Interventional radiology for paediatric trauma

Embolization for pediatric trauma

BACKGROUND

The management of pediatric trauma with trans-arterial embolization is uncommon, even in level 1 trauma centers; hence, there is a dearth of literature on this subject compared to the adult experience.

OBJECTIVE

To describe a single-center, level 1 trauma center experience with arterial embolization for pediatric trauma.

MATERIALS AND METHODS

A retrospective review was performed to identify demographics, transfusion requirements, pre-procedure imaging, procedural details, adverse events, and arterial embolization outcomes over a 19-year period. Twenty children (age 4.5 months to 17 years, median 13.5 years; weight 3.6 to 108 kg, median 53 kg) were included. Technical success was defined as angiographic resolution of the bleeding-related abnormality on post-embolization angiography or successful empiric embolization in the absence of an angiographic finding. Clinical success was defined as not requiring additional intervention after embolization.

RESULTS

Seventy-five percent (n=15/20) of patients required red blood cell transfusions prior to embolization with a mean volume replacement 64 ml/kg (range 12-166 ml/kg) and the median time from injury to intervention was 3 days (range 0-16 days). Technical success was achieved in 100% (20/20) of children while clinical success was achieved in 80% (n=16/20). For the 4 children (20%) with continued bleeding following initial embolization, 2 underwent repeat embolization, 1 underwent surgery, and 1 underwent repeat embolization and surgery. Mortality prior to discharge was 15% (n=3). A post-embolization mild adverse event included one groin hematoma, while a severe adverse event included one common iliac artery pseudoaneurysm requiring open surgical ligation.

CONCLUSIONS

In this single-center experience, arterial embolization for hemorrhage control in children after trauma is feasible but can be challenging and the clinical failure rate of 20% in this series reflects this complexity. Standardization of pre-embolization trauma assessment parameters and embolic techniques may improve outcomes.

Paediatric axillary artery pseudo-aneurysm after simple shoulder dislocation

We report the unique case of a 14-year-old male with axillary artery pseudo-aneurysm associated with brachial plexus compression after a simple shoulder dislocation. Following shoulder reduction under anaesthetic, the child was discharged on chemical deep vein thrombosis (DVT) prophylaxis. However, progressive shoulder swelling and upper limb neurological symptoms developed. A multi-disciplinary approach was taken to diagnose and treat this complication. After stopping the anti-coagulants, a combination of endovascular stent-graft and open surgical decompression of the brachial plexus was employed. Paediatric guidelines on DVT prophylaxis are scarce but DVT has never been reported in children following upper limb trauma.

Utilization of angiography and embolization for abdominopelvic trauma: 14 years' experience at a level I trauma center

OBJECTIVE

The objective of our study was to evaluate the long-term trends in the use of angiography and embolization for abdominopelvic injuries.

MATERIALS AND METHODS

Utilization rates for pelvic and abdominal angiography, arterial embolization, and CT were analyzed for trauma patients with pelvic fractures and liver and kidney injuries admitted to a level 1 trauma center from 1996 to 2010. Multivariable linear regression was used to evaluate trends in the use of angioembolization.

RESULTS

A total of 9145 patients were admitted for abdominopelvic injuries during the study period. Pelvic angiography decreased annually by 5.0% (95% CI, -6.4% to -3.7%) from 1996 to 2002 and by 1.8% (-2.4% to -1.2%) from 2003 to 2010. Embolization rates for these patients varied from 49% in 1997 to 100% in 2010. Utilization of pelvic CT on the day of admission increased significantly during this period. Abdominal angiography for liver and kidney injuries decreased annually by 3.3% (95% CI, -4.8% to -1.8%) and 2.0% (-4.3% to 0.3%) between 1996 and 2002 and by 0.8% (95% CI, -1.4% to -0.1%) and 0.9% (-2.0% to 0.1%) from 2003 to 2010, respectively. Embolization rates ranged from 25% in 1999 to 100% in 2010 for liver injuries and from 0% in 1997 to 80% in 2002 for kidney injuries. Abdominal CT for liver and kidney injuries on the day of admission also increased.

CONCLUSION

A significant decrease in angiography use for trauma patients with pelvic fractures, liver injuries, and kidney injuries from 1996 to 2010 and a trend toward increasing embolization rates among patients who underwent angiography were found. These findings reflect a declining role of angiography for diagnostic purposes and emphasize the importance of angiography as a means to embolization for management.

Non-operative management of hepatic trauma and the interventional radiology: an update review

The growing trend to manage hepatic injuries nonoperatively has been increasing demand for advanced endovascular interventions. This brings up the necessity for general and trauma surgeons to update their knowledge in such matter. Effective treatment mandates a multispecialty team effort that is usually led by the trauma surgeon and includes vascular surgery, orthopedics, and, increasingly, interventional radiology. The focus on hemorrhage control and the angiographer's unique access to vascular structures gives interventional radiology (IR) an important and increasingly recognized role in the treatment of patients with hemodynamic instability. Our aim is to review the basic concepts of IR primarily in hepatic trauma and secondarily in some other special situations. A liver vascular anatomy review is also needed for better understanding the roles of IR. As a final point we propose a guideline for the operative/nonoperative management of traumatic hepatic injuries. The benefit of multidisciplinary approach (TAE) appears to be a powerful weapon in the medical arsenal against the high mortality of injured trauma liver patients.