Tag Archives: angiography

Does Time To Angioembolization Make A Difference?

Angiography and angioembolization (AE) have helped trauma professionals stop pesky bleeding from the pelvis, solid organs, and other hard to reach places for decades. The American College of Surgeons has recognized its importance and even has a specific criterion for interventional radiologist response times.

Many centers have found this 30-minute response for radiologist arrival to be onerous. So, of course, someone decided to look at the data to see if it was really warranted. The group at the University of Arizona at Tucson did a big data dive using the Trauma Quality Improvement Program database to try to tease out the consequences of prompt vs delayed access to AE in blunt trauma patients.

Four years of TQIP data were analyzed. The authors focused on the records of patients who underwent AE within 4 hours of arrival for blunt injury to liver, spleen, or kidney. They excluded transfers in, burn patients, and those who underwent an operation prior to AE. The 4 hour AE period was subdivided into hourly segments and outcomes were examined for each.

Here are the factoids:

  • Out of over a million records, 924 met study inclusion criteria
  • Patients were relatively young with a mean age of 44, and seriously injured with a median ISS of 29
  • Spleen injuries were most common (64%), followed by liver (50%), and kidney (27%)
  • Overall 24 hour mortality was 5% and in-hospital mortality was 15%
  • The 24 hour mortality significantly increased as each hour passed until AE, from 2% to 24%. 
  • On multivariate analysis, in-hospital mortality showed the same hourly increase
  • No differences in the amount of blood, plasma, or platelets given were noted in any of the groups
  • Average time to AE correlated with trauma center AE volume, with 1.6 hours at centers doing more than 14 cases per year to 2.7 hours at those doing less than 9 cases

The authors concluded that delayed AE for solid organ injury resulted in increased mortality without any difference in transfused blood products. They encouraged centers to ensure rapid access to this vital procedure.

Bottom line: This is an important paper. Other research on angiography in blunt trauma has not shown the survival differences that we see here. But they did not focus on patients who underwent actual embolization. This one shows that time to AE is very important in those patients who really need it.

It appears that the most important factor is door to angiography suite time. There are many factors involved, though. First, the specific injury must be recognized by the clinicians. This involves access to CT, timeliness of radiologist report, decision making by the trauma professional, and timeliness of response by the interventional radiologist and the IR team.

Most centers focus only on that 30-minute response time required of the interventionalist. But as you can see, there are many more moving parts. I would urge all centers to look at their door to AE time and compare to what was found in this study. If you find that it is taking more than an hour and a half, it’s probably time for a PI project to tighten it up. This is particularly important in centers with low AE volume.

Reference: Angioembolization in intra-abdominal solid organ injury: Does delay in angioembolization affect outcomes? J Trauma 89(4):723-729, 2020.

Does Time To Interventional Radiography Make a Difference In Solid Organ Injury?

Solid organ injury is one of the more common manifestations of blunt abdominal trauma. Most trauma centers have some sort of practice guideline for managing these injuries. Frequently, interventional radiology (IR) and angioembolization (AE) are part of this algorithm, especially when active bleeding is noted on CT scan.

So it makes sense that getting to IR in a timely manner would serve to stop the bleeding sooner and help the patient. But in most hospitals, interventional radiology is not in-house 24/7. Calls after hours require mobilization of a call team, which may be costly and take time.

For this reason, it is important to know if rapid access to angioembolization makes sense. Couldn’t the patient just wait until the start of business the next morning when the IR team normally arrives?

The group at the University of Arizona at Tucson tackled this problem. They performed a 4-year retrospective review of the TQIP database. They included all adult patients who underwent AE within four hours of admission. Outcome measures were 24-hour mortality, blood product usage, and in-hospital mortality.

Here are the factoids:

  • Out of over a million records in the database, only 924 met the inclusion criteria
  • Mean time to AE was 2 hours and 22 minutes, with 92% of patients getting this procedure more than an hour after arrival
  • Average 24-hour mortality was 5%. Mortality by hours to AE was as follows:
    • Within 1 hour: 2.6%
    • Within 2 hours: 3.6%
    • Within 3 hours: 4.0%
    • Within 4 hours: 8.8%
  • There was no difference in the use of blood products

The authors concluded that delayed angioembolization for solid organ injury is associated with increased mortality but no increase in blood product usage. They recommend that improving time to AE is a worthy performance improvement project.

Bottom line: This study has the usual limitations of a retrospective database review. But it is really the only way to obtain the range of data needed for the analysis. 

The results seem straightforward: early angioembolization saves lives. What puzzles me is that these patients should be bleeding from their solid organ injury. Yet longer delays did not result in the use of more blood products.

