Embolotherapy in Trauma

1. Embolotherapy in Trauma JS Vermaak University of the Witwatersrand Fellow: Department Vascular Surgery VASSA 6th October 2012

2. Chuang VP, Reuter RSSelective arterial embolization for the control of traumatic splenic bleedingInvest Radiol 1975;10:18-24 • 10 dogs with splenic trauma • All controlled within 3 hours • 7 dogs survived to 2 months

3. Walter JF, Paaso BT, Cannon WBSuccessful 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

4. Walter JF, Paaso BT, Cannon WBSuccessful transcatheter embolic control of massive hematobilia secondary to liver biopsyAm J Roentegenol 1976;127:847-9

5. Jander HP, Laws HL, Kogutt MS et alEmergency Embolization in Blunt Hepatic TraumaAm J Roentgenol 1977;129:249-252 18 year old female MVC # facial bones, pelvis, both lower extremities Laparotomy: spleen lacerated and resected 1cm hepatic hematoma identified Hb ↓

6. Jander HP, Laws HL, Kogutt MS et alEmergency Embolization in Blunt Hepatic TraumaAm J Roentgenol 1977;129:249-252

7. Maull KI, Sachatello CRCurrent management of pelvic fractures: a combined surgical-angiographic approach to hemorrhageSouth Med J 1976;69:1285-9

8. Richman SD, Green WM, Kroll R et alSuperselectiveTranscatheterEmbolization of Traumatic Renal HemorrahgeAm J Roentgenol 1977;128:843-844 40yr old Gunshot left upper abdomen Through and through spleen – splenectomy Noticed a large tense retroperitoneal haematoma. “left intentionally to ulilizeangiopgraphicembolization” Drains placed Embolized after 2 hours Using gelatin sponge pellets (Gelfoam)

9. Richman SD, Green WM, Kroll R et alSuperselectiveTranscatheterEmbolization of Traumatic Renal HemorrahgeAm J Roentgenol 1977;128:843-844

10. Rubin BE, Katzen BTSelective Hepatic Artery Embolization to control massive hepatic haemorrhage after traumaAm J Roentgenol 1977;129:253-256

11. Chang J, Katzen BT, Sullivan KPTranscathetergelfoamembolization of posttraumatic bleeding pseudoaneurysmsAm J Roentgenol 1978;131:645-650

12. Pubmed publications regarding embolotherapy

13. Chuang, VP, Wallace S, Gianturco C et al.Complications of coil embolization: Prevention and managementAm J Roentgenol 1981;137:809-813 7 cases Coil lost and retrieved coil lost and not retrieved misplaced coil to undesirable site misplaced coil during surgery

14. Current indications for embolotherapy

15. Algorithm for Splenic Injury

17. False aneurysm of Vertebral Artery

20. 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

21. Publications in 2012

22. Evidence Based Medicine • “Analysis of prospective database” • Case reports and retrospective series • Theorizing where it belongs in the algorithm of management of trauma patients

23. Hamaguchi S, Nakajima YTwo cases of tracheoinnominate artery fistula following tracheostomy treated successfully by endovascular embolization of the innominate arteryJ VascSurg 2012;55:545-547

24. Tanizaki S, Maeda S, Hayashi H, et alEarly embolization without external fixation in pelvic traumaAm J Emerg Med 2012;30:342-346 VS Thorson CM, Ryan ML, Otero CA, et alOperating room or angiography suite for hemodynamically unstable pelvic fracturesJ Trauma Acute Care Surg 2012;72:364-370

25. Tanizaki S, Maeda S, Hayashi H, et alEarly embolization without external fixation in pelvic traumaAm 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

26. Tanizaki S, Maeda S, Hayashi H, et alEarly embolization without external fixation in pelvic traumaAm 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

27. Tanizaki S, Maeda S, Hayashi H, et alEarly embolization without external fixation in pelvic traumaAm 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...”

28. Tanizaki S, Maeda S, Hayashi H, et alEarly embolization without external fixation in pelvic traumaAm J Emerg Med 2012;30:342-346 Conclude in this Retrospective review No control group Small numbers Ignoring early fixation

30. Thorson CM, Ryan ML, Otero CA, et alOperating room or angiography suite for hemodynamically unstable pelvic fracturesJ Trauma Acute Care Surg 2012;72:364-370 Retrospective review 1999-2011 2922 pelvic fractures • 183 (6%) unstable and went to OR 1st or Angiosuite 1st • OR 1st : 134 Patients • Angio 1st : 49 Patients

31. Thorson CM, Ryan ML, Otero CA, et alOperating 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 sicker Sys Bp lower p=0.038 BE 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

32. Costantini TW, Bosarge PL, Fortlage D, et alArterial embolization for pelvic fractures after blunt trauma: are we all talk?Am J Surg 2010;200:752-757

33. Costantini TW, Bosarge PL, Fortlage D, et alArterial 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%) angio 18 (2.2%) active bleeding

34. Costantini TW, Bosarge PL, Fortlage D, et alArterial 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”

35. Michailidou M, Velmahos GC, van derWilden G, et al“Blush” on trauma computed tomograhy: Not as bad as we think!J Trauma Acute Care Surg 2012;73:580-586

36. Michailidou M, Velmahos GC, van derWilden G, et al“Blush” on trauma computed tomograhy: Not as bad as we think!J Trauma Acute Care Surg 2012;73:580-586 Retrospective review Contrast extravasation seen on trauma CT 69 patients with 81 IVCEs 48 intra-abdominal solid organs 18 pelvic retroperitoneal space 15 other locations

37. Michailidou M, Velmahos GC, van derWilden 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 intervention Predictors for intervention Admission Bp <100 mmHg sys Large Extravasations (>1.5cm) Abbreviated Injury Score of the abdomen of 3 or higher If all 3 present = 100% intervention

38. 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