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.