Blunt Splenic Injury in Hemophilia A: Embolic Agent Selection When Hemostasis Cannot be Assumed.
Çağrı Akalın, Hüseyin Akkaya
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Case in brief
A 66-year-old man with mild hemophilia A (factor VIII activity 13%), cardiac comorbidity, and plasma allergy sustained a blunt AAST Grade II splenic laceration. Angiography on hospital day 3, without interim computed tomography, identified an arteriovenous fistula not seen initially. Coils and particulate embolic agents did not occlude the vessel; a 1:3 N-butyl cyanoacrylate–lipiodol mixture achieved immediate, complete sealing through coagulation-independent polymerization.
What made this case unusual
The delayed fistula was not apparent at presentation, and conventional embolic agents failed to occlude it. A coagulation-independent adhesive achieved complete sealing in a patient whose hemophilia made hemostasis uncertain.
Diagnostic / clinical pearl
In hemophilia A with splenic injury, delayed vascular complications may emerge despite an initially absent fistula; when coagulation-dependent agents fail, a coagulation-independent embolic agent may achieve occlusion.
Why it matters
Inherited coagulopathies are not represented in the trials and guidelines underpinning standard nonoperative splenic-injury management, making individualized, multidisciplinary decisions important.