Faffing or fixing?(Part 2)

Straight to theatre?• Time to laparotomy • Trauma centre 127 mins• NCEPOD 200

mins– NO CT 110 mins– CT 499 mins

• NO CT group unstable• ?Relevance to QE

– 24/7 on site CT radiographers

Delaying surgery or scanning ‘towait for stabilisation’ does not make sense. If the patient isconsidered too unstable for CT scan then transfer to theatreis required instead.

Time to intervention

• On a good day– 45 minutes from

referral

• On a bad day– “Don’t know, I’ll phone

around and get back to you”

– Not available!

When?

IR indications

• No good surgical alternative– Aortic transection– Major haemorrhage from pelvic fracture

• Organ preservation– Splenic artery embolization– Selective renal artery embolization

• Vascular trauma– AV Fistula/intimal flap etc

• Many others so ask!

Surgical indications

• Needs a laparotomy anyway– Bowel injury– Gunshot wounds

• Major liver trauma-liver packing

• May need both surgery and IR

Aortic transection

4 Case seriesN 12 5 9 12

Technical success

100% 100% 100% 100%

30 day mortality

8% 0% 0% 16.7%

Mortality surgical series 12-35%

Transection Pitfalls

• Access difficult in female patients– Large diameter

devices– Small iliac arteries

• 4% iliac artery rupture/avulsion rate

• Stent collapse

Pelvic fractures

• Haemorrhage main cause of death

• Main sources– Internal iliac artery

branches– Venous – Bone /soft tissues

• Lethal triad– Unstable fracture– Hypotension– Free abdominal fluid

=83-95% mortality

QE 29/06/08

Complications• Skin and buttock necrosis

• 165 patients with pelvic fractures embolized for bleeding• 12/165 skin and buttock necrosis• All had bilateral IIA occlusion with gelfoam slurry• 5/12 buttock abrasions+/- gas• 1/12 open fracture• 3 died from buttock sepsis

• Rectal necrosis• Lower limb weakness

Suzuki, Takashi (2005) Clinical characteristics of pelvic fracture patients with gluteal necrosis resulting from transcatheter arterial embolization. Archives of Orthopaedic and Trauma Surgery 125(7)

Suzuki, TakashiTranscatheter Arterial Embolization for Pelvic Fractures May Potentially Cause a Triad of Sequela: Gluteal Necrosis, Rectal Necrosis, and Lower Limb Paresis. Case Report Journal of Trauma-Injury Infection & Critical Care. 65(6):1547-1550, December 2008.

Splenic embolization

• Pros– Avoid splenectomy

• Lifelong risk of overwheming post-splenectomy infection

• Thrombotic tendency

• Complications– Failure – Inadvertent

embolization – Splenic infarction

and/or abscess

Vascular trauma

What we need from referrer

• Awareness– Role of trauma IR– Imaging requirements

• Senior level involvement– Consultant A&E,

Surgical and Anaesthetic involvement

• Support

What referrers need from us

• Rapid consistent access to imaging

• All relevant imaging in 1 visit

• Comprehensive IR cover

• A service you can have confidence in