Introduction <p>Splenic artery embolisation (SAE) is a well-established treatment for high-grade splenic laceration due to blunt trauma in haemodynamically stable patients supported by major societal guidelines. However, guidelines support splenectomy in unstable patients, and there are limited data assessing the efficacy and role of SAE in this cohort. This study aimed to analyse the efficacy of splenic artery embolisation for unstable trauma patients in preventing mortality.</p> Methods <p>A single-centre retrospective case–control study was performed covering a 13.5-year period. Patients with splenic laceration due to blunt trauma who underwent splenic artery embolisation or splenectomy were identified and analysed. Haemodynamically unstable patients, as defined by a shock index of ≥ 1.0 or systolic blood pressure of &lt; 90&#xa0;mmHg, who underwent SAE versus upfront splenectomy were compared as specific cohorts. The primary outcomes were all-cause 30-day mortality and splenic salvage rates.</p> Results <p>A total of 126 haemodynamically unstable patients underwent SAE for blunt trauma, and eight haemodynamically unstable patients underwent upfront splenectomy. Among unstable patients who underwent SAE, splenic salvage was achieved in 98%, with 4% mortality at 30&#xa0;days. Comparing unstable patients who underwent SAE versus upfront splenectomy, there was no significant difference in mortality at 30&#xa0;days (p = 0.34).</p> Conclusion <p>Splenic artery embolisation is a safe and efficacious treatment in unstable patients with splenic laceration due to blunt trauma, with no significant difference in mortality compared to upfront splenectomy, supporting SAE as a primary treatment standard in this patient cohort.</p> Graphical Abstract <p></p>