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Dr R Uberoi
John Radcliffe Hospital
Oxford
Trauma
� Early treatment focus on:� Resuscitation� Diagnosis� Treatment of bleeding
� Most preventable cause of death due to unrecognized/untreated haemorrhage.
� Multiple level 2 evidence i.e. predominantly retrospective cohort series demonstrate benefit of IR
� NCEPOD into patient outcome and death. Trauma:who cares?2007.� Zacharias SR et al :AACN clin Issues 1999:10:95-103.
� Kessel D and Nicholson AA: BMJ 2008:336:1205.� Gibson DE et al: J Emer Med 2006:31:215-21.
Trauma IR
� Minimally invasive techniques to stem bleeding
� Blocking vessels� Catheter embolizations
� Selective catheter and Micro-catheters and wires.
� Coils� Glue� Plugs� Thrombin� Gelfoam
� Relining vessels:� Stentgrafts
� Other� IVC filters� Drainage
Traumatic Major Arterial Injuries
� Penetrating injury/dislocations/blunt injury
� Dissection/Rupture/Occlusion/False aneurysm and AVF.
� Upper/Lower extremities 70%
� Associated with 10-20% amputation rate
� Iliac artery injury associated with almost 40% mortality
� Carotid 5-10%
� Aortic injuries
Traumatic arterial injuries
� Thoracic aorta
� Majority die at the scene.
� 85% immediate mortality
� 50% “survivors” die within 24 hours
� 90% “survivors” die within 4 months
� Almost all occur at the level of the isthmus 2-3cm distal the subclavian origin.
� Traumatic injury of the abdominal aorta uncommon� Jamieson WR et al Am J Surg 2002:183:571-575.
Stentgrafting
� Stenting/Stentgrafting attractive option in patients with major arterial injury.
� Obtain haemostasis and vessel patency.
� Significant reduction in morbidity and mortality compared to open surgical repair
� Hoffer EK. 2002. JVIR 13: 1037 – 1041.
� Morgan R. 200225: 291 – 294.
� Semba. C 1997 JVIR 8: 337 – 342.
� Katsanos K et al CVIR 2009:16:175-184.
� Schonholz CJ et al J Cardiovasc Surg 2007:48:537-49.
Site of Injury
� Distribution of injuries on CT
% of patients % of patients
� Site Patients Unstable group
� Spleen 35 53� Liver 24 44� Kidney 13 15� Pancreas 12 0� Bowel 9 6� Pelvic fracture 22 15
� Fang JF et al: World J Surg 2006:30:176-82.� Smith et al :ANZ J Surg:75:790-784.
CT
� Value of MSCT increasingly recognized
� Many guidelines still state unstable patient should go to surgery without CT
� 97% of US surgeons would go immediately to surgery for splenic injury.
� Retroperitoneal injuries missed at laparotomy with delay in treatment
� Many of the organ trauma grading based on CT/similar angiography criteria.
� American college ATLS: Advanced trauma and life support program for doctors: American college of surgeons 2008.
� Fata P et al: J Trauma 2005:59:836-842.
� Frevert S et al:Injury 2008:39:1290-4.
Spleen Injury-IR
� Traditional treatment Splenectomy
� Reduction of short and long term immunity
� 2-10x increased risk of infection
� Embolisation technical success 87-100%
� Clinical success of 73-97%
� Reduced laparatomy from 55% to 30%- same survival
� Cohort of 154 patients
� 85% survival V 82% historical controls
� Gaarder C et al: J Trauma 2006:61:192-8.
� Cassar K et al: J R coll Surg Edinb 2002:47:731-41.
� Wisemann et al: Am Surg 2006:72: 947-50.
� Duchesne JC et al: J Trauma 2008:65:1346-53.
� Cornelis H et al: CVIR 2010:1079-1087.
Spleen trauma� Outcomes of embolisation
� Level I trauma center, retrospective, 126 patients� Patient selections: positive CT finding, stable� 68% had negative angiographic finding.
� Splenic salvage rate: 92%
� 32% had positive angiographic finding, then embolized� Splenic salvage rate: 92%� Salvage rate in Gr. IV and V injury: ~70%� CT is a predictive tool
� Prognostic factors� AV fisfula: poor prognosis� Hemoperitoneum, extravasation, pseudoaneurysm� Old age: not significant� Intraperitoneal hemorrhage: not significant
J Trauma 2004;56;542-47 J Trauma 2001;51;1161-65
Liver� Haemodynamically unstable patients
� ‘damage control surgery’
� Packing of liver injuries
� IR hugely attractive
� Blood transfusion and infective complications significantly reduced if embolisation used first line.
