The role of interventional radiology in abdominopelvic trauma

Cutoff of the reverse shock index multiplied by the Glasgow coma scale for predicting in-hospital mortality in adult patients with trauma: a retrospective cohort study

BACKGROUND

Early identification of patients at risk of potential death and timely transfer to appropriate healthcare facilities are critical for reducing the number of preventable trauma deaths. This study aimed to establish a cutoff value to predict in-hospital mortality using the reverse shock index multiplied by the Glasgow Coma Scale (rSIG).

METHODS

This multicenter retrospective cohort study used data from 23 emergency departments in South Korea between January 2011 and December 2020. The outcome variable was the in-hospital mortality. The relationship between rSIG and in-hospital mortality was plotted using the shape-restricted regression spline method. To set a cutoff for rSIG, we found the point on the curve where mortality started to increase and the point where the slope of the mortality curve changed the most. We also calculated the cutoff value for rSIG using Youden's index.

RESULTS

A total of 318,506 adult patients with trauma were included. The shape-restricted regression spline curve showed that in-hospital mortality began to increase when the rSIG value was less than 18.86, and the slope of the graph increased the most at 12.57. The cutoff of 16.5, calculated using Youden's index, was closest to the target under-triage and over-triage rates, as suggested by the American College of Surgeons, when applied to patients with an rSIG of 20 or less. In addition, in patients with traumatic brain injury, when the rSIG value was over 25, in-hospital mortality tended to increase as the rSIG value increased.

CONCLUSIONS

We propose an rSIG cutoff value of 16.5 as a predictor of in-hospital mortality in adult patients with trauma. However, in patients with traumatic brain injury, a high rSIG is also associated with in-hospital mortality. Appropriate cutoffs should be established for this group in the future.

Does time to angiography affect the survival of trauma patients with embolization to the pelvis? A retrospective study across trauma centers in the United States

INTRODUCTION

Traumatic pelvic injuries can result in rapid exsanguination. Bleeding control interventions include stabilization, angiography, and possible embolization. Previous studies yielded conflicting results regarding the benefit of a shorter time to embolization.

OBJECTIVES

The aim of this study is to examine the impact of the time to angioembolization on the survival of patients presenting with pelvic injuries using a national database.

MATERIALS AND METHODS

This was an observational retrospective study that used the National Trauma Data Bank 2017 dataset. Adult patients with pelvic injuries and who received angiography with embolization to the pelvis were included. Univariate and bivariate analyses (survival to hospital discharge yes/no) were done. This was followed by a multivariable logistic regression analysis to assess the impact of time to angiography on survival to hospital discharge after adjusting for potential confounders.

RESULTS

A total of 1,057 patients were included. They were predominantly of male gender (69.3 %) with a median age of 50 years (IQR = [31-64]). The mean time to pelvic angiography was 264.0 ± 204.4 min. The overall survival rate at hospital discharge was 72.0 %. Time to angiography was not significantly associated with survival to hospital discharge before and after adjusting for clinically and statistically significant confounders (aOR = 1.000; 95 %CI=[0.999 - 1.001]; p = 0.866).

CONCLUSION

Time to angiography was not associated with survival to hospital discharge of patients with pelvic injuries who required embolization. Further research examining specific patterns of injuries and assessing the impact of early angioembolization is needed.

Pelvic ring fractures with concomitant large hematomas: diagnostic investigation with arteriography and eventual embolization in 157 trauma patients, with or without contrast extravasation at emergency CT

PURPOSE

This study aims to evaluate the diagnostic value of pelvic arteriography in patients with pelvic ring fractures and associated large hematomas, in both cases of positive or negative findings of contrast agent extravasation at emergency CT; in those patients with positive DSA subsequently treated with embolization, correlations with clinical-radiological parameters were investigated.

MATERIALS AND METHODS

In this single-center retrospective study, patients with acute blunt pelvic trauma showing at CT pelvic ring fractures with associated large (> 3 cm) hematoma, with or without signs of arterial bleeding, were investigated with DSA. Technical success was considered radiographic bleeding control with disappearance of angiographic bleeding; clinical success was defined as clinical bleeding control hemodynamically stable, before applying other surgical maneuvers. Pelvic ring fractures were evaluated according to Tile classification system.

RESULTS

One hundred and fifty-seven patients, mean age 54years, were analyzed. 70.7% had polytrauma; 14.6% patients assumed antiplatelets and/or anticoagulation therapy. False-negative and false-positive rates at CT were 29.6% and 27.1%, respectively. Polytrauma and B3/C1 Tile pattern fractures were significantly associated with bleeding signs at DSA. Seventy-two patients required embolization: 52.8% showed direct signs of DSA bleeding; among these, technical and clinical successes were 88.8% and 81.9%, respectively.

