1. The role of IR in Visceral Trauma Dr Robert Morgan MRCP, FRCR, EBIR, FCIRSE St George’s Hospital and Medical School, London

2. Financial Disclosures Consultant: W Cook Europe CovidienAngiodynamics

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

4. 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

5. Management options ConservativeEmbolizationSurgery

6. Conservative Mangement  60 - 90% 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

7. 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

8. Introduction Introduction Organ specific Organ specific Spleen Spleen Liver Liver Kidney Kidney

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

10. Moore et al, J Trauma 1995

11. AAST does NOT include active contrast extravasation and vascular injuries

12. 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

13. Peitzman et al. J Trauma 2000

14. 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

15. Technique of Embolization Catheterize proximal splenic artery Sidewinder vs Cobra

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

17. 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

18. 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

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

22. Similar success Major complications requiring splenectomy are similar between two groups

23. 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

24. 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

25. Introduction Introduction Organ specific Organ specific Spleen Spleen Liver Liver Kidney Kidney

26. 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

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

28. Moore et al. J Trauma 1995

29. 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

30. 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

31. 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

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

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

34. 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

37. Overall success 80-100% Overall success 80-100% Overall survival 88-100% Overall survival 88-100%

38. 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

39. 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

40. 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

41. Introduction Introduction Organ specific Organ specific Spleen Spleen Liver Liver Kidney Kidney

42. RENAL TRAUMA 3 rd most common injured organ Commonest in children

43. Moore et al. J Trauma 1995

44. 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: 80 - 100% Success rate: children > adults Santucci et al. J Trauma 2006

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

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

47. 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

49. Follow up 3 days 3 weeks5 weeks

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

51. 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

52. CONCLUSIONS Conservative management for majority of patients

53. CONCLUSIONS Embolization is effective and safe

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

55. 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

56. 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

57. You are all very welcome to the CIRSE 2013 congress!

59. 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

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

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

62. Consensus on GU trauma. BJU 2004