embolotherapy in trauma js vermaak university of the witwatersrand fellow: department vascular...

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


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

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Chuang, VP, Wallace S, Gianturco C et al.

Complications of coil embolization: Prevention and management


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



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



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



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...”



Am J Emerg Med 2012;30:342-346

Conclude in thisRetrospective reviewNo control groupSmall numbers Ignoring early fixation




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




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



Am J Surg 2010;200:752-757

Retrospective review 2001-2009 of 819 pelvic fractures

31 (3.8%) angio18 (2.2%) active bleeding



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




Retrospective reviewContrast extravasation seen on trauma CT69 patients with 81 IVCEs

48 intra-abdominal solid organs18 pelvic retroperitoneal space15 other locations




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

embolotherapy in trauma js vermaak university of the witwatersrand fellow: department vascular...

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