CONCLUSIONS

In this study, patients with pelvic ring fractures and concomitant hematomas > 3 cm, with or without contrast extravasation at CT, have been examined in depth with DSA focusing on both direct and indirect angiographic signs of bleeding, finding polytrauma and Tile fracture patterns B3/C1 predictive factors for arterial hemorrhage detection at DSA despite negative CT findings.

The value of contrast-enhanced ultrasound in vascular injury from blunt abdominal trauma in solid organs: Comparison with multidetector computed tomography using angiography as the reference standard

To evaluate the accuracy of contrast-enhanced ultrasound (CEUS) for assessing vascular injury from blunt abdominal trauma in solid organs using angiography as the reference standard and to compare it with contrast-enhanced multidetector computed tomography (MDCT). Forty-nine patients with 52 blunt abdominal trauma lesions who underwent CEUS, MDCT, and angiography were enrolled in this retrospective study. Injuries included the liver (n = 23), kidney (n = 10), and spleen (n = 19). Vascular injury in solid organs was classified into 3 types: isolated pseudoaneurysm, pseudoaneurysm with low-velocity extravasation, and active bleeding. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of CEUS and MDCT for the detection and classification of vascular injury in solid organs were calculated based on angiography. The receiver operating characteristic curve analysis of each test was performed and compared. Thirty-nine vascular injuries in solid organs were detected and classified into 9 isolated pseudoaneurysms, 9 pseudoaneurysms with low-velocity extravasation, and 21 active bleeding based on angiography as the reference standard. The sensitivity, specificity, PPV, NPV, and accuracy for bleeding detection were 97.44%, 100.00%, 100.00%, 92.86%, and 98.08%, respectively, for CEUS and MDCT. The sensitivity, specificity, PPV, NPV, and accuracy of classification (isolated pseudoaneurysm vs. pseudoaneurysm with low-velocity extravasation or active bleeding) of bleeding were 96.67%, 87.50%, 96.67%, 87.50%, and 94.74%, respectively, for CEUS and 100.00%, 75.00%, 93.75%, 100.00%, and 94.74%, respectively, for MDCT. The area under the receiver operating characteristic curves of CEUS and MDCT for bleeding detection was 0.987, and the area under the receiver operating characteristic curves for CEUS and MDCT bleeding classification were 0.921 and 0.875, respectively. CEUS and MDCT exhibited comparable consistency with angiography for detecting and classifying vascular injury from blunt abdominal trauma in solid organs. Therefore, CEUS may be an accurate and rapid imaging tool to detect bleeding and determine the need for transcatheter arterial embolization. We suggest that CEUS could be considered a first-line approach during the preparation time before MDCT to determine the appropriate management for blunt abdominal trauma.

[Role of Interventional Radiologists in Trauma Centers]

Based on statistics available in Korea, trauma centers play a critical role in treatment of patients with trauma. Interventional radiologists in trauma centers perform various procedures, including embolization, which constitutes the basic treatment for control of hemorrhage, although interventions such as stent graft insertion may also be used. Although emergency interventional procedures have been used conventionally, rapid and effective hemorrhage control is important in patients with trauma. Therefore, it is important to accurately understand and implement the concept of damage control interventional radiology, which has gained attention in recent times, to reduce preventable trauma-induced mortality rates.

Emergent vessel embolization for major traumatic and non-traumatic hemorrhage: Indications, tools and outcomes

Endovascular embolization of bleeding vessels in trauma and non-trauma patients is frequently used and is an important tool for bleeding control. It is included in the EVTM (endovascular resuscitation and trauma management) concept and its use in patients with hemodynamic instability is increasing. When the correct embolization tool is chosen, a dedicated multidisciplinary team can rapidly and effectively achieve bleeding control. In this article, we will describe the current use and possibilities for embolization of major hemorrhage (traumatic and non-traumatic) and the published data supporting these techniques as part of the EVTM concept.

Factors associated with survival in adult trauma patients undergoing angiography with and without embolization across trauma centers in the United States

INTRODUCTION

Interventional angiography is increasingly utilized in trauma management for various injuries. Despite published guidelines by the Eastern Association for the Surgery of Trauma on the use of angiography, limited data exist on factors associated with outcomes in angiography procedures. This study examines factors associated with survival to hospital discharge in trauma patients undergoing angiography with or without embolization across US trauma centers.

MATERIALS AND METHODS

This retrospective observational study used the National Trauma Data Bank 2017 dataset and included adult trauma patients who underwent conventional angiography with or without embolization. A bivariate analysis was done to compare patients' characteristics by outcome (survived/died), followed by a multivariable logistic regression analysis to determine factors associated with survival to hospital discharge after adjusting for important confounders.

