Availability of on-site acute vascular interventional radiology techniques performed by trained acute care specialists: A single-emergency center experience

Emergency angiography for trauma patients and potential association with acute kidney injury

BACKGROUND

Angiography has been conducted as a hemostatic procedure for trauma patients. While several complications, such as tissue necrosis after embolization, have been reported, little is known regarding subsequent acute kidney injury (AKI) due to contrast media. To elucidate whether emergency angiography would introduce kidney dysfunction in trauma victims, we compared the incidence of AKI between patients who underwent emergency angiography and those who did not.

METHODS

A retrospective cohort study was conducted using a nationwide trauma database (2004-2019), and adult trauma patients were included. The indication of emergency angiography was determined by both trauma surgeons and radiologists, and AKI was diagnosed by treating physicians based on a rise in serum creatinine and/or fall in urine output according to any published standard criteria. Incidence of AKI was compared between patients who underwent emergency angiography and those who did not. Propensity score matching was conducted to adjust baseline characteristics including age, comorbidities, mechanism of injury, vital signs on admission, Injury Severity Scale (ISS), degree of traumatic kidney injury, surgical procedures, and surgery on the kidney, such as nephrectomy and nephrorrhaphy.

RESULTS

Among 230,776 patients eligible for the study, 14,180 underwent emergency angiography. The abdomen/pelvis was major site for angiography (10,624 [83.5%]). Embolization was performed in 5,541 (43.5%). Propensity score matching selected 12,724 pairs of severely injured patients (median age, 59; median ISS, 25). While the incidence of AKI was rare, it was higher among patients who underwent emergency angiography than in those who did not (140 [1.1%] vs. 67 [0.5%]; odds ratio = 2.10 [1.57-2.82]; p < 0.01). The association between emergency angiography and subsequent AKI was observed regardless of vasopressor usage or injury severity in subgroup analyses.

CONCLUSIONS

Emergency angiography in trauma patients was probably associated with increased incidence of AKI. The results should be validated in future studies.

Impact of a streamlined trauma management approach and determinants of mortality among hemodynamically unstable patients with severe multiple injuries: a before-and-after retrospective cohort study

Background

Trauma management requires a multidisciplinary approach, but coordination of staff and procedures is challenging in patients with severe trauma. In October 2014, we implemented a streamlined trauma management system involving emergency physicians trained in severe trauma management, surgical techniques, and interventional radiology. We evaluated the impact of streamlined trauma management on patient management and outcomes (study 1) and evaluated determinants of mortality in patients with severe trauma (study 2).

Methods

We conducted a retrospective cohort study of 125 patients admitted between January 2011 and 2019 with severe trauma (Injury Severity Score ≥16) and persistent hypotension (≥2 systolic blood pressure measurements <90 mm Hg). Patients were divided into a Before cohort (January 2011 to September 2014) and an After cohort (October 2014 to January 2019) according to whether they were admitted before or after the new approach was implemented. The primary outcome was in-hospital mortality.

Results

Compared with the Before cohort (n=59), the After cohort (n=66) had a significantly lower in-hospital mortality (36.4% vs. 64.4%); required less time from hospital arrival to initiation of surgery/interventional radiology (median, 41.0 vs. 71.5 minutes); and was more likely to undergo resuscitative endovascular balloon occlusion of the aorta (24.2% vs. 6.8%). Plasma administration before initiating hemostasis (adjusted OR 1.49 (95% CI 1.04 to 2.14)), resuscitative endovascular balloon occlusion of the aorta (9.48 (95% CI 1.25 to 71.96)), and shorter time to initiation of surgery/interventional radiology (0.97 (95% CI 0.96 to 0.99)) were associated with significantly lower mortality.

Discussion

Implementing a streamlined trauma management protocol improved outcomes among hemodynamically unstable patients with severe multiple trauma.

Level of evidence

Level III.

Prophylactic absorbable gelatin sponge embolization for angiographically occult splenic hemorrhage

Nonoperative management of traumatic splenic hemorrhage includes the targeted administration of embolic agents. In certain instances where computed tomography angiography cannot exclude a bleed, prophylactic embolization with absorbable gelatin sponge has been used. In this retrospective case series review, we characterized the demographic data and clinical outcomes associated with 4 patients who underwent prophylactic transarterial splenic artery embolization after blunt abdominal trauma. Embolization was employed in cases where computed tomography angiography findings suggested at least a moderate splenic injury, and simultaneously where hemorrhage was not apparent during fluoroscopic angiography. Periprocedural hemodynamic status, technical success, and postoperative complications are discussed. The goal of this report was to discuss the safety and efficacy of prophylactic gelatin sponge embolization for occult splenic hemorrhage. In cases where a hemorrhagic site might be occult, this approach has the potential to minimize bleeding complications and the need for further intervention.

