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The role of IR in Visceral Trauma

The role of IR in Visceral Trauma. Dr Robert Morgan MRCP, FRCR, EBIR, FCIRSE St George’s Hospital and Medical School, London. Financial Disclosures. Consultant: W Cook Europe Covidien Angiodynamics. OVERVIEW. Introduction Organ specific trauma Spleen Liver Kidney. Introduction.

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The role of IR in Visceral Trauma

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  1. The role of IR in Visceral Trauma Dr Robert Morgan MRCP, FRCR, EBIR, FCIRSE St George’s Hospital and Medical School, London

  2. Financial Disclosures • Consultant: W Cook Europe Covidien Angiodynamics

  3. OVERVIEW • Introduction • Organ specific trauma • Spleen • Liver • Kidney

  4. Introduction • Uncontrolled post-traumatic bleeding is the leading cause of potentially preventable death among trauma patients up to 80% is due to visceral organ injury 20% of pts have multiple vascular injuries • Visceral organ injury occurs in ~30% of abdominal trauma • Van der Vlies et al, Int J Emerg Med 2010 • World Health Organisation 2004 • Deunk J et al. Ann Surg 2010

  5. Management options • Conservative • Embolization • Surgery

  6. Conservative Mangement • 60 - 90% of blunt hepatic, renal or splenic injuries • Predictors of success Hemodynamic stability Liver, Kidney trauma > Splenic trauma No hemoperitoneum Diamond et al. J Trauma 2009

  7. Embolization • Increasingly used as a first interventional option vs surgery • Aim  stop hemorrhage and minimize ischemia • Proximal vs Distal embolization • Sometimes SPEED is better than OPTIMAL EMBOLIC DEPLOYMENT

  8. Introduction • Organ specific • Spleen Liver Kidney

  9. SPLENIC TRAUMA • Most commonly injured abdominal organ (40%) • Circulation Splenic artery Collaterals (eg short gastric a)

  10. Moore et al, J Trauma 1995

  11. AAST does NOT include active contrast extravasation and vascular injuries

  12. Conservative Rx of low grade AAST injuries is successful in >80-90% of pts Failure of conservative Rx: High grade injuries (up to 70%) Contrast blush on CTA (up to 80%) Vascular injuries on CTA Intervention vs conservative Rx

  13. Peitzman et al. J Trauma 2000

  14. Indications for embolization • CT indications • Extravasation of contrast • Evidence of vascular injury • Vessel truncation • Pseudoaneurysm • AV fistula • AAST III-V (depending on haemodynamic stability) • Overall success 90% Schnuriger et al. J Trauma 2011

  15. Technique of Embolization • Catheterize proximal splenic artery Sidewinder vs Cobra

  16. Technique of Embolization • Catheterize proximal splenic artery Sidewinder vs Cobra • Decide whether to perform proximal vs distal Embolization

  17. Technique of Embolization • Catheterize proximal splenic artery Sidewinder vs Cobra • Decide whether to perform proximal vs distal Embolization • Distal embolization Microcatheter to site of vascular injury  Coils, glue

  18. Technique of Embolization • Catheterize proximal splenic artery Sidewinder vs Cobra • Decide whether to perform proximal vs distal Embolization • Distal embolization Microcatheter to site of vascular injury  Coils, glue • Proximal embolization Amplatzer plug vs Coils through selective catheter

  19. Proximal embolization Amplatzer 4 plug for proximal splenic Artery embolization in blunt trauma Ng et al. al JVIR 2012;23:976-9

  20. Similar success • Major complications requiring splenectomy are similar between two groups

  21. Hyposplenism after SAE? • Bessoud et al. J Trauma 2007 • Normal well perfused spleen after prox SAE n=24 • Malhotra et al. J Trauma 2008 • Splenectomy lower CD4+ cells, SAE normal levels, n=8 • Tominaga et al. J Trauma 2009 • No diff in immune markers SAE vs normal patients • Nakae et al. J Trauma 2009 • No diff in immune markers SAE/partial splenectomy vs NOM, n=100 • Malhotra et al. J Trauma 2010 • No diff in immune markers SAE vs NOM, n=23