RESULTS

In the included sample of 4242 patients, median age was 41 years and male gender was predominant (72.6%). Overall mean time to angiography was 263.77 ± 750.19 min. Factors positively associated with survival included treatment at large facilities with over 401 beds (OR = 2.170; 95% CI, [1.277-3.685]), helicopter ambulance/fixed-wing transport (OR = 1.736; 95% CI, [1.325-2.275]), mild Glasgow Coma Scale (OR = 7.621; 95% CI, [5.868-9.898]) and moderate Glasgow Coma Scale (OR = 3.127; 95% CI, [2.080-4.701]), SBP ≥ 90 (OR = 1.516; 95% CI [1.199-1.916]), and spleen as embolization site (OR = 1.647; 95% CI [1.119-2.423]).

CONCLUSION

This nationwide study identified variables associated with survival in trauma patients who underwent angiography. These variables can serve in creating standardized risk stratification tools that could be incorporated into evidence-based guidelines for angiography candidates.

Hepatectomy During the Pandemic, a Curative Treatment in High-Grade and/or Hemodynamically Unstable Blunt Liver Trauma

The liver is among the most affected organs in the case of abdominal trauma. In the last decades there have been significant changes in therapeutic protocols, non-operative management is now the first intention in most cases due to good results offered previously. In high-grade or hemodynamically unstable injuries, hepatectomy is the best approach, even though this was viewed with skepticism in the past, technical advances in medicine have proven otherwise. This article presents a case report of a 29-year-old man with blunt abdominal trauma, who initially underwent conservative atypical right hepatectomy without a favourable outcome, later he was transferred to a liver transplant center where he underwent a controlled right hepatectomy, all this in a new epidemiological context, the COVID-19 Pandemic. We want to present the hypothesis that in making a therapeutic decision, the hemodynamic status of the patient must be considered equally along with the injury degree. This case represents an opportunity to review the role of liver resection in the management of complex liver injuries.

The Role of Renal Artery Embolisation in the Management of Blunt Renal Injuries: A Review

Renal injuries are the most common urinary tract injury secondary to external abdominal trauma. They are caused by blunt, penetrating and iatrogenic mechanisms. Despite the high number of blunt renal injuries, little evidence is available to guide management, especially with the evolution of embolisation as a minimally invasive treatment. Consequently, clinical practice is driven by results of observational studies and anecdote. We have reviewed the current trends in practice when using renal artery embolisation in the management of blunt renal injuries. Three key principles are highlighted. First, high-grade blunt renal injuries can be successfully managed with embolisation. Second, embolisation should be considered when there is radiological evidence of active contrast extravasation, pseudoaneurysm or arteriovenous fistula. Third, embolisation can be used to manage blunt renal injuries in haemodynamically unstable patients. Beyond this, evidence regarding optimal technique, CT indications, clinical status, comorbidities and complications are inconclusive. We discuss the implications for clinical practice and how these findings should define the agenda for future clinical research.

Interventional angiography utilization for adult trauma patients in Trauma Centers across the United States: An observational study using the National Trauma Data Bank

Angiography and embolization are part of trauma management protocols for various injuries. This study examines the use of angiography and embolization use in trauma care across Trauma Centers in the United States. We used the National Trauma Data Bank (NTDB) 2017 dataset in this retrospective observational study. Adult trauma patients (≥16 years) who underwent conventional angiography with or without embolization were included. A univariate analysis was carried out to describe patients' demographic and injury characteristics as well as the time to angiography, angiography details, complications, and outcome (survival to hospital discharge: yes/no). One-year period prevalence proportion of angiography procedure was determined. A total of 4242 patients were included. The 1-year period prevalence proportion of angiography procedure with or without embolization was 0.53% (95% confidence intervals: 0.527-0.529). The median age was 41 years (interquartile range: 27-58) with most patients being in the age group 16 to 64 (83.8%) and males (72.6%). Over half of the patients, 55.4% had an embolization procedure performed in addition to angiography. The mean time to angiography was 263.77 ± 750.19 minutes. The most common embolization sites were the pelvis (24.9%), spleen (11.8%), and liver (9%). This study described angiography and embolization utilization in adult trauma patients in Trauma Centers in the US. Its findings provide the basis for future studies to examine more closely angiography/embolization utilization in specific subpopulations, and to create standardized risk stratification tools for trauma patients who are candidates for this procedure.

Trauma-Angio score as a predictor of urgent angioembolization for blunt trauma: development and validation using independent cohorts

PURPOSE

This research aimed to establish a scoring system for selecting candidates for urgent angioembolization (AE).

