean, you don't have to do it two or three in the morning. It can wait, because if you look at the reintervention rate, they were similar between the two arms, but they're also delayed. So maybe that's a good thing that you don't have to commit to in the morning and allies being actually doing a seven rate Moines. If I can't sleep on the phone call. Well, exactly. I mean that that is important to you. know that maybe you don't have to fly to play in the storm of two in the morning. You wake in the morning. That's a very good point. It's like there's definitely a psychological component to it, for sure. So just all night is actually zero very interesting one. So, doctor, the Russian Year. So if you if you were to do the NGO Do you do that quite soon after the the your CT or do you do weight? Um, it's variable that we used, you know, clinical status. More. You know, we don't treat the CT or, um well, you know, if the patient needs urgent angiography, you know, they they have given a bolus of fluids, and they responded, and then they notice a drop in blood pressure. Our threshold is pretty, pretty low toe. Come in and and just do that. Do that procedure, get it over with. Um, so we try to keep our trauma surgeons happy. Um, could I am asked doctor duration. Yeah. And also, I know some of the guys at Emory is what is your current practice for splenic imaging? Follow up? Yeah. For those who had an intervention of those have not. Yeah, usually one week is kind of the kind of the the 1st 1st imaging data point when we get anywhere from anywhere from five days to toe one week is ah, and then and then before there, discharged. Um, because, you know, it's so hard to follow up sometimes these patients, the trouble you do you do Resita your intervention. Static interventions. Do you reseated? The patients would have not had a splenic intervention. Yes, we do. Those are typically those are typically, um it's the least before they before they get discharged home before they get just ourselves on. What are you looking for? If they're well, um, and looking for delayed pseudoaneurysm formation, if I may push you, and I must must speculatively. And if you do see a small cyst, there is not your history of it is. It may just sit there, but, I mean, I'm being a deficit. Pick it deliberately. What are your thoughts on that? And like and mold the interesting thoughts to Yeah, um, we're pretty Well, we tend to be pretty aggressive. So, um, if we see, uh, even a small pseudoaneurysm, it's a least bought occupation and angiography. Um, even even, you know, delayed No of weaker two weeks out. Yeah, we have. We have got that same one little bit more guns. Aware of this, we do the follow up. We do a limited like a triple phase, depending on the purposely. But we do like a limited triple face spleen, a 72 hours, and then we do one at six weeks afterwards, and we've actually picked up two pseudoaneurysms. It's six weeks completely benign, but it's one of those scenarios that when you see it, you can't. You know, I just think why we're scanning these patients. But then it's just very tough because I think most of what we've developed is based on practice rather than actual science, because we don't have it. And everyone is our experience. That's driving. A practice is I find, which is obviously your practice. Two different two hours for this. Both of them are working, and we have good outcomes. So it's interesting that even though we have different practices, outcomes working, which kind of goes to my previous point with her, we're still kind of not using the science of it because we don't have the data for it, right? Yeah. That that pseudo aneurysm is this is a special problem. Not a special, but it's a problem for me as well. Um, because the it's like the visitor aneurysms thie evidence for it is not level one. Um, the the problem with this with the in the context of splenic injury that the if there is, um, it's two centimeter or three. It's easy. Okay, mister, be done. But the problem if the aneurysm is like five millimeter or if it is a centimeter and into the middle of the parenchyma, what you're going to do with it? The patient's stable is day five. Um, if you leave it, it's obviously it will be more and more imaging on my delayed ah discharge. And I don't think anyone has, uh, uh, definite answer. I usually follow my hand feeling so if the aneurysm is is large, that's not a question. That's easy. But if it is a centimeter and below and near the laceration near the capsule, and I don't feel that it is sort of protected Ah, very anecdotal thing. Then I go and embolize and the the interesting thing that happened to me several times. When I go into angiogram, I don't see it, but it is done. It's a scene in the CT done couple of hours. Exactly. The same scenario for us is well, we've had this a couple of times on our days, and it's just the same. It's just very frustrating. And then you're stuck because you visualize something, you can visualize it