  22. Splenic traumaTake Home Points • Conservative management for low grade injuries • Embolization indicated for: • contrast extravasation • false aneurysm • AVF • high grade injuries • Proximal embolization is adequate • Residual splenic function post SAE is satisfactory

  23. Introduction • Organ specific Spleen • Liver Kidney

  24. HEPATIC TRAUMA • 2nd most commonly injured organ • Right Lobe > left lobe • Dual blood supply • 80% Portal vein • 20% Hepatic artery • *cystic a & bile ducts

  25. Remember the anatomic variants of the hepatic arteries • Remember the right hepatic artery arises from the SMA in 11%

  26. Moore et al. J Trauma 1995

  27. Conservative Management • Hemodynamically stable patients with no extravasation (even with extensive parenchymal injury) • >70% of all cases • Grade I - III – almost always • Grade IV-V – selective Christmas AB et al. Surgery 2005

  28. Primary Surgery • Grade IV-V + >2000ml fluid requirements • Juxtahepatic vein injuries - IVC • Extra-hepatic portal vein laceration/rupture • Associated stomach/small or large bowel injury Gaarder C, Int J Care Injured 2007 Hagiwara A, J Trauma 2005

  29. Indications for embolization • Blunt or penetrating trauma • Active bleeding/vascular injury on CT • Hemodynamic instability • Large Hemoperitoneum • Persistent bleeding after Surgery Fang JF, J Trauma 2006, 61:547-53

  30. Technique of Embolization • Selective celiac/hepatic angiography to define site of injury • Catheterize common/proper hepatic artery Sidewinder vs Cobra

  31. Technique of Embolization • Selective celiac/hepatic angiography to define site of injury • Catheterize common/proper hepatic artery Sidewinder vs Cobra • Distal >>> proximal embolization

  32. Technique of Embolization • Selective celiac/hepatic angiography to define site of injury • Catheterize common/proper hepatic artery Sidewinder vs Cobra • Distal >>> proximal embolization • Microcatheter to site of injury • Front and back door embolization • Coils glue

  33. Overall success 80-100% • Overall survival 88-100%

  34. Complications of embolization • More likely if extensive injury requiring diffuse embolization • Overall 40-60% • Necrosis 40% • Abscess 17% • Gallbladder necrosis 7% • Biliary leak/biloma 20% Gaarder et al. Injury 2007

  35. Portal vein embolization • May have a role in recurrent hemorrhage • Little published data • High risk of hepatic ischemia

  36. LiverTake Home Points • Conservative management for low grade injuries • even some IV and V • Know your vascular variant anatomy and also perform SMA angiography • Avoid proximal embolization unless absolutely necessary • Watch for complications after embolization CT vs US

  37. Introduction • Organ specific Spleen Liver • Kidney

  38. RENAL TRAUMA • 3rd most common injured organ • Commonest in children

  39. Moore et al. J Trauma 1995

  40. Conservative Management • Growing trend for Grades I-IV • Advantages: • ↓ 3-6x need for nephrectomy • ↓ hospital stay • No increase in complications or long-term hypertension • Success rate: 80 - 100% • Success rate: children > adults Santucci et al. J Trauma 2006

  41. Indications for embolization • Renovascular injuries (unstable) • Stab/penetrating wounds • Increasing transfusion requirements • Active hemorrhage on CTA Constantinos et al. CVIR 2005

  42. Technique of Embolization • Selective angiography to define site of injury Cobra vs Sidewinder vs Sosomni • Distal embolization >>> Proximal embolization

  43. Technique of Embolization • Selective angiography to define site of injury Cobra vs Sidewinder vs Sosomni • Distal embolization >>> Proximal embolization • Microcatheter to site of injury • Embolize feeding artery (back door occlusion not necessary) • Coils • glue

  44. Follow up 3 days 3 weeks 5 weeks

  45. Outcomes of Embolization • Overall success rate ~90-95% • Significant complications <5% Constantinos et al. CVIR 2005

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