METHODS

Patients with blunt trauma were retrospectively identified in a nationwide trauma registry. Patients aged ≥ 15 years with a systolic blood pressure of ≥90 mmHg were included. These individuals were then categorized into development and validation cohorts based on the date of admission. Next, an eight-point scaled system was developed using odds ratios obtained from the multivariate analysis of patients' clinical factors on their arrival at the hospital, with the implementation of urgent AE as a dependent variable.

RESULTS

The development cohort and validation cohort included 158,192 and 116,941 patients, respectively, and 3296 (2.1%) patients in the development cohort and 2,550 (2.2%) patients in the validation cohort underwent urgent AE. The frequency of transfusion within 24 h after arrival and the Injury Severity Score were similar between the two cohorts (16,867 [10.7%] vs. 11,222 [9.6%] and 10 [9-18] vs. 10 [9-17], respectively). The number of patients who were discharged and hospital-free days were comparable between the two cohorts (139,436 [94.4%] vs. 106,107 [95.6%] and 72 [53-84] vs. 73 [57-84] days, respectively). The probabilities and the observed rates of urgent AE increased proportionally from 2% at a score of ≤ 3 to almost 15% at a score of ≥ 7. In terms of predictive factors, no significant interaction was noted.

CONCLUSION

The Trauma-Angio scoring system can be used as a trigger to suggest the possibility of urgent AE.

TRIAL REGISTRATION

20090087, 31st July 2009.

Endovascular embolization techniques in acute thoracic and abdominal bleedings can be technically reproduced and trained in a standardized simulation setting using SLA 3D printing: a 1-year single-center study

Background

Endovascular embolization techniques are nowadays well established in the management of acute arterial bleedings. However, the education and training of the next generation of interventionalists are still based on the traditional apprenticeship model, where the trainee learns and practices directly at the patient, which potentially affects the patient’s safety. The objective of this study was to design and develop a standardized endovascular simulation concept for the training of acute bleeding embolizations, based on real-life cases.

Results

An adaptable and cost-effective endovascular simulator was developed using an in-house 3D print laboratory. All thoracic and abdominal acute bleeding embolizations over more than a year with appropriate pre-interventional computed tomography scans were included to manufacture 3D printed vascular models. A peristaltic pump was used to generate pulsatile flow curves. Forty embolization cases were engaged in this study, and 27 cases were fully reproduced in the simulation setting (69.23%). The simulation success was significantly lower in pulmonary embolizations (p = 0.031) and significantly higher in soft tissue (p = 0.032) and coil embolizations (p = 0.045). The overall simulation success was 7.8 out of 10 available points.

Conclusions

Using stereolithography 3D printing in a standardized simulation concept, endovascular embolization techniques for treating acute internal hemorrhages in the chest and abdomen can be simulated and trained based on the patient-specific anatomy in a majority of the cases and at a broad spectrum of different causes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13244-022-01206-7.

Safety and efficacy of Endovascular Management of high-grade blunt renal injury

Objectives

To provide data on the safety and efficacy of renal arterial embolization (RAE) in patients with high-grade blunt renal injury.

Materials and methods

Fifteen patients with high-grade blunt renal injury (AAST grades IV-V) admitted to our hospital from July 2014 to December 2019 were retrospectively reviewed in this study. Their clinical success rate and complications were investigated accordingly.

Results

Fifteen patients with high-grade blunt renal injury, 13 men and 2 women with an average age of 41.6 years, including 11 hemodynamically unstable patients and 4 stable patients, were treated with RAE. Among these patients, 73.3% (11 of 15) had grade IV, and 26.7% (4 of 15) had grade V injuries, while 53.3% (8 of 15) patients had concomitant injuries. One patient received main RAE and 14 patients received selective RAE. The clinical success rate after the first embolization was 93.3% (14 of 15). RAE was repeated and was successfully performed in one patient with sustained hematuria. No significant difference in creatinine levels was found before and after embolization. During the follow-up period of 2–82 months, two patients required tube drainage due to urine leaks, one patient developed renal failure requiring renal replacement therapy, and one patient developed secondary hypertension.

Conclusions

RAE can provide a high success rate of hemostasis for both hemodynamically stable and unstable patients with high-grade blunt renal injury, and only minor complications are observed with this procedure.

Novel score for predicting early emergency endovascular therapy in trauma care using logistic LASSO regression

Aim

To support decision‐making for early interventional radiology, this study aimed to derive and validate a novel and simple scoring system for predicting the necessity of interventional radiology therapies in trauma patients.

