図４〜図９は省略．図２と図３の▲は大動脈より低濃度だからextravasationではなく凝血塊であろう，図３の白矢印は生理的な分葉腺か損傷か鑑別は困難だが，周囲にextravasationを認めないので損傷であってもminor injuryである．Extravasationはないと診断し経過観察したが，腹部エコー検査で腹水量が増加したので血管造影を行った．図Aと図Bでextravasation（↑）を認めたのでスポンゼル細片で塞栓を試みたが，成功せず（図Cと図D，白矢印はextravasation），手術となった．脾臓下極から脾門部に裂創を認め活動性に出血しており，脾臓摘出を行った．Retrospectiveに見れば図１２と図１３の△は脾臓よりややdensityが高くextravasationを示している．Double phase 造影CTを撮れば正確な診断がなされた可能性が高い．

文献考察１）：脾動脈本幹での塞栓術．AAST grade III以上の損傷例と，CTでextravasationを示した37例に脾動脈本幹での塞栓術を行った．手術を要した例は2.7%だけで，特に合併症も認めなかった．
AJR Am J Roentgenol. 2006 Mar;186(3):779-85.
Nonoperative management of traumatic splenic injuries: is there a role for proximal splenic artery embolization?
Bessoud B, Denys A, Calmes JM, Madoff D, Qanadli S, Schnyder P, Doenz F.

OBJECTIVE: The objective of our study was to evaluate our experience with transcatheter proximal (i.e., main) splenic artery embolization (TPSAE) in the nonsurgical management of patients with grade III-V splenic injuries, according to the American Association for the Surgery of Trauma (AAST) guidelines, and patients with splenic injuries associated with CT evidence of active contrast extravasation or blush (or cases meeting both criteria). MATERIALS AND METHODS: The records of patients with traumatic splenic injuries admitted during a 52-month period were retrospectively reviewed for patient age and sex, mechanism of injury, injury severity score (ISS), RBC transfusion requirements, AAST splenic injury CT grade, presence of active contrast extravasation or blush on CT examination, and amount of hemoperitoneum on CT examination. Demographics, CT findings, transfusion requirements, and outcome were compared using the Student's t test or chi-square test in patients undergoing standard nonoperative management and nonoperative management TPSAE-that is, TPSAE followed by nonoperative management. RESULTS: Of the 79 identified patients with splenic trauma, 67 were managed nonoperatively. Thirty-seven patients (28 men, nine women; mean age, 40 years; mean ISS, 28.8) underwent nonoperative management TPSAE and 30 patients (27 men, three women; mean age, 37 years; mean ISS, 25.1) underwent nonoperative management. Age, sex, and ISS were not significantly different between the two groups. TPSAE was always technically feasible. Splenic injuries were significantly more severe in the nonoperative management TPSAE group than in the nonoperative management group with respect to the mean splenic injury AAST CT grade (3.7 vs 2, respectively; p
文献考察２）：脾動脈本幹での塞栓術後の免疫機能に異常を認めない．
J Trauma. 2007 Jun;62(6):1481-6.
Proximal splenic artery embolization for blunt splenic injury: clinical, immunologic, and ultrasound-Doppler follow-up.
Bessoud B, Duchosal MA, Siegrist CA, Schlegel S, Doenz F, Calmes JM, Qanadli SD, Schnyder P, Denys A.

BACKGROUND: To evaluate the clinical, US (ultrasound)-Doppler and hematologic findings after proximal splenic artery embolization (PSAE) for blunt injury. METHODS: From August 1998 to February 2003, 37 patients (28 men and 9 women; 20-89 years old, mean 40 years) underwent PSAE for blunt injuries. One patient required secondary splenectomy after PSAE. Early complications were investigated during the hospital stay. Delayed follow-up included review of the outpatient records, telephone interview, consultation, US-Doppler splenic study, Howell-Jolly body search, and serum antibody titer determinations (pneumococcus and Haemophilus influenzae B). RESULTS: No early postprocedural complications were depicted. Ten patients were lost on follow-up. Two patients had a telephone interview that revealed no complication. Twenty-four patients were examined 6 to 63 (mean 26) months after the embolization. No late complication was reported. Splenic measurements were in the normal range: length (53-110 mm; mean, 73), width (49-110 mm; 76), thickness (26-56 mm; 38), volume (61-508 mL; 226), standard ellipsoid formula volume (32-265 mL; 118), corrected volume (29-238 mL; 106), and splenic volumetric index (2.3-18.8; 8.4). The spleen was homogeneous in 23 patients (96%). Intrasplenic vascularization was present and splenic vein was patent in all patients. Howell-Jolly bodies were found in two patients. All patients (24 of 24) evaluated for exposure-driven immunity against Haemophilus Influenza b had sufficient immunity. Seventeen of the 18 patients (94%) evaluated for exposure-driven immunity against pneumococcus had sufficient immunity. Five of the six patients (83%) evaluated for pneumococcus vaccine response had a sufficient response. CONCLUSIONS: Proximal splenic artery embolization in blunt splenic injuries is a well-tolerated technique without major long-term impact on the splenic anatomy and immune function.PMID: 17563670