Utility of Angioembolization in Patients with Abdominal and Pelvic Traumatic Bleeding:
      Descriptive Observational Analysis from a Level 1 Trauma Center

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Abstract

Background

Massive bleeding is a major preventable cause of early death in trauma. It often requires surgical and/or endovascular intervention. We aimed to describe the utilization of angioembolization in patients with abdominal and pelvic traumatic bleeding at a level 1 trauma center.

Methods

We conducted a retrospective analysis for all trauma patients who underwent angioembolization post-traumatic bleeding between January 2012 and April 2018. Patients’ data and details of injuries, angiography procedures and outcomes were extracted from the Qatar national trauma registry.

Results

A total of 175 trauma patients underwent angioembolization during the study period (103 for solid organ injury, 51 for pelvic injury and 21 for other injuries). The majority were young males. The main cause of injury was blunt trauma in 95.4% of the patients. The most common indication of angioembolization was evident active bleeding on the initial CT scan (contrast pool or blushes). Blood transfusion was needed in two-third of patients. The hepatic injury cases had higher ISS, higher shock index and more blood transfusion. Absorbable particles (Gelfoam) were the most commonly used embolic material. The overall technical and clinical success rate was 93.7% and 95%, respectively, with low rebleeding and complication rates. The hospital and ICU length of stay were 13 and 6 days, respectively. The median injury to intervention time was 320 min while hospital arrival to intervention time was 274 min. The median follow-up time was 215 days. The overall cohort mortality was 15%.

Conclusion

Angioembolization is an effective intervention to stop bleeding and support nonoperative management for both solid organ injuries and pelvic trauma. It has a high success rate with a careful selection and proper implementation.

Most cited references 33

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Exsanguination in trauma: A review of diagnostics and treatment options.

L.M.G. Geeraedts, H.A.H. Kaasjager, A.B. van Vugt … (2009)

Trauma patients with haemorrhagic shock who only transiently respond or do not respond to fluid therapy and/or the administration of blood products have exsanguinating injuries. Recognising shock due to (exsanguinating) haemorrhage in trauma is about constructing a synthesis of trauma mechanism, injuries, vital signs and the therapeutic response of the patient. The aim of prehospital care of bleeding trauma patients is to deliver the patient to a facility for definitive care within the shortest amount of time by rapid transport and minimise therapy to what is necessary to maintain adequate vital signs. Rapid decisions have to be made using regional trauma triage protocols that have incorporated patient condition, transport times and the level of care than can be performed by the prehospital care providers and the receiving hospitals. The treatment of bleeding patients is aimed at two major goals: stopping the bleeding and restoration of the blood volume. Fluid resuscitation should allow for preservation of vital functions without increasing the risk for further (re)bleeding. To prevent further deterioration and subsequent exsanguinations 'permissive hypotension' may be the goal to achieve. Within the hospital, a sound trauma team activation system, including the logistic procedure as well as activation criteria, is essential for a fast and adequate response. After determination of haemorrhagic shock, all efforts have to be directed to stop the bleeding in order to prevent exsanguinations. A simultaneous effort is made to restore blood volume and correct coagulation. Reversal of coagulopathy with pharmacotherapeutic interventions may be a promising concept to limit blood loss after trauma. Abdominal ultrasound has replaced diagnostic peritoneal lavage for detection of haemoperitoneum. With the development of sliding-gantry based computer tomography diagnostic systems, rapid evaluation by CT-scanning of the trauma patient is possible during resuscitation. The concept of damage control surgery, the staged approach in treatment of severe trauma, has proven to be of vital importance in the treatment of exsanguinating trauma patients and is adopted worldwide. When performing 'blind' transfusion or 'damage control resuscitation', a predetermined fixed ratio of blood components may result in the administration of higher plasma and platelets doses and may improve outcome. The role of thromboelastography and thromboelastometry as point-of-care tests for coagulation in massive blood loss is emerging, providing information about actual clot formation and clot stability, shortly (10min) after the blood sample is taken. Thus, therapy guided by the test results will allow for administration of specific coagulation factors that will be depleted despite administration with fresh frozen plasma during massive transfusion of blood components.

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Outcomes of proximal versus distal splenic artery embolization after trauma: a systematic review and meta-analysis.