Methods

This retrospective study used data derived from the medical records of patients with severe traumatic injuries treated at a tertiary‐level emergency institution. The score was derived from 168 patients treated between April 2015 and October 2016 and validated using data from 68 patients treated between November 2016 and July 2017. Logistic “least absolute shrinkage and selection operator (LASSO)” regression was used to select predictors. In order to compose the score, odds ratios derived from the logistic model were simplified to integer score coefficients. The score was evaluated using the area under the receiver operating characteristic curve. The best cut‐off point for the score was determined using Youden’s index, and sensitivity and specificity were calculated.

Results

The derived score comprised three predictors (systolic blood pressure, positive findings in abdominal ultrasound assessment, and pelvic fracture) and ranged from 0 to 30. On validation, the area under the receiver operating characteristic curve for the score was 0.86 (95% confidence interval, 0.64–1.00). The sensitivity and specificity were 80% and 89%, respectively, with a cut‐off point of 3.

Conclusion

This simple score, requiring variables obtainable immediately after hospital arrival, could aid in facilitating early interventional radiology team activation.

Endovascular embolization in renal trauma: a narrative review

Approximately 1–3% of all trauma patients have a renal injury. Eighty percent of renal trauma is due to blunt injury, with the remainder due to penetrating trauma which is most often iatrogenic. Contrast enhanced computed tomography is used to triage patients and offers a quick and accurate assessment of any potential organ injury. If injury is present, The American Association for the Surgery of Trauma grading system can both grade renal injuries and be used to help guide management and intervention. Grades are assigned based on imaging and clinical features of renal trauma, and have prognostic and treatment implications for patients. The objective of this narrative review is to identify optimal management of patients with renal trauma, specifically which patients can be treated with endovascular interventions following renal trauma, which can be observed, and which would be best managed surgically. For hemodynamically stable patients with renal trauma, endovascular angiography and embolization is a non-invasive approach that can be used to control bleeding and potentially avoid surgery or nephrectomy in select cases. Future research is needed to determine if a specific antibiotic regimen is needed prior to or following embolization. Further research is needed to evaluate the effectiveness of endovascular management of high-grade renal trauma (grade V). Complications of renal embolization include short-term hypertension, long term hypertension in cases of significant ischemia, acute kidney injury, and infection.

Transarterial embolization with n-butyl cyanoacrylate for the treatment of active abdominopelvic bleeding in the polytraumatized patient

PURPOSE

An increasing number of polytraumatized patient presenting with active abdominal pelvic bleeding (APB) have been treated by endovascular selective embolization. However, reports on evaluate the efficacy, safety and complications caused by this technique have been limited. The aim of this study was to assess the safety and efficacy of embolization of APB using N-butyl cyanoacrylate glue (NBCA).

MATERIALS AND METHODS

Single center retrospective study, that included consecutive 47 patients presenting with traumatic APB treated by embolization with NBCA between January 2013 and June 2019. The efficacy endpoint was defined as the absence of contrast extravasation immediately after procedure and clinical stabilization in the following 24 h after procedure. Clinical stabilization was defined as no rebleeding after embolization or the need for a surgical approach until the patient is discharged. Safety endpoint were any technical or clinical complications related to the embolization procedure.

RESULTS

The mean age of patients was 38.6 years (3-81), with a predominance of males (87.2%). The major causal factor of APB being involvement in a car accident, accounting for 68% of cases. Of the 47 cases, 29.8% presented pelvic trauma and the remaining (70.2%) presented abdominal trauma. The efficacy rate was 100%, while no complications related to the procedure were observed. The mortality rate was 14.8% (7/47) due to neurologic decompensation and other clinical causes.

CONCLUSION

Endovascular embolization of traumatic abdominopelvic bleedings appear to be a highly safe and effective treatment, while avoiding emergent exploratory open surgeries.

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

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.

Interventional radiology management of high flow priapism: review of the literature

Introduction:

High-flow priapism is a persistent partial penile tumescence, related to high flow arterial blood into the corpora. It is much less common than the low-flow priapism, and history of trauma is the more common aetiology. In the treatment of high flow priapism, super-selective embolization is considered treatment of choice when conservative treatment fails as reported in the “European Association of Urology Guidelines on Priapism”, but there are only few series reporting the outcome, the efficacy of different embolic materials and these studies are uncontrolled and relatively small.

Objectives:

The aim of this study is to review the literature to outline the state of the art of this interventional treatment and to analyse the outcome of the different embolic agents.

Methods:

Through Medline database (via PubMed) we searched all the English-language published articles related to priapism. Keywords were chosen according to MeSH terms. We selected case-series from 1990 to 2020 including at least five cases of high-flow priapism. The variables extracted from the selected articles were: number of patients, mean age, diagnostic imaging modality, mono or bilateral involvement of the arteries, embolization material, technical success, clinical success, complications, recurrence rate and type of reintervention, mean follow up, onset of erectile dysfunction.