� Mohr Am et al: J Trauma 2003:55:1077-82.
� Velmahos GC et al: Arch Surg 2003:138:47-81.
� Holden A: et al: Injury 2008:39:1275-89
� Johnson W K et al: J Trauma:2002:52:1102-6.
Liver trauma: Outcomes� Low CT grading, stable hemodynamics, non-
operative management� Common complications
� AV fistula
� Bile leaks
� Abscess, intrahepatic or extrahepatic
� Hemobilia or bilhemia (vascular-biliary fistula)
� Early intervention of these complications succesful in 85% of patients� Embolization, CT-guided drainage, ERCP…
J Trauma 1999; 46(4):619-22
Liver trauma: Outcomes� CT grading Gr. IV and V: advantages
� Grade 4 or 5 lesion -fluid requirements >2L/h to maintain BP-absolute indication for surgery
� Embolisation can decrease the amount of resuscitation fluid to maintain vital sign. J Trauma 1998;45:353-359; J Trauma. 2002;52:1097–1101; J Trauma. 2003;55:1077–1082
� Embolisation can decrease shock index AJR 1997, 169, 1151-1156
� Operation with adjunct embolisation can decrease the mortality rate.(65%� 30%, p=0.02)
J Trauma 2003;54:647–654
J Trauma. 2003;55:1077–1082
J Trauma. 2002;52:1097–1101
Renal Injury� Usually occur in
conjunction with other other solid organs
� Embolization effective in controlling bleeding
� Technical success 90-100%- Clinical 80%
� Chow SJD et al: Injury 2008:40: 844-50.
� Sofoleous CT et al:CVIR 2005:28:39-47.
� Dinkel HP et al:Radiology 2002:223:723-30.
� Huppert PE etal: CViR 1993:16:361-7.
Pelvic fracture
� Bleeding from bone, muscle and or vessels (vein and or arteries)
� Commonly associated with other pelvic injuries- CT essential
� Surgery challenging and may disrupt the tamponade
� Rupture of a main pelvic artery carries a mortality of 50-75%
� Endovascular management now established
� Frevert S et al:Injury 2008:39:1290-4.� Hagiwara A et al: J Trauma 2004:57:271-7.� Miller PR et al: J Trauma 2003:54:437-43.� Angolini S et al: J Trauma 1997:43:395-7.
Pelvic trauma: outcomes� In a center which uses intervention early� 100% stop bleeding� Survival rate: 87%� Angiography reduce the need for surgery� The predictors of death included
� posterior pelvic arterial injury � elevated Acute Physiology and Chronic Health Evaluation II score � Need of fluids for resuscitation� The risk of dying increased by 62% for every 1 unit/h increase of
transfusion rate.
J Trauma 2000; 49(1):71-5
J Trauma 2003;55(4):696-703
Complications of embolisation� Complications reported in organ and pelvic embolisations which at least in
part due to initial injury� Reported complications :
� In cohort of 100 patients 67 with embolization and 37 without� Identical rate:
� Skin Necrosis-ulceration� Perineal infection� Nerve injury� Claudication � Region pain
� Regional paraesthesia more common after embolisation
� Totterman A et al: Acta Orthopaedica 2008:77:462-8.� Frevert S et al: Injury, int, J Care Injured 2008:39:1290-1294.� Eur Radiol 2002;12:979-993
PE-Prophylaxis in Trauma patients?
� In many patients, anticoagulation therapy contraindicated because of risk of hemorrhage.
� Randomized trial also shown anti-coagulation also shown to be safe.� Additional studies of cost-effectiveness or risk-benefit considerations
do not support prophylactic filter placement in patients with trauma . ie� Severe head injury with prolonged ventilator dependence � Major abdominal or pelvic penetrating venous injury � Spinal cord injury with or without paralysis � Severe head injury with multiple lower extremity fractures � Pelvic fracture with or without lower extremity fractures
Geerts WH. Prevention of venous thromboembolism in high-risk patients. Hematology Am Soc Hematol Educ Program. 2006:462–466.Geerts WH, Jay RM, Code KI, et al. A comparison of low-dose heparin with low-molecular-weight heparin as prophylaxis against venous
thromboembolism after major trauma. N Engl J Med. 1996; 335:701–707.
Retrievable filters in Trauma
� Increasing use of retrievable IVC filters
� Lowering of the threshold for placement of IVC filters.
� Increase use of temporary filters in the last 10 years.
� In some studies as few as 10- 22% actually retrieved.
Conclusion
� Increasing Level 2 evidence confirms that IR treatment can improve outcomes either as an alternative or adjunct to surgery.
� Include in Trauma protcols/pathways
� CT plays a central role in diagnosis and planning treatment.