1. Faffing or fixing? (Part 2)

2. Straight to theatre? Time to laparotomy Trauma centre127 mins NCEPOD200 mins –NO CT110 mins –CT499 mins NO CT group unstable ?Relevance to QE –24/7 on site CT radiographers Delaying surgery or scanning ‘to wait for stabilisation’ does not make sense. If the patient is considered too unstable for CT scan then transfer to theatre is required instead.

3. 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!

4. When?

5. 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!

6. Surgical indications Needs a laparotomy anyway –Bowel injury –Gunshot wounds Major liver trauma-liver packing May need both surgery and IR

7. Aortic transection 4 Case series N1259 Technical success 100% 30 day mortality 8%0% 16.7% Mortality surgical series 12-35%

8. Transection Pitfalls Access difficult in female patients –Large diameter devices –Small iliac arteries 4% iliac artery rupture/avulsion rate Stent collapse

9. 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

10. QE 29/06/08

11. 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.

12. Splenic embolization Pros –Avoid splenectomy Lifelong risk of overwheming post- splenectomy infection Thrombotic tendency Complications –Failure –Inadvertent embolization –Splenic infarction and/or abscess

13. Vascular trauma

14. What we need from referrer Awareness –Role of trauma IR –Imaging requirements Senior level involvement –Consultant A&E, Surgical and Anaesthetic involvement Support

15. 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