again, do the nebulizer or not. So it's It's an interesting point, because I I've been just in know what tone Sean thinks. Because I've seen exactly the same scenario. Yeah, um, but in the past, I've I've been pretty, Um, but if I don't see a bleed on angiography, but I have not embolized, um But, you know, I think our practice I think our practice is somewhat changed over the last couple years. You know, just just for the risk of in an hour now. And I don't want to admit this, but I think, uh, you know, the United States we often are. We often practice under the medical legal, um, the medical legal umbrella, and I'm not saying that's good. Um, and it's it doesn't often follow the data, but, um, you know if you if you see something on CT, you've got a small pseudoaneurysm. And you, um you don't see it on angiography, which is a conundrum patient about ready to be discharged. Um, do you, You know, just leave it alone. Do you do the embolize it? But I don't know, I guess especially in our population. Could we, Um a lot of our paper population is we will not be filed up again. Ever. So, um, I think we were starting to our practice is just starting to veering more towards symbolizing prophylactically. Um, you mean, if you don't see it on the angiography? I have a question. Ah, coming from the just the paper made me think about it. The they use ah, what they call it stiff coil, something. They use the word describing the or 35 coils. Um, and they haven't. They said we haven't used micro calls because to reduce the risk off in fortune, what else can shown? Think about this, I think. No, I think they're the thought. Was that that, um, you put in? It was, uh, 18 micro coils. You the risk of just almost a shin is greater I don't. Compared to go 35 coils, which could be a little bit, um, you know more proximal. Yeah. Oh, no. That's best for how I interpreted it. I don't know. I think with with technology available with the three files, well, you can get you can get It's the more flexible causes. Well, so I think there is availability of doing what you feel is right. No, you one feels is right. So I think there are definitely more. I'm not a massive fan of them, but definitely more flexible quells available that are, Oh, 3 503 8. Um, and I'm not a fan of plugs. Generally, I like to use cause cause I just I think I just like the motion of feeling one control of them. But I have done combination of quails, plugs, plugs on their own microcars. It'll depend on the anatomy and the access. How far can I get? And I think it's multifactorial rather than a simple This is what you do and just hold that. I know it's outside the paper, but just the benefit off genius they do use liquid or particles or slurry. Why is that uh, personally, I don't like to use liquid or while slurry I have used when there's active bleeding and spend some special When a patient comes on the table and they become quite unwell and they need sudden increase in in input, you have to sort of block and plug the areas you would do slow gelfoam slurry. But I think because of the collaterals around there from the short gastric pancreas omentum and going down to the colon, I generally like to have control of war of embolizer where I am belies. I wanted to be there, so I personally don't feel. And I think the literature says the news of particles is if I advised, but, um, liquids. I have seen people use it on literature, but I passed. You don't feel it's appropriate. Yeah. No, you you used, we'll use probably liquids for for, uh, you know, hyper splint is, um um you know, for partial one and for a minute. So it's interesting because I don't remember that I think that that works for that one because that's an abnormal area where the vascular she was developed with it. Whereas these guys have got supposedly normal anatomy to the basket and has developed that. That's enough. How I think about it is the same thing with the livers and tumors, and we do use particles in the liver for trauma. But not in the first instance. It's more to do with, like, cut the pathology of the whole process. Where is the pathology? Here is just the transected artery that that's how I feel or liver or spleen. That's how I kind of process it in my head, and I'm always, um, aware of the pancreas. It is nearby, so I know it is very rare. But when it happens, pancreatitis, it's a horrible complication. And ah, particles. Ah, yeah, I mean theoretically, because that I've seen it once. Ah, and when it happens is it's a very regrettable complication. Would you find that the practices, as you say you've had one incident and for me is is a psychological issue. I don't have a fine and it's not with me, but I don't know exactly, but I think for me it's just for me. It's what my my practice is done. I've got no scientific data to say. Don't use particles. It's just my logic of the anatomy and everything. And it's just one of those things where the data just isn't out their first. It's not randomizing to liquid