DISCUSSION
Figure 1 displayed a wedge-shaped, low-density splenic lesion suggestive of infarction. No evidence of dissection or extravasation was observed. An incidental left adrenal gland mass measuring 1.6 cm was detected. The gallbladder had been removed, the kidneys were not obstructed, and no renal mass was seen. Diverticula were present in the sigmoid colon, but there was no indication of diverticulitis.
Abdominal CT scans obtained earlier were reviewed to rule out any acute symptoms of chronic diseases. The most recent scan available for comparison was one obtained without contrast (Figure 2). That scan, as well as scans obtained even earlier, showed a normal spleen. The changes on the current CT scan coupled with the onset of new symptoms confirmed the diagnosis of acute splenic infarction.
The preferred diagnostic modality to confirm splenic infarction is CT of the abdomen with contrast.1 There is a remote chance that CT performed without contrast could miss an infarction. This patient had previous scans obtained with and without contrast, however, and none showed an abnormality.
Splenic infarction Symptoms manifested themselves after the patient's cardiac catheterization, a procedure known to carry risks of atheroembolism. Calciferous debris can be scraped from the aortic wall during the procedure, but this debris does not always cause atheroembolism. Calciferous debris has been present in as many as 51% of patients who undergo catheterization. Despite these high reported rates, no increase in ischemic complications secondary to cardiac catheterization-related atheroembolism has been reported.2 Debris can cause systemic embolization leading to cutaneous, renal, retinal, cerebral, and GI emboli. Although splenic infarct may follow cardiac catheterization, the frequency of reported, clinically evident embolization is less than 1%.3
Only two other isolated splenic infarcts after cardiac catheterization without associated abdominal aortic aneurysm have been reported.1,4 Both cases had symptoms and history similar to this patient's. The symptoms started immediately after the procedure and progressively worsened. Additionally, a medical history that includes hypertension and smoking
is common.
Embolic events occurring during cardiac catheterization presumably arise in two ways. The first is thrombogenesis, occurring either on the catheter or the guide wire surface. The second is dislodgement of a large particle calcification from the arterial wall.5 Splenic infarction is thought to have a very low incidence rate due to the anatomy of the splenic artery. The largest of the arteries originating at the celiac trunk, the splenic artery subdivides into five or more branches, ultimately entering the hilum of the spleen. The diversity of arterial vessels does not easily predispose the spleen to infarction.6 For most patients, the exact cause of infarction is unknown. Regardless of etiology, the treatment of splenic infarction after cardiac catheterization is the same.
Treatment This patient was initially treated in the ED with acute pain management. The cardiologist and interventional radiologist were then notified of the patient's condition. The decision was made to treat conservatively with close follow-up. Conservative treatment for splenic infarction typically involves pain management and usually leads to a complete resolution of symptoms.7 This patient was placed on a fentanyl patch and oral hydrocodone/acetaminophen as needed.
A surgical consult was obtained, but surgical management is not indicated unless complications develop. The complications of splenic infarction include hemorrhage, rupture, or abscess and may require splenectomy.
Conclusion Splenic infarction is a rare complication of cardiac catheterization. After this patient presented to the ED, a careful history and physical examination followed by CT uncovered left flank pain caused by splenic infarction resulting from a cardiac catheterization. This case demonstrates that the provider should closely consider the patient's history and maintain a high index of suspicion for a rare complication of a procedure when the history justifies this suspicion. Uncommon complications can have devastating consequences if they are missed. JAAPA
Steve Andrews and Jennifer Pitts Hanopole are students in the Jefferson College of Health Sciences physician assistant program, Roanoke, Virginia. Andres Marte-Grau and Rathnakar Sherigar practice at the Veterans Affairs Medical Center, Salem, Virginia. Urvi Shah is a volunteer in the emergency department, VA Medical Center, Salem, Virginia. The authors have indicated no relationships to disclose relating to the content of this article.
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