atraumatic splenic rupture ( asr ) is an uncommon pathologic condition in which bleeding from the spleen occurs for a variety of reasons [ 13 ] . while the current trend in traumatic splenic rupture is nonoperative management including transcatheter arterial embolization [ 4 , 5 ] , splenectomy is recommended in most patients with asr as a consequence of underlying splenic pathology such as bacterial infection , malarial infection , hematological disorders , drugs or amyloidosis .
two patients with asr , concomitant hemorrhagic shock and anticoagulation therapy , presented to us for definitive treatment .
our successful treatment algorithm included a three - step strategy : ( i ) rapid transient hemostasis by splenic artery occlusion using a microballoon catheter , ( ii ) damage control resuscitation in the intensive care unit ( icu ) and ( iii ) splenectomy as a definitive hemostatic treatment .
a 66-year - old man presented after suffering sudden hypotension and abdominal distension , followed by a rapid and progressive anemia . after arriving at hospital , he collapsed and went into cardiac arrest .
return of spontaneous circulation occurred after 36 min of cardiopulmonary resuscitation and rapid blood transfusion .
abdominal contrast - enhanced computed tomography ( cect ) revealed a large hematoma around the spleen and liver , in paracolic gutters and the pelvis with active arterial extravasation and apparent capsular disruption ( fig .  1 ) .
his systolic blood pressure ( bp ) was 90 mmhg ; heart rate ( hr ) , 80 bpm ; hemoglobin ( hb ) level , 6.7 g / dl ; hematocrit ( ht ) , 19.0% ; prothrombin time - international normalized ratio ( pt - inr ) , 2.16 and activated partial thromboplastin time ( aptt ) , 63.9 s ( under massive transfusion ) .
he was currently on warfarin therapy for anticoagulation following a total aortic arch replacement including aortic valve replacement at the age of 60 .
he presented with no history of trauma , and moraxella catarrhalis had been detected in a blood culture taken on initial presentation .
however , his transfusion requirement was massive and the risk of significantly worsened hemorrhage during any operative procedure was increased by his iatrogenic coagulopathy .
after discussion with surgery team and interventional radiology ( ir ) team , transient occlusion of the splenic artery using a microballoon catheter was performed ( logos , piolax , inc .
, kanagawa , japan ; arrival to occlusion , 90 min ; arrival to angiography suite , 60 min ; procedure time to occlusion , 15 min ; fig .  2 ) .
soon after balloon occlusion , the patient 's hemodynamic state improved and his anemia stabilized .
perioperatively , 6 units of red cell concentrate ( rcc ) and 10 units of fresh frozen plasma ( ffp ) were transfused .
the patient 's coagulopathy improved on hospital day 2 ( ht , 25% ; pt - inr , 1.35 and aptt , 33.5 s ) and was taken to the operating theater for open splenectomy .
the spleen was swollen and capsular rupture was indeed identified , but there was no finding of a solid tumor or abscess formation .
he was extubated on day 4 , and was discharged from the icu on day 6 .
the patient was transferred to another hospital on day 25 without residual deficits or complications from his cardiac arrest . 

figure  1:there was a massive hematoma in the peritoneum surrounding the spleen and the liver , and extending into the paracolic gutter and the pelvic cavity .
the capsule of the spleen was disrupted , and active arterial extravasation can be seen around the spleen ( arrow ) . 