Results:

We analyzed 11 papers. A total of 117 patients, mean age of 30 years, were studied during a period of 8 to 72 months. Technical success average was 99%, varying from 93 to 100%. Clinical success average was 88%, varying from 56 to 100%. After two or more treatments, resolution of priapism was obtained in all patients. No major adverse events registered. Recurrence rate of 21% (25/117) was observed, and only 4 patients underwent surgery. A total of 17 patients (15%) developed erectile dysfunction (ED). We also created a subgroup analysis focusing on specific outcome with different types of materials. Technical success was very high, 100% for all materials except for PVA particles Clinical Success was at least 70% with all kind of material. Best result was obtained with gel-foam (89%) and the worse with PVA (70%).

Conclusion:

Our data suggested comparable outcomes using different types of materials. In line with the last evidences we suggest that the choice of the embolic material should be selected basing on the expertise of the operator, the characteristic of the fistula and characteristic of the patients. (www.actabiomedica.it)

What is the Role of Image-Guided Endovascular Surgery in Postbariatric Surgery Bleeding Complications?

Background: Obesity treatment requires surgical procedures included in bariatric surgery. Bleeding complications are reported in 1%-4%. Image-guided surgery (IGS) includes minimally invasive procedures that have the advantage of less aggression to the patient, fewer complications, and a quick recovery. Endovascular therapy by interventional radiology (IR) is a minimally invasive image-guided procedure widely used in central, peripheral, and splanchnic vascular pathology. Treatment of postoperative bleeding in bariatric surgery can be aided by image-guided endovascular procedures. Objectives: The aim of this study is to carry out an update on the application of IR in bariatric surgery bleeding complications. Bleeding Complications: General rate of postoperative complications in bariatric surgery is 0%-10%. Postoperative bleeding (1%-4%) can be gastrointestinal (endoscopic treatment) or intra-abdominal (surgical treatment/relaparoscopy). In the case of arterial vascular lesions that cannot be resolved either endoscopically or surgically, the option of endovascular treatment with IR should be considered. Conclusions: Endovascular approach through IR and IGS in bleeding complications after bariatric surgery is presented as a valid minimally invasive therapy option in this group of patients.

Basic embolization techniques: tips and tricks

Good knowledge of the various approaches of embolization of peripheral bleedings and different embolic materials available is of paramount importance for successful and safe embolization. We review and illustrate the main endovascular and percutaneous techniques used for embolization, along with the characteristics of the different embolic materials, and the potential complications.

Effectiveness of transcatheter arterial embolization for patients with shock from abdominopelvic trauma: A retrospective cohort study

BACKGROUND

Transcatheter arterial embolization (TAE) is a useful endovascular technique for controlling hemorrhage in blunt abdominopelvic trauma without shock. However, several studies have reported that TAE is safe and effective for controlling hemorrhage in hypovolemic shock.

OBJECTIVE

To evaluate the effectiveness of TAE for patients with shock from abdominopelvic trauma.

METHOD

The medical records of patients with abdominopelvic trauma at Her Royal Highness Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot University from January 2014 to January 2019 were retrospectively reviewed. We enrolled patients with shock caused by injury to solid organs or pelvic fractures who underwent TAE.

RESULT

Of the 320 patients, 14 patients with shock underwent TAE. A total of 78.6% were male. The mean age was 37.5 years. The average injury severity score was 31.3. The most common mechanism of injury was traffic accidents (85.7%). Embolization was performed for 8 liver injuries, 5 pelvic fractures and 1 splenic injury. The treatment time for TAE was approximately 47.9 ± 33.2 min. The mean length of hospital stay was 21.3 ± 15.9 days. Two patients died (14.3%). There were no embolization-related complications. A significant improvement in systolic blood pressure (p = 0.028) and a decrease in heart rate (p = 0.001), lactate concentration (p = 0.011), and crystalloid fluid (p = 0.001) and blood transfusion requirements (p = 0.002) were observed after TAE.

CONCLUSIONS

TAE is a safe and effective method for treating shock patients with a rapid or transient response to resuscitation. For patients who are nonresponsive to resuscitation, TAE is an additional useful option for arterial hemorrhage control in abdominopelvic trauma.

Use of Interventional Radiology in Critically Injured Children Admitted in a Pediatric Intensive Care Unit of a Developing Country

Objective

The aim of this study was to describe the outcome of the use of interventional radiological procedures (IRP) (angioembolization) in critically injured children.

