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

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Presentation on theme: "Embolotherapy in Trauma JS Vermaak University of the Witwatersrand Fellow: Department Vascular Surgery VASSA 6 th October 2012."— Presentation transcript:

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

2 Chuang VP, Reuter RS Selective arterial embolization for the control of traumatic splenic bleeding Invest Radiol 1975;10: dogs with splenic trauma All controlled within 3 hours 7 dogs survived to 2 months

3 Walter JF, Paaso BT, Cannon WB Successful transcatheter embolic control of massive hematobilia secondary to liver biopsy Am J Roentegenol 1976;127: 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 WB Successful transcatheter embolic control of massive hematobilia secondary to liver biopsy Am J Roentegenol 1976;127:847-9

5 Jander HP, Laws HL, Kogutt MS et al Emergency Embolization in Blunt Hepatic Trauma Am J Roentgenol 1977;129: 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 al Emergency Embolization in Blunt Hepatic Trauma Am J Roentgenol 1977;129:

7 Maull KI, Sachatello CR Current management of pelvic fractures: a combined surgical- angiographic approach to hemorrhage South Med J 1976;69:1285-9

8 Richman SD, Green WM, Kroll R et al Superselective Transcatheter Embolization of Traumatic Renal Hemorrahge Am J Roentgenol 1977;128: yr old Gunshot left upper abdomen Through and through spleen – splenectomy Noticed a large tense retroperitoneal haematoma. “left intentionally to ulilize angiopgraphic embolization” Drains placed Embolized after 2 hours Using gelatin sponge pellets (Gelfoam)

9 Richman SD, Green WM, Kroll R et al Superselective Transcatheter Embolization of Traumatic Renal Hemorrahge Am J Roentgenol 1977;128:

10 Rubin BE, Katzen BT Selective Hepatic Artery Embolization to control massive hepatic haemorrhage after trauma Am J Roentgenol 1977;129:

11 Chang J, Katzen BT, Sullivan KP Transcatheter gelfoam embolization of posttraumatic bleeding pseudoaneurysms Am J Roentgenol 1978;131:

12 Pubmed publications regarding embolotherapy

13 Chuang, VP, Wallace S, Gianturco C et al. Complications of coil embolization: Prevention and management Am J Roentgenol 1981;137: 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

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17 False aneurysm of Vertebral Artery

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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 Y Two cases of tracheoinnominate artery fistula following tracheostomy treated successfully by endovascular embolization of the innominate artery J Vasc Surg 2012;55:

24 Tanizaki S, Maeda S, Hayashi H, et al Early embolization without external fixation in pelvic trauma Am J Emerg Med 2012;30: Thorson CM, Ryan ML, Otero CA, et al Operating room or angiography suite for hemodynamically unstable pelvic fractures J Trauma Acute Care Surg 2012;72: VS

25 Tanizaki S, Maeda S, Hayashi H, et al Early embolization without external fixation in pelvic trauma Am J Emerg Med 2012;30: Retrospective review 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 al Early embolization without external fixation in pelvic trauma Am J Emerg Med 2012;30: 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 al Early embolization without external fixation in pelvic trauma Am J Emerg Med 2012;30: Average time to angiography suite was min Average transfusion in 1 st 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 al Early embolization without external fixation in pelvic trauma Am J Emerg Med 2012;30: Conclude in this Retrospective review No control group Small numbers Ignoring early fixation

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30 Thorson CM, Ryan ML, Otero CA, et al Operating room or angiography suite for hemodynamically unstable pelvic fractures J Trauma Acute Care Surg 2012;72: Retrospective review pelvic fractures 183 (6%) unstable and went to OR 1 st or Angiosuite 1 st » OR 1 st :134 Patients » Angio 1 st : 49Patients

31 Thorson CM, Ryan ML, Otero CA, et al Operating room or angiography suite for hemodynamically unstable pelvic fractures J Trauma Acute Care Surg 2012;72: Those who went to OR immediately tend to be sicker Sys Bp lower p=0.038 BE lower: -9 vs -5p<0.001 BUT OR 1 st 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 al Arterial embolization for pelvic fractures after blunt trauma: are we all talk? Am J Surg 2010;200:

33 Retrospective review of 819 pelvic fractures 31 (3.8%) angio 18 (2.2%) active bleeding

34 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: “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 der Wilden G, et al “Blush” on trauma computed tomograhy: Not as bad as we think! J Trauma Acute Care Surg 2012;73:

36 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 der Wilden G, et al “Blush” on trauma computed tomograhy: Not as bad as we think! J Trauma Acute Care Surg 2012;73: % 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


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