The effect of angioembolization for life-threatening retroperitoneal hemorrhage in patients with pelvic fracture

BACKGROUND

Conventionally, pelvic fracture-related acute retroperitoneal hemorrhage (ARH) is life threatening and difficult to control. However, the use of angioembolization to treat fracture-associated ARH improves the hemodynamic stability of patients with pelvic fractures. The role of angioembolization in the management of patients with pelvic fracture-related ARH was examined.

MATERIALS AND METHODS

We retrospectively reviewed a large case series of patients with pelvic fractures between January 2010 and December 2014. Comparisons were made between patients with and without ARH. In addition, the characteristics of mortality were delineated, whereas the causes of death in patients with pelvic fracture were discussed and analyzed.

RESULTS

A total of 1070 patient records were reviewed during the 60-month study period, and the overall mortality rate of pelvic fracture was 7.7% (82/1070). However, there were only seven patients who died due to uncontrolled ARH (0.7%). The patients with ARH had more injuries to other organs than did the patients without ARH (head: 79.7% vs. 31.7%, p < 0.001; chest: 50.3% vs. 10.9%, p < 0.001; abdomen: 72.0% vs. 22.7%, p < 0.001; spine: 12.6% vs. 4.4%, p < 0.001; extremities: 69.2% vs. 44.3%, p < 0.001).

CONCLUSION

The treatment for pelvic fracture patients declared dead upon arrival remains limited. However, pelvic fracture-related ARH could be controlled effectively with angioembolization. In addition to ARH, injuries to other organs may play a key role in the mortality of patients with pelvic fractures.

High-grade traumatic torso visceral injury with hemodynamic instability: effectiveness of transarterial embolization using n-butyl cyanoacrylate

Trauma patients with uncontrolled hemorrhage encountering coagulopathy are often associated with poor outcome. Recently, the concept of damage control interventional radiology, which focuses on "speedy stoppage of bleeding" by interventional radiology among trauma patients with hemodynamic instability and acute traumatic coagulopathy, was proposed as an alternative to damage control surgery. N-butyl cyanoacrylate (NBCA) has been used as a liquid embolic agent in various non-traumatic situations, where it has been shown to have a high technical success rate and low recurrent bleeding rate, especially in patients with coagulopathy. In this case, we treated a young patient with hemodynamic instability caused by a high-grade hepatic injury, who underwent arterial embolization (AE) using NBCA assisted with resuscitative endovascular balloon occlusion of the aorta and achieved successful hemostasis. A review of published works using PUBMED was carried out, and 10 published reports involving 23 trauma patients who underwent AE using NBCA were identified. Among them, only four reports involving five trauma patients with torso visceral injuries were identified. Three of five patients who were hemodynamically unstable underwent AE using NBCA, resulting in the stabilization of hemodynamics. We concluded that AE with resuscitative endovascular balloon occlusion of the aorta as a damage control interventional radiology procedure might be acceptable for the hemodynamically unstable hepatic injury, and NBCA could be one of the effective hemostatic agents for this purpose, in cases of trauma-induced coagulopathy.

Achieving Multidisciplinary Collaboration for the Creation of a Pulmonary Embolism Response Team: Creating a "Team of Rivals"

Pulmonary embolism response teams (PERTs) have recently been developed to streamline care for patients with life-threatening pulmonary embolism (PE). PERTs are unique among rapid response teams, in that they bring together a multidisciplinary team of specialists to care for a single disease for which there are novel treatments but few comparative data to guide treatment. The PERT model describes a process that includes activation of the team; real-time, multidisciplinary consultation; communication of treatment recommendations; mobilization of resources; and collection of research data. Interventional radiologists, along with cardiologists, emergency physicians, hematologists, pulmonary/critical care physicians, and surgeons, are core members of most PERTs. Bringing together such a wide array of experts leverages the expertise and strengths of each specialty. However, it can also lead to challenges that threaten team cohesion and cooperation. The purpose of this article is to discuss ways to integrate multiple specialists, with diverse perspectives and skills, into a cohesive PERT. The authors will discuss the purpose of forming a PERT, strengths of different PERT specialties, strategies to leverage these strengths to optimize participation and cooperation across team members, as well as unresolved challenges.