The role of IR in Visceral Trauma

Dr Robert MorganMRCP, FRCR, EBIR, FCIRSE

St George’s Hospital and Medical School, London

Financial Disclosures

Consultant: W Cook EuropeCovidienAngiodynamics

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 injury20% of pts have multiple vascular injuries

Visceral organ injury occurs in ~30% of abdominal trauma

Van der Vlies et al, Int J Emerg Med 2010World Health Organisation 2004Deunk J et al. Ann Surg 2010

Management optionsConservativeEmbolization

Surgery

Conservative Mangement

60 - 90% of blunt hepatic, renal or splenic injuries

Predictors of successHemodynamic stabilityLiver, Kidney trauma > Splenic traumaNo hemoperitoneum

Diamond et al. J Trauma 2009

EmbolizationIncreasingly 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 Organ specific

Spleen Liver Kidney

SPLENIC TRAUMA

Most commonly injured abdominal organ (40%)

CirculationSplenic arteryCollaterals (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 truncationPseudoaneurysmAV fistula

– AAST III-V (depending on haemodynamic stability)

Overall success 90%Schnuriger et al. J Trauma 2011

Technique of Embolization

Catheterize proximal splenic arterySidewinder vs Cobra

Technique of Embolization

Catheterize proximal splenic arterySidewinder vs Cobra

Decide whether to perform proximal vs distal Embolization

Technique of Embolization

Catheterize proximal splenic arterySidewinder vs Cobra

Decide whether to perform proximal vs distal Embolization

Distal embolizationMicrocatheter to site of vascular injury Coils, glue

Technique of Embolization

Catheterize proximal splenic arterySidewinder vs Cobra

Decide whether to perform proximal vs distal Embolization

Distal embolizationMicrocatheter 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 traumaNg 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– 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 injuriesEmbolization indicated for:– contrast extravasation– false aneurysm– AVF– high grade injuries

Proximal embolization is adequate Residual splenic function post SAE is satisfactory

Introduction Organ specific

SpleenLiver Kidney

HEPATIC TRAUMA

2nd 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 requirementsJuxtahepatic vein injuries - IVCExtra-hepatic portal vein laceration/rupture

Associated stomach/small or large bowel injury

Gaarder C, Int J Care Injured 2007Hagiwara 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 EmbolizationSelective celiac/hepatic angiography to define site of injuryCatheterize common/proper hepatic artery

Sidewinder vs Cobra

Technique of EmbolizationSelective celiac/hepatic angiography to define site of injuryCatheterize common/proper hepatic artery

Sidewinder vs CobraDistal >>> proximal embolization

Technique of EmbolizationSelective celiac/hepatic angiography to define site of injuryCatheterize common/proper hepatic artery

Sidewinder vs CobraDistal >>> proximal embolizationMicrocatheter to site of injuryFront and back door embolizationCoilsglue

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

Complications of embolization

More likely if extensive injury requiring diffuse embolization

Overall 40-60% Necrosis 40%Abscess 17%Gallbladder necrosis 7%Biliary leak/biloma 20%

Gaarder et al. Injury 2007

Portal vein embolization

May have a role in recurrent hemorrhage

Little published data

High risk of hepatic ischemia

Liver Take 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 embolizationCT vs US

Introduction Organ specific

Spleen LiverKidney

RENAL TRAUMA

3rd most common injured organ

Commonest in children

Moore et al. J Trauma 1995

Conservative Management

Growing trend for Grades I-IVAdvantages:– ↓ 3-6x need for nephrectomy– ↓ hospital stay– No increase in complications or long-term

hypertensionSuccess rate: 80 - 100%Success rate: children > adults

Santucci et al. J Trauma 2006

Indications for embolization

Renovascular injuries (unstable)Stab/penetrating woundsIncreasing transfusion requirements

Active hemorrhage on CTA

Constantinos et al. CVIR 2005

Technique of Embolization

Selective angiography to define site of injuryCobra vs Sidewinder vs Sos omni

Distal embolization >>> Proximal embolization

Technique of Embolization

Selective angiography to define site of injuryCobra vs Sidewinder vs Sos omni

Distal embolization >>> Proximal embolization

Microcatheter to site of injuryEmbolize feeding artery

(back door occlusion not necessary)

Coils – glue

Follow up

3 days 3 weeks 5 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

Conservative management for majority of patients

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 147All retrospective, no RCTs, n=497Mostly 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