G. Konstantinidis, Beat Schnüriger, Kenji Inaba … (2010)

The objective of this systematic review and meta-analysis was to assess the outcomes after angioembolization in blunt trauma patients with splenic injuries and to examine specifically the impact of the technique used. Studies evaluating adult trauma patients who sustained blunt splenic injuries managed by angioembolization were systematically evaluated. The following data were required for inclusion: grade of splenic injury, indication for embolization, and site of embolization (proximal [main splenic artery] or distal [selective]). In addition, major (requiring splenectomy) or minor (not requiring splenectomy) rebleeding, infarction, and infection in relation to the site of embolization (proximal vs. distal) was required. Pooled outcomes were compared between proximal and distal embolizations. To eliminate between-study heterogeneity, a sensitivity analysis was conducted on three reduced sets of studies. Fifteen of 147 evaluated studies were included for analysis. All were retrospective cohort studies and incorporated a total of 479 embolized patients. The overall failure rate of angioembolization was 10.2% (range, 0.0-33.3%). Injury severity and basic demographics did not differ among the study populations. However, the indications for angioembolization (contrast extravasation, large amount of hemoperitoneum, or high-grade splenic injury) differed between the populations but were not associated with a change in the failure rates. Rebleeding was the most common reason for failure; however, it did not differ statistically between the used techniques, and with the 95% confidence interval crossing the 5% zone of clinical indifference, this result was inconclusive. Minor complications occurred statistically and clinically more often after distal than after proximal embolization. The available literature is inconclusive regarding whether proximal or distal embolization should be used to avoid significant rebleeding and larger prospective cohort studies are required. However, both techniques have an equivalent rate of infarctions and infections requiring splenectomy. Minor complications occur more often after distal embolization. This is primarily explained by the higher rate of segmental infarctions after distal embolization.

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Hepatic arterial embolization in the management of blunt hepatic trauma: indications and complications.

Sunny Yao-Chen Yang, Valérie Monnin, Christian Letoublon … (2011)

The objective was to clarify the role of hepatic arterial embolization (AE) in the management of blunt hepatic trauma. Retrospective observational study of 183 patients with blunt hepatic trauma admitted to a trauma referral center over a 9-year period. The charts of 29 patients (16%) who underwent hepatic angiography were reviewed for demographics, injury specific data, management strategy, angiographic indication, efficacy and complications of embolization, and outcome. AE was performed in 23 (79%) of the patients requiring angiography. Thirteen patients managed conservatively underwent emergency embolization after preliminary computed tomography scan. Six had postoperative embolization after damage control laparotomy and four had delayed embolization. Arterial bleeding was controlled in all the cases. Sixteen patients (70%) had one or more liver-related complications; temporary biliary leak (n=11), intra-abdominal hypertension (n=14), inflammatory peritonitis (n=3), hepatic necrosis (n=3), gallbladder infarction (n=2), and compressive subcapsular hematoma (n=1). Unrecognized hepatic necrosis could have contributed to the late posttraumatic death of one patient. AE is a key element in modern management of high-grade liver injuries. Two principal indications exist in the acute postinjury phase: primary hemostatic control in hemodynamically stable or stabilized patients with radiologic computed tomography evidence of active arterial bleeding and adjunctive hemostatic control in patients with uncontrolled suspected arterial bleeding despite emergency laparotomy. Successful management of injuries of grade III upward often entails a combined angiographic and surgical approach. Awareness of the ischemic complications due to angioembolization is important.

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Author and article information

Journal

Journal ID (nlm-ta): Ther Clin Risk Manag

Journal ID (iso-abbrev): Ther Clin Risk Manag

Journal ID (publisher-id): tcrm

Journal ID (pmc): tcriskman

Title: Therapeutics and Clinical Risk Management

Publisher: Dove

ISSN (Print): 1176-6336

ISSN (Electronic): 1178-203X

Publication date (Electronic): 19 April 2021

Publication date Collection: 2021

Volume: 17

Pages: 333-343

Affiliations

[1 ]Department of Surgery, Trauma&Vascular Surgery, Hamad General Hospital , Doha, Qatar

[2 ]Department of Surgery, Trauma Surgery, Hamad General Hospital , Doha, Qatar

[3 ]Department of Radiology, Hamad General Hospital , Doha, Qatar

[4 ]Department of Surgery, Clinical Research, Trauma & Vascular Surgery, Hamad General Hospital , Doha, Qatar

[5 ]Department of Clinical Medicine, Weill Cornell Medical School , Doha, Qatar

Author notes

Correspondence: Ayman El-Menyar Clinical Research, Trauma &vascular Surgery, Hamad General Hospital , Doha, QatarTel +974 44394029 Email aymanco65@yahoo.com

Author information

Ayman El-Menyar http://orcid.org/0000-0003-2584-953X

Article

Publisher ID: 303518

DOI: 10.2147/TCRM.S303518

PMC ID: 8064722

PubMed ID: 33907407

SO-VID: 936590c1-6d93-4d95-abd0-fcdfec4c464a

License:

This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

History

Date received : 24 January 2021

Date accepted : 29 March 2021

Page count

Figures: 3, Tables: 9, References: 33, Pages: 11

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