Methods

A retrospective review of medical records of all children who underwent an IRP from January 2010 to December 2015 was done. Data were collected on a structured proforma and results are presented as mean with standard deviation and frequency with percentages.

Result

Eighteen patients were identified who underwent IRP during the study period. The mean age was 10.4 ± 4.3 years and 10 (55%) were males. Ten patients had a road traffic accident, four had a history of fall, one patient had glass cut pelvic injury, and two patients had blunt abdominal trauma, while one patient had bleeding secondary to hemipelvectomy. The genitourinary system was involved in five patients, liver in four, and spleen in two and pancreas in one patient. Bleeding was from branches of internal iliac artery in seven patients, hepatic artery in three patients, splenic artery in two patients, and middle colic artery in one patient, while one patient had blood oozing from the bone after hemi-pelvictomy. Four French vascular access sheath was placed under ultrasound guidance; this was followed by the placement of C1 catheter (Cordis, Miami, FL). After vessel identification, a 2.7F Progreat microcatheter (Terumo, Tokyo) was used for super-selective cannulation of the bleeding vessel. Intravascular coil, polyvinyl alcohol (PVA) particles, or gel foam was used for the embolization of bleeding vessels. No procedural complications were observed except minor oozing in one patient. One patient expired due to multiorgan dysfunction.

Conclusion

Angioembolization is a useful and relatively safe procedure in the management of vitally stable children with hemorrhagic abdominopelvic injuries. However, further studies may be needed to evaluate the efficacy and cost-effectiveness of this practice, especially in resource-constrained settings.

Trans-arterial embolisation (TAE) in haemorrhagic pelvic injury: review of management and mid-term outcome of a major trauma centre

BACKGROUND

Management of pelvic fracture associated haemorrhage is often complex with high morbidity and mortality rates. Different treatment options are used to control bleeding with an on-going discussion in the trauma community regarding the best management algorithm.

MAIN BODY

Recent studies have shown trans-arterial embolisation (TAE) to be a safe and effective technique to control pelvic fracture associated haemorrhage. Computed tomography (CT) evidence of active bleeding, haemodynamic instability, and pelvic fracture patterns are amongst important indicators for TAE.

CONCLUSION

Herein, we aim to provide a comprehensive literature review of the effectiveness of TAE in controlling haemorrhage secondary to pelvic fracture according to the indications, technique and embolic agents, and outcomes, whilst incorporating our Level 1 major trauma centre's (MTC) results between 2014-2017.

Imaging and endovascular management of traumatic pelvic fractures with vascular injuries

This paper will give an overview of the relevant anatomy, management and imaging, aspects as well as therapeutic aspects of traumatic pelvic fractures with vascular injuries.

Cone beam computed tomography improves the detection of injured vessels and involved vascular territories in patients with bleeding of uncertain origin

OBJECTIVE

The purpose of this preliminary retrospective study was to analyse if cone beam CT (CBCT) is able to identify more bleeding sites and corresponding feeding arteries in patients with haemorrhage of uncertain origin.

METHODS

In 18 vascular territories (16 patients), pre-interventional CT angiography (CTA) and selective angiograms resulted in discordant information regarding the suspected bleeding site and hence received CBCT. Image data of CTA and selective angiograms in comparison to CBCT were independently reviewed by two interventional radiologists. Image quality, diagnostic confidence, number of bleeding sites and involved vascular territories were investigated. Additionally, the correlation between number of bleeding sites and involved vascular territories with a  clinical gold-standard (super-selective angiographic findings and definitive clinical outcomes) was analysed.

RESULTS

Overall, subjective image quality did not significantly differ between investigated imaging modalities. However, CBCT significantly improved diagnostic confidence in both readers in detecting bleeding vessel (s) (p = 0.0024/0.0005; Reader 1/Reader2). High correlation coefficients regarding the number of bleeding sites (r = 0.9163/0.7692) in contrast to the number of involved vascular territories (r = 0.2888/0.0105) were observed for CTA in comparison to clinical gold-standard. In this context, CBCT demonstrated a very strong correlation for both parameters, the number of bleeding vessels (r = 0.9720/0.9721) and the number involved vascular territories (r = 0.9441/0.9441).

CONCLUSION

In complex cases of suspected haemorrhage, CBCT images can aid the interventionalist in detecting bleeding sites as well as narrowing down the number of involved vascular territories and thereby identifying feeding arteries of the bleeding source. Advances in knowledge: (1) CBCT showed no improvement in image quality. However, in complex bleeding cases CBCT information might aid in treatment planning. (2) CBCT improves visualization of bleeding vessels and involved feeding arteries. (3) Particularly, less experienced interventionalists might benefit from the three-dimensional information gathered by CBCT.

