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Embolotherapy in Trauma
JS VermaakUniversity of the Witwatersrand
Fellow: Department Vascular SurgeryVASSA 6th October 2012
Chuang VP, Reuter RS
Selective arterial embolization for the control of traumatic splenic bleeding
Invest Radiol 1975;10:18-24
• 10 dogs with splenic trauma• All controlled within 3 hours• 7 dogs survived to 2 months
Walter JF, Paaso BT, Cannon WB
Successful transcatheter embolic control of massive hematobilia secondary to liver
biopsyAm J Roentegenol 1976;127:847-9
• 43 year old female• Bleeding following liver biopsy• Hepatic artery portal vein fistula• Recurrent upper GI bleeds over 2 weeks• 16 units of blood• Gelfoam sponge used
Walter JF, Paaso BT, Cannon WB
Successful transcatheter embolic control of massive hematobilia secondary to liver
biopsyAm J Roentegenol 1976;127:847-9
Jander HP, Laws HL, Kogutt MS et al
Emergency Embolization in Blunt Hepatic Trauma
Am J Roentgenol 1977;129:249-252
18 year old female MVC# facial bones, pelvis, both lower extremitiesLaparotomy: spleen lacerated and resected1cm hepatic hematoma identifiedHb ↓
Jander HP, Laws HL, Kogutt MS et al
Emergency Embolization in Blunt Hepatic Trauma
Am J Roentgenol 1977;129:249-252
Maull KI, Sachatello CR
Current management of pelvic fractures: a combined surgical-
angiographic approach to hemorrhageSouth Med J 1976;69:1285-9
Richman SD, Green WM, Kroll R et al
Superselective Transcatheter Embolization of Traumatic Renal
HemorrahgeAm J Roentgenol 1977;128:843-844
40yr old Gunshot left upper abdomenThrough and through spleen – splenectomyNoticed a large tense retroperitoneal haematoma. “left intentionally to ulilize angiopgraphic embolization”Drains placedEmbolized after 2 hoursUsing gelatin sponge pellets (Gelfoam)
Richman SD, Green WM, Kroll R et al
Superselective Transcatheter Embolization of Traumatic Renal
HemorrahgeAm J Roentgenol 1977;128:843-844
Rubin BE, Katzen BT
Selective Hepatic Artery Embolization to control massive hepatic haemorrhage
after traumaAm J Roentgenol 1977;129:253-256
Chang J, Katzen BT, Sullivan KP
Transcatheter gelfoam embolization of posttraumatic bleeding
pseudoaneurysmsAm J Roentgenol 1978;131:645-650
Pubmed publications regarding embolotherapy
19751977
19791981
19831985
19871989
19911993
19951997
19992001
20032005
20072009
20110
50
100
150
200
250
300
Chuang, VP, Wallace S, Gianturco C et al.
Complications of coil embolization: Prevention and management
Am J Roentgenol 1981;137:809-813
7 casesCoil lost and retrievedcoil lost and not retrievedmisplaced coil to undesirable sitemisplaced coil during surgery
Current indications for embolotherapy
Algorithm for Splenic Injury
O BSER VATIO N
N EG ATIVE
O BSER VATIO N
N O EXTR AVASATIO N
O BSER VATIO N
SPLEN IC A C O IL
EXTR AVASATIO N
AN G IO G R APH Y
SPLENIC INJUR Y
U S or C T
STABLE
C T or PELVIC AN G IO
N EG ATIVE
R EC O VER Y
LAPAR O TO M Y
H EM O PER ITO N EU M
U ltrasound or D PL
U N STABLE
Blunt T raum a
False aneurysm of Vertebral Artery
Current indications of embolotherapy in trauma
• Keep patient stable• Spleen
• Make patient stable• Liver, Pelvis
• Difficult to reach areas• Facial fractures, Vertebral artery etc
• Availability of • Angiosuite• Angio-personnel• Experience vs Experimentation vs Desperation
Publications in 2012
Evidence Based Medicine
• “Analysis of prospective database”• Case reports and retrospective series• Theorizing where it belongs in the algorithm
of management of trauma patients
Hamaguchi S, Nakajima Y
Two cases of tracheoinnominate artery fistula following tracheostomy treated
successfully by endovascular embolization of the innominate artery
J Vasc Surg 2012;55:545-547
Tanizaki S, Maeda S, Hayashi H, et al
Early embolization without external fixation in pelvic trauma
Am J Emerg Med 2012;30:342-346
Thorson CM, Ryan ML, Otero CA, et al
Operating room or angiography suite for hemodynamically unstable pelvic
fracturesJ Trauma Acute Care Surg 2012;72:364-370
VS
Tanizaki S, Maeda S, Hayashi H, et al
Early embolization without external fixation in pelvic trauma
Am J Emerg Med 2012;30:342-346
• Retrospective review 2005-2009• 88 patients with pelvic fracture • Managed by protocol of hemodynamic
resuscitation and early pelvic embolization• Early fixation not used in their protocol
Tanizaki S, Maeda S, Hayashi H, et al
Early embolization without external fixation in pelvic trauma
Am J Emerg Med 2012;30:342-346
• 88 patients with pelvic fracture • 43 underwent angiography
• 29 (67%) had +ve angiographic blush• 28 (65%) were unstable• 25 (58%) had major ligamentous disruption
Tanizaki S, Maeda S, Hayashi H, et al
Early embolization without external fixation in pelvic trauma
Am J Emerg Med 2012;30:342-346
• Average time to angiography suite was 76.3 +- 34.5 min• Average transfusion in 1st 24 hours 8.4 +/- 8.2 Units• Mortality of angio patients was 11%• Conclusion:
• “Early pelvic embolization without external fixation may be useful for patients with hemodynamic instability...”
