To compare the outcomes of splenic artery embolization (SAE) for acute splenic injury (ASI) between patients who are hemodynamically stable (HDS) and hemodynamically unstable (HDU). Nonoperative management with SAE has become an accepted practice for patients who are HDS with ASI; however, SAE for the treatment of patients who are HDU with ASI has not been well studied.A retrospective cohort study was performed, including 52 patients who were HDU and HDS who underwent SAE for ASI at a Level 1 trauma center. HDU was defined as the lowest recorded systolic blood pressure prior to intervention90 mm Hg. Utilizing the American Association for Surgery of Trauma (AAST) splenic injury scale, AAST Grades 1-3 were defined as low grade, and Grades 4-5 were defined as high grade. The primary outcomes were survival at 30 days and the need for subsequent splenectomy.Seventy-five percent (n = 39) of the patients were HDS, and 25% (n = 13) were HDU. The majority (69%) of patients who were HDU who underwent SAE did not require splenectomy, compared with 95% of patients who were HDS (P = .03). No significant difference in 30-day survival between patients who were HDU and HDS was noted. No major adverse events were recorded. There was no significant difference in 30-day patient survival or the rate of subsequent splenectomy between high-grade and low-grade splenic injuries.In this retrospective cohort study, there was no statistically significant difference in the adverse events or 30-day post-SAE survival rates between patients who were HDS and HDU with ASI. The authors conclude that SAE can be a safe and effective treatment option for patients who are HDU with ASI, including high-grade splenic injury.