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 CovidienAngiodynamics

OVERVIEW  Introduction  Organ specific trauma  Spleen  Liver  Kidney

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

Management options ConservativeEmbolizationSurgery

Conservative Mangement  % 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

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

Introduction Introduction Organ specific Organ specific Spleen Spleen Liver Liver Kidney Kidney

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

Moore et al, J Trauma 1995

AAST does NOT include active contrast extravasation and vascular injuries

Intervention vs conservative Rx  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

Peitzman et al. J Trauma 2000

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

Technique of Embolization Catheterize proximal splenic artery Sidewinder vs Cobra

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

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

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

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

Similar success Major complications requiring splenectomy are similar between two groups

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 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

Splenic trauma Take 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

Introduction Introduction Organ specific Organ specific Spleen Spleen Liver Liver Kidney Kidney

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

 Remember the anatomic variants of the hepatic arteries  Remember the right hepatic artery arises from the SMA in 11%

Moore et al. J Trauma 1995

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

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

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

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

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

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

Overall success % Overall success % Overall survival % Overall survival %

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

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

Liver Tak e 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

Introduction Introduction Organ specific Organ specific Spleen Spleen Liver Liver Kidney Kidney

RENAL TRAUMA 3 rd most common injured organ Commonest in children

Moore et al. J Trauma 1995

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: % Success rate: children > adults Santucci et al. J Trauma 2006

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

Technique of Embolization Selective angiography to define site of injury Cobra vs Sidewinder vs Sos omni Distal embolization >>> Proximal embolization

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

Follow up 3 days 3 weeks5 weeks

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

Kidney Take home points  Literature increasingly supports conservative management or embolization vs Surgery  Renal Injuries tend to recover well  Super selective embolization is safe and effective  If possible, distal embolization should be performed

CONCLUSIONS Conservative management for majority of patients

CONCLUSIONS Embolization is effective and safe

CONCLUSIONS Conservative management for majority of patients Embolization is effective and safe “Embolization first - before surgery” strategy is being increasingly used

CONCLUSIONS Conservative management for majority of patients Embolization is effective and safe “Embolization first - before surgery” strategy is being increasingly used Embolization is indicated if there is active hemorrhage on CTA

CONCLUSIONS Conservative management for majority of patients Embolization is effective and safe “Embolization first - before surgery” strategy is being increasingly used Embolization is indicated if there is active hemorrhage on CTA Embolization of visceral trauma is a classic IR procedure that all IRs must be able to perform

You are all very welcome to the CIRSE 2013 congress!

400 splenic embolisations 54 low grade AAST injuries upgraded to 4a/b –20/54 would have NOM by AAST –16/20 had splenic embolisation and 2 had splenectomy Marmery et al. AJR 2007

Proximal or distal? 15 of 147 All retrospective, no RCTs, n=497 Mostly AAST Grade III+

But... Frequent complications with or without surgery –50% with Grade III+ No RCTs/observational studies convincingly prove embolotherapy promotes complications

Consensus on GU trauma. BJU 2004