and coil. No. Um, well, that was a question. Please complete the feedback survey to receive the certificate of attendance. Everybody. So, Morgan, can I can I ask a question if if we went to to take this paper and move forward with another sort of research? What? How would you do it or what would you do? I think you have to specifically look at those patients who had a contrast rush and super select those out on one compared to him. Examine on. Well, patient went straight theater. And that would be one nice group and to look at if her own answer questions are the paste, you don't have a contrast. Bush. We just have a venous injury to explain. What's the natural history? Because again, a lot of base our practice is on a special Surgeons is old data. And traditionally, you know, we talked non operative success rate of splenic preservations. Only about 65% off we do know now is that's retrospective date. Of course, that tells you what was done rather than what should have been done. We now know this being this far more Boston, that in the hemodynamically well, patient and do the question is but spleen and south and in for action. What do you use coils or something? Embolization Chemical. We don't really know what percentage of Spain we need. Keep immune function, especially the adult population, because most of these adults we live a normal life without explains anyway. On the old fashioned rest of overwhelming post back to the infection is almost unheard of an adult. It's almost unheard of, um, so you're gonna need a huge population of patients. Try answer the questions that we have you argue about. The one final question I would ask is, I know other kinds. Ask this before. Is there room toe have specifically trauma subspecialized interventionist at the training athlete? I'll be right in to a lot of our audience, and I think that probably is. Oh, yeah, for sure. I mean, look at how much we've spent just talking about one component of one organ, I think so fast as a huge area somewhere that academically were so weak in both in surgery and and I are in radio radiology. Lesser, because I think my dinner is very good at making fancy papers out of everything. But I offer sure, Onda, I think what What you mentioned about Spelich infarction is actually going back to that point is very important because I think we used to go for entire gets last time's gone by. The literature is shifted towards the whole proximal embolization to just give enough profusion. Pressure drop but not in function on. There's no real scientific way off actually measuring the Spanish function, or does it take a hit? Does it have? It doesn't have its own little local realization syndrome, we don't know. But what we do know is obviously scanning them at six weeks. It allows us to assess the vasculature, which is one of the reasons we bring the back in six weeks. I would very similar to you, Sean, where our stabbings don't tend to come back to us. So it's just a follow on from that. I'm I'm Oh, as I would like to see a proper, longer triple study following this small cylinders, Yes. See what the natural history is? Yep, I agree. that it might take some guts to do it. Um, but I think we don't know what what the natural history is that I would suspect that small pseudoaneurysms I would suspect most of the way. Yeah, even at this paper of the few pseudoaneurysms they were equal of A I think at one month they're significantly difference between the two arms. But then they equalized. Then we have one question here, I think, doing to read it up pretty soon. So how do you manage patients? You decide not to coil. If they most likely to bleed from the 1st 72 hours. Do you observe for 72 hours and then discharged? They are stable. Or do we say a special pray to the trauma God's on. Ask for the bleeding to stop. It always works. I give you my take on it. So if you don't intervene, that's the question. Yeah, because they haven't got arterial complications. Response. So it's prank. Um, a little dizziness, leaving as a general rule. So, um, you take greater Spain. I know. I said already. Don't really believe great anymore. You know, great for research. Not great for informing you. Greatest spleen that state the Grade three that patients scores themselves three shifts in the high dependence to prepare, you know, being very closely monitor on three days. It's not great science, and it comes from a Children's hospital. Philadelphia, based on pediatric patients, will be no tend to do better anyway. What Spleen's What's the best data we have out there, right? So it tends to be more based, just telling a patient and whatever clinically, exactly throw 11 more caveat. Then, if they remain him abandoning rock solid someone who is needing continuous Pulis off loves sort of bleeding slowly that isn't that in itself can be an indication. Take out spring. Okay, great or embolize this me or embolize, leave the room over me, the room with a date of the audience like exactly know, But I