there was a massive hematoma in the peritoneum surrounding the spleen and the liver , and extending into the paracolic gutter and the pelvic cavity .
the capsule of the spleen was disrupted , and active arterial extravasation can be seen around the spleen ( arrow ) . the right gastroepiploic artery with platinum coils after embolization .
a 52-year - old woman was admitted to the emergency department with altered mental status . on admission ,
her mental status improved to e3v4m6 on the glasgow coma scale with a bp of 95/72 mmhg and hr of 92 bpm .
she was found to be anemic and coagulopathic ( hb , 9.6 g / dl ; ht , 31.0% ; pt - inr , 2.68 and aptt , 38.4 s ) .
she had a history of mitral valve replacement 3 months ago and was taking warfarin and sarpogrelate .
cect showed a giant splenic artery aneurysm , splenic laceration and hematoma ( fig . 
a diagnosis of hemorrhagic shock secondary to ruptured splenic aneurysm was made and ir was consulted .
the source of hemorrhage could not be identified because of the giant aneurysm and therefore hemorrhagic shock persisted , despite aggressive resuscitation .
localization of the hemorrhagic source was abandoned and transient occlusion of the splenic artery using a microballoon catheter was performed ( arrival to occlusion , 140 min ; arrival to angiography suite , 110 min and procedure time to occlusion , 17 min ) .
the hemorrhage and patient 's hemodynamics subsequently improved after a total of 4 units of rcc and 6 units of ffp being transfused .
a splenectomy was performed on day 2 after correction of the patient 's coagulopathy ( ht , 27% ; pt - inr , 1.02 and aptt , 33.8 s ) . on examination ,
the giant splenic aneurysm was found to be a pseudoaneurysm complicated by an abscess at the hilum of the spleen , yielding a final diagnosis of asr due to infection .
the patient was moved to the general ward on day 3 , and discharged from the hospital on day 12 . 

a giant splenic aneurysm ( 40  50 mm ) and splenic laceration are seen ( arrow ) .
a giant splenic aneurysm ( 40  50 mm ) and splenic laceration are seen ( arrow ) .
a 66-year - old man presented after suffering sudden hypotension and abdominal distension , followed by a rapid and progressive anemia . after arriving at hospital , he collapsed and went into cardiac arrest .
return of spontaneous circulation occurred after 36 min of cardiopulmonary resuscitation and rapid blood transfusion .
abdominal contrast - enhanced computed tomography ( cect ) revealed a large hematoma around the spleen and liver , in paracolic gutters and the pelvis with active arterial extravasation and apparent capsular disruption ( fig .  1 ) .
his systolic blood pressure ( bp ) was 90 mmhg ; heart rate ( hr ) , 80 bpm ; hemoglobin ( hb ) level , 6.7 g / dl ; hematocrit ( ht ) , 19.0% ; prothrombin time - international normalized ratio ( pt - inr ) , 2.16 and activated partial thromboplastin time ( aptt ) , 63.9 s ( under massive transfusion ) .
he was currently on warfarin therapy for anticoagulation following a total aortic arch replacement including aortic valve replacement at the age of 60 .
he presented with no history of trauma , and moraxella catarrhalis had been detected in a blood culture taken on initial presentation .
however , his transfusion requirement was massive and the risk of significantly worsened hemorrhage during any operative procedure was increased by his iatrogenic coagulopathy .
after discussion with surgery team and interventional radiology ( ir ) team , transient occlusion of the splenic artery using a microballoon catheter was performed ( logos , piolax , inc .
, kanagawa , japan ; arrival to occlusion , 90 min ; arrival to angiography suite , 60 min ; procedure time to occlusion , 15 min ; fig .  2 ) .
soon after balloon occlusion , the patient 's hemodynamic state improved and his anemia stabilized .
perioperatively , 6 units of red cell concentrate ( rcc ) and 10 units of fresh frozen plasma ( ffp ) were transfused .
the patient 's coagulopathy improved on hospital day 2 ( ht , 25% ; pt - inr , 1.35 and aptt , 33.5 s ) and was taken to the operating theater for open splenectomy .
the spleen was swollen and capsular rupture was indeed identified , but there was no finding of a solid tumor or abscess formation .
he was extubated on day 4 , and was discharged from the icu on day 6 .
the patient was transferred to another hospital on day 25 without residual deficits or complications from his cardiac arrest . 

figure  1:there was a massive hematoma in the peritoneum surrounding the spleen and the liver , and extending into the paracolic gutter and the pelvic cavity .
the capsule of the spleen was disrupted , and active arterial extravasation can be seen around the spleen ( arrow ) . 