Liver trauma: What current management?

BACKGROUND

The liver is the most commonly damaged organ in abdominal trauma. The management of liver trauma has experienced many changes over the last two decades. Currently there is a trend toward a non-operative treatment warranted by the successful pediatric experience and better results recorded in many trauma centers worldwide. This study aimed to evaluate outcomes of operative and non-operative management of liver trauma in our institution over the last five years.

METHODS

The patients with a diagnosis of blunt or penetrating liver injuries, admitted and managed in our hospital from January 2012 to December 2016 were retrospectively studied. The patients were divided into 2 groups, operated and non-operated groups, according to the initial management considered appropriate at the time of patient admission. Clinical features and outcomes were analyzed.

RESULTS

The study involved 83 patients, with a mean age of 33 years and a marked male predominance (85.5%). The most common type of lesions was blunt trauma and the main cause was road traffic accidents. Sixty-eight liver injuries (81.9%) were of low severity (grades I, II, III), while 15 (18.1%) were of high severity (grade IV or greater). Fifty-six patients (67.5%) had multiple injuries. Surgical treatment was performed in 26 (31.3%) patients. Non-operative management was undertaken in 57 cases (68.7%). The morbidity and mortality rates were clearly lower in non-operative patients compared to those in the operated group.

CONCLUSIONS

Careful non-operative management is an adequate therapeutic strategy for the patients suffering from liver trauma with stable hemodynamics. Patients with complex hepatic trauma and especially those with other organ injuries continue to have significantly higher mortality.

Contemporary Role of Embolization of Solid Organ and Pelvic Injuries in Polytrauma Patients

Abdominopelvic trauma (APT) remains a leading cause of morbidity and mortality in the 15- to 44-year-old age group in the Western World. It can be life-threatening as abdominopelvic organs, specifically those in the retroperitoneal space, can bleed profusely. APT is divided into blunt and penetrating types. While surgery is notably considered as a definitive solution for bleeding control, it is not always the optimum treatment for the stabilization of a polytrauma patient. Over the past decades, there has been a shift toward more sophisticated strategies, such as non-operative management of abdominopelvic vascular trauma for haemodynamically stable patients. Angiographic embolization for bleeding control following blunt and/or penetrating intra- and retroperitoneal injuries has proven to be safe and effective. Embolization can achieve hemostasis and salvage organs without the morbidity of surgery, and the development and refinement of embolization techniques has widened the indications for non-operative treatment in solid organ injury. Moreover, advances in computed tomography provided more efficient scanning times with improved image quality. While surgery is still usually recommended for patients with penetrating injuries, non-operative management can be effectively used as well as an alternative treatment. We review indications, technical considerations, efficacy, and complication rates of angiographic embolization in APT.

Endovascular management of arterial injuries after blunt or iatrogenic renal trauma

The kidney is the third most common abdominal organ to be injured in trauma, following the spleen and liver, respectively. The most commonly used classification scheme is the American Association for the Surgery of Trauma (AAST) classification of blunt renal injuries, which grades renal injury according to the size of laceration and its proximity to the renal hilum. Arteriovenous fistula and pseudoaneurysm are the most common iatrogenic biopsy-related or surgery-related vascular injuries in native kidneys. The approach to renal artery injuries has changed over time from more aggressive intervention to more conservative observational or endovascular management, including selective transcatheter arterial embolization (TAE) and the placement of stents/stent grafts. In this article, we describe the role and technical aspects of endovascular interventions in the management of arterial injuries after blunt or iatrogenic renal trauma.

Renal trauma

The kidney is the most commonly injured genitourinary organ, and renal involvement has been reported in 1–5% of all trauma cases. Two mechanisms of renal injury are described, namely blunt (direct blow to the kidney, rapid acceleration/deceleration or a combination) and penetrating (from stab or gunshot wounds), with blunt injuries being most common in the UK. It is important to keep an index of suspicion for renal trauma as given by the mechanism of the injury or in poly-trauma. Accurate assessment and resuscitation are vital in the initial management. Imaging with computed tomography is critical to the accurate grading of the injury and helps guide subsequent treatment. The approach to management of renal injuries has changed over time. During the past two decades, advances in cross-sectional imaging coupled with minimally invasive intervention strategies (like angiography, embolisation and ureteric stenting) for managing traumatic renal injuries have allowed increased renal preservation by reducing the need for major surgical intervention. Nowadays, the vast majority of blunt injuries (up to 95%) are managed conservatively with accumulated experience suggesting this is safe. However, there is still a role for open surgical exploration in patients with haemodynamic instability or those who fail initial conservative/minimally invasive management.