Blunt Splenic Injury in Hemophilia A: Embolic Agent Selection When Hemostasis Cannot be Assumed

Blunt splenic injury in a patient with hemophilia A presents a dilemma that has traditionally been settled by splenectomy. Removing the spleen leaves a patient already prone to bleeding without its immune function, and the factor VIII (FVIII) exposure that open surgery requires is itself a recognized trigger for inhibitor formation. In the general trauma population, nonoperative management is now the standard for hemodynamically stable patients: observation suffices in most, and splenic artery embolization is reserved for higher-risk injuries. Patients with inherited coagulopathy, however, sit outside the trials and guidelines that built this paradigm. We present a 66-year-old man with mild hemophilia A (FVIII activity 13%), cardiac comorbidity, and a plasma allergy who sustained a blunt splenic laceration graded as American Association for the Surgery of Trauma (AAST) Grade II. No interim computed tomography was obtained; by hospital day 3, selective angiography showed an arteriovenous fistula that had been absent at presentation, a delayed vascular complication of the original injury. Coils and particulate agents failed to achieve occlusion, whereas a 1:3 N-butyl cyanoacrylate (NBCA)-lipiodol mixture produced immediate and complete vessel sealing via coagulation-independent polymerization. Using this case as an anchor, we review nonoperative management of splenic injury across inherited and acquired coagulopathy, compare coagulation-dependent and coagulation-independent embolic agents, and propose a multidisciplinary approach spanning factor replacement, agent selection, and immunoprophylaxis for this underserved population.