there was a massive hematoma in the peritoneum surrounding the spleen and the liver , and extending into the paracolic gutter and the pelvic cavity .
the capsule of the spleen was disrupted , and active arterial extravasation can be seen around the spleen ( arrow ) . the right gastroepiploic artery with platinum coils after embolization .
a 52-year - old woman was admitted to the emergency department with altered mental status . on admission ,
her mental status improved to e3v4m6 on the glasgow coma scale with a bp of 95/72 mmhg and hr of 92 bpm .
she was found to be anemic and coagulopathic ( hb , 9.6 g / dl ; ht , 31.0% ; pt - inr , 2.68 and aptt , 38.4 s ) .
she had a history of mitral valve replacement 3 months ago and was taking warfarin and sarpogrelate .
cect showed a giant splenic artery aneurysm , splenic laceration and hematoma ( fig .  3 ) .
a diagnosis of hemorrhagic shock secondary to ruptured splenic aneurysm was made and ir was consulted .
the source of hemorrhage could not be identified because of the giant aneurysm and therefore hemorrhagic shock persisted , despite aggressive resuscitation .
localization of the hemorrhagic source was abandoned and transient occlusion of the splenic artery using a microballoon catheter was performed ( arrival to occlusion , 140 min ; arrival to angiography suite , 110 min and procedure time to occlusion , 17 min ) .
the hemorrhage and patient 's hemodynamics subsequently improved after a total of 4 units of rcc and 6 units of ffp being transfused .
a splenectomy was performed on day 2 after correction of the patient 's coagulopathy ( ht , 27% ; pt - inr , 1.02 and aptt , 33.8 s ) . on examination ,
the giant splenic aneurysm was found to be a pseudoaneurysm complicated by an abscess at the hilum of the spleen , yielding a final diagnosis of asr due to infection .
the patient was moved to the general ward on day 3 , and discharged from the hospital on day 12 . 

a giant splenic aneurysm ( 40  50 mm ) and splenic laceration are seen ( arrow ) .
a giant splenic aneurysm ( 40  50 mm ) and splenic laceration are seen ( arrow ) .
splenectomy is still considered the treatment of choice for asr . however , ir hemostasis in emergency or trauma patients is gaining acceptance .
our three - step strategy using temporary balloon occlusion was chosen over the more widely used coils , because balloon occlusion occludes the vessel lumen completely and is therefore effective in the setting of coagulopathy .
combined with critical care resuscitation and operative intervention , ir may allow a more rapid and safer hemostatic strategy than conventional ir or surgery alone .
there have been few reports on the effectiveness of balloon catheters used in damage control interventional radiology for trauma or critical hemorrhage . however , we believe they represent a useful hemostatic device for transient , proximal bleeding control , especially in hemorrhagic shock with coagulopathy
conventional balloon catheters ( e.g. selecon mp , terumo clinical supply , gifu , japan , or moiyan , tokai medical products , aichi , japan ) could be used as well . however
, anatomical and/or technical problems might make it difficult to select and advance the catheter in similar cases . as described in the presented cases , the microballoon catheter ( e.g. logos , piolax , inc . or attendant , terumo clinical supply )
the presented cases demonstrate that splenic artery occlusion using a microballoon catheter before splenectomy can be a useful hemostatic strategy in asr patients with hemorrhagic shock and coagulopathy .
 atraumatic splenic rupture ( asr ) is an uncommon pathologic condition in which bleeding from the spleen occurs for a variety of nontraumatic reasons . while the current trend in traumatic splenic rupture is nonoperative management including transcatheter arterial embolization , the current recommendation for the treatment of most patients with asr is splenectomy . in this report , we describe two cases of asr presenting with hemorrhagic shock and complicated by anticoagulation therapy . in patients with severe hemorrhagic shock and coagulopathy , a damage control strategy is recommended . 
 our successful treatment of these patients included a three - step strategy as a damage control : ( i ) rapid transient hemostasis by splenic artery occlusion using a microballoon catheter , ( ii ) damage control resuscitation and ( iii ) splenectomy as a definitive hemostatic treatment . 
INTRODUCTION
CASE REPORT
Case 1
Case 2
DISCUSSION
CONFLICT OF INTEREST STATEMENT