know I was going exactly what you you said it as I was about to say it and cut in to say that for us, the drop in the Matic ribs on an ongoing support needed isn't with no other cause. It's really important that we know there's nothing else going on because obviously, then you have to think about the whole thing. But if it's just this back in June, you keep dropping your hemoglobin. Just little drop. It doesn't have to drop to a significant level. That isn't an indication for intervention, not to spend it to me. It's not okay. One quick question from May for post embolization patients. When do you decide Teo, Go for the A splitting of the asplenia, your splenectomy, prophylaxes, antibiotics and vaccine. When do you choose to give the patients? That's long term embolization? Yes, falling anvil ization We don't give. Don't give a long term, but we treat them as the immediate period. They get the little cocktail that they would get if you have the splenectomy, but we don't know for long term antibiotics, the best time to give the vaccines is when the spleen is in situ, if you can. So even if you're gonna manage it nonoperatively I practice is to give it a while. The spleen is still there, even if it ends up coming out a couple days later. So if if you embolize by definition you don't need a blood stream, is there? Let's see the immunization fails it off, giving them now It's benign thing to do, I'll explain, is in situ um G in the UK The guidelines are you should be on lifelong. I'm spotting CDC in United States and I'm incorrect and Shaun been correctly, if you wish. Is does not recommend lifelong antibiotics. I don't believe life, and it's worked in adults because of your issue. With compliance they don't take. Just don't take them. They just develop. Resistance is yes, my, my general vices. The patient is not a spleen. Get the vaccines up to date on a bit like a patient with an artificial heart valve. If they become on well, then stage. They want want to a short course of antibiotics. Maybe I have no evidence one way or the other to say it makes a difference. Stroke longevity. Great. Thank you. Any other comments? Any questions from the audience? I think there's no more questions being asked. I just had a question, Um, mainly about just from obviously work in a public health care system. Um, do we have? Do you know what it costs to take someone to do a prophylactic splenic artery embolism? Cause obviously, if they you know what you've got these 26 patients that in the in the surveillance that go on toe need, it's funny country and listen, book the embolization. But if you know, if we don't get anyone any on, do you need to balance it with a, you know, cost benefit. How do we know how much it does cost to take these patients toe to the interventional sweet? I can, I can tell you in United States, it's it runs anywhere from 8 to $10,000 so it's not cheap. But then the balance that with with, you know, uh, and I see you bed Yeah, that's cost several $1000 per night, you know, But they might need to think than going to develop. Yeah, you did a bleeding. Yeah, but you know, this is coming the United States, where a cost of healthcare is just ridiculous. And it's, you know, you guys do it better. I think all right, economy, and it's it's still cost money. It's just paid in a different way. Well, I mean, I think alkylate in an ANA test is extremely difficult, and it's most of the time. It's virtual accountancy. Uh, the, uh the, uh, the money It's his cost off girls. That's the Mexicans, the catheters and wires and conscious of old, cheap but eventually the oldest of the cheapest. Ah, thing in that equation. Ah, it is. The coils use 45 coils. Each coils around 2, 5200. So you can't can't collect that. I mean, there are obviously there are costing is being done all the time about that. I don't have the numbers. We try to not worry the talent with the costs, you know, So we don't know the exact figures. Partner Coast Think for five embolization is around 5000 lbs. So this is less so. Uh, yeah, you can make comparison. I think five words have proven cost effective. This is enough for the number beds days recovery returned to work and for the whole economy rather than just the hospital. So it's a multi factorial. Some suspect the trial would be similar, but obviously it's a lot more complicated. So I don't think anyone got a true figure for it. That project for you juniors. If anyone's interested, it's a big project. But I think that's an interesting want to look into. Thank you. Great. Thank you. very much. I think we had a wonderful discussions there tonight. Thank you for the audience participating this session as well. And particularly thank you for the penalties. Teo, give us your precious time to our discussion. Thank you very much. I think we should conclude this session here on hope. You have a very good night. Thank you very much. Thank you. By everybody. Teo feel in the feedback from the link is in the chaps. Thank you.