Tanizaki S, Maeda S, Hayashi H, et al
Early embolization without external fixation in pelvic trauma
Am J Emerg Med 2012;30:342-346
Conclude in thisRetrospective reviewNo control groupSmall numbers Ignoring early fixation
Thorson CM, Ryan ML, Otero CA, et al
Operating room or angiography suite for hemodynamically unstable pelvic
fracturesJ Trauma Acute Care Surg 2012;72:364-370
Retrospective review 1999-20112922 pelvic fractures
• 183 (6%) unstable and went to OR 1st or Angiosuite 1st » OR 1st : 134 Patients» Angio 1st : 49 Patients
Thorson CM, Ryan ML, Otero CA, et al
Operating room or angiography suite for hemodynamically unstable pelvic
fracturesJ Trauma Acute Care Surg 2012;72:364-370
Those who went to OR immediately tend to be sickerSys Bp lower p=0.038BE lower: -9 vs -5 p<0.001
BUT OR 1st patients:Outcomes were the same or better:
• Overall mortality was the same• Hospital stay was the same• Decreased mortality in unstable fractures 67% vs 20% p = 0.011
Costantini TW, Bosarge PL, Fortlage D, et al
Arterial embolization for pelvic fractures after blunt trauma: are we all talk?
Am J Surg 2010;200:752-757
Costantini TW, Bosarge PL, Fortlage D, et al
Arterial embolization for pelvic fractures after blunt trauma: are we all talk?
Am J Surg 2010;200:752-757
Retrospective review 2001-2009 of 819 pelvic fractures
31 (3.8%) angio18 (2.2%) active bleeding
Costantini TW, Bosarge PL, Fortlage D, et al
Arterial embolization for pelvic fractures after blunt trauma: are we all talk?
Am J Surg 2010;200:752-757
“Actual need for angiography and therapeutic embolization is quite small in patients sustaining pelvic fracture. Although factors associated with the need for pelvic angiography frequently are debated, we may discuss angiography for pelvic fractures more often than is actually performed”
Michailidou M, Velmahos GC, van der Wilden G, et al
“Blush” on trauma computed tomograhy: Not as bad as we think!
J Trauma Acute Care Surg 2012;73:580-586
Michailidou M, Velmahos GC, van der Wilden G, et al
“Blush” on trauma computed tomograhy: Not as bad as we think!
J Trauma Acute Care Surg 2012;73:580-586
Retrospective reviewContrast extravasation seen on trauma CT69 patients with 81 IVCEs
48 intra-abdominal solid organs18 pelvic retroperitoneal space15 other locations
Michailidou M, Velmahos GC, van der Wilden G, et al
“Blush” on trauma computed tomograhy: Not as bad as we think!
J Trauma Acute Care Surg 2012;73:580-586
43.5% no interventionPredictors for intervention
Admission Bp <100 mmHg sysLarge Extravasations (>1.5cm)Abbreviated Injury Score of the abdomen of 3 or higher
If all 3 present = 100% intervention
Conclusion:Embolotherapy in Trauma
• Patient factors• Stability• Associated injuries• Risk – Benefit ratio calculation• Induce stability• Maintain stability• Difficult to reach
• Institution factors• Angiosuite• Angio- personnel• Experience