There are two possibilities for this: there are other important factors that were not accounted for, or the sample size was too small to identify a difference. As we know, there are huge variations in how clinicians choose to administer blood products. This could easily account for the apparent similarities between products given at various time intervals to AE.

My advice? Act like your patient is bleeding to death. If the CT scan indicates that they have active extravasation, they actually are. If a parenchymal pseudoaneurysm is present, they are about to. So call in your IR team immediately! Minutes count!

Reference: Angioembolization in intra-abdominal solid organ injury:
Does delay in angioembolization affect outcomes?  J Trauma 89(4):723-729, 2020.

Post-Embolization Syndrome In Trauma

A reader requested that I write about post-embolization syndrome. Not being an oncologist or oncologic surgeon, I honestly had never heard about this before, let alone in trauma care. So I figured I would read up and share. And fortunately it was easy; there’s all of one paper about it in the trauma literature.

Post-embolization syndrome is a constellation of symptoms including pain, fever, nausea, and ileus that occurs after angio-embolization of the liver or spleen. There are reports that it is a common occurrence (60-80%) in patients being treated for cancer, and there are a few papers describing it in patients with splenic aneurysm. But only one for trauma.

Children’s Hospital of Boston / Harvard Medical School retrospectively reviewed 12 years of their pediatric  trauma registry data. For every child with a spleen injury who underwent angio-embolization, they matched four others with the same grade of injury who did not. A total of 448 children with blunt splenic injury were identified, and (thankfully) only 11 underwent angio-embolization. Nine had ongoing bleeding despite resuscitation, and two had developed splenic pseudoaneursyms.

Here are the factoids:

  • More of the children who underwent embolization had extravasation seen initially and required more blood products.  They also had longer ICU (3 vs 1 day) and hospital stays (8 vs 5 days). Not surprising, as that is why they had the procedure.
  • 90% of embolized kids had an ileus vs 2% of those not embolized, and they took longer to resume regular diet (5 vs 2 days)
  • Respiratory rate and blood pressure were higher on days 3 and 4 in the embolized group, as was the temperature on day 5 (? see below)
  • Pain was higher on day 5 in the embolized group (? see below again)

Bottom line: Sorry, but I’m not convinced. Yes, I have observed increased pain and temperature elevations in patients who have been embolized. Some have also had an ileus, but it’s difficult to say if that’s from the procedure or other injuries. And this very small series just doesn’t have enough power to convince me of any clinically significant differences in injured children.

Look at the results above. “Significant” differences were only identified on a few select days, but not on the same days across charts. And although the authors may have demonstrated statistical differences, are they clinically relevant? Is a respiratory rate of 22 different from 18? A temp of 37.8 vs 37.2? I don’t think so. And length of stay does not reveal anything because the time in the ICU or hospital is completely dependent on the whims of the surgeon.

I agree that post-embolization syndrome exists in cancer patients. But the findings in trauma patients are too nondescript. They just don’t stand out well enough on their own for me to consider them a real syndrome. As a trauma professional, be aware that your patient probably will experience more pain over the affected organ for a few days, and they will be slow to resume their diet. But other than supportive care and patience, nothing special need be done.

Related posts:

Reference: Transarterial embolization in children with blunt splenic injury
results in postembolization syndrome: A matched
case-control study. J Trauma 73(6):1558-1563, 2012.

Complications Of Iliac Artery Embolization

The main cause of mortality in patients with severe pelvic fractures is major hemorrhage. Over the years, trauma professionals have developed and tested a number of maneuvers to reduce mortality in these patients. These include wrapping or fixing the pelvis, embolization, and more recently, pre-peritoneal packing and REBOA.

Pelvic wrap/fixation and embolization have been around for a long, long time. For both, it’s been long enough so that we should have a fairly decent appreciation of the complications. For pelvic binders, they principally involve the skin. But aside for the potential access site complications (bleeding, pseudoaneurysm), angiography has been thought to be relatively benign.

But as with any medical procedure, especially invasive ones, there are risks. A paper published five years ago retrospectively reviewed the 13 year experience with pelvic angiography at UC Davis. Study patients were matched with controls who underwent angiography for pelvic fracture but not embolization. Short-term (within 30 days) and long-term complications were assessed while in hospital and by telephone survey. Mean followup time was 18 months.

Here are the factoids:

  • There were no differences in complications attributable to embolization within 30 days of the procedure
  • There were 5 cases of short-term skin sloughing or necrosis in 55 patients, and 4 of 5 occurred in patients with nonselective embolization. However, this was not a statistically significant complication.
  • Long-term complications such as buttock claudication or skin ulceration, pain, and impotence were not significantly different in embolized vs non-embolized patients
  • There was a significantly increased incidence of buttock, perineal, or thigh paresthesias in the long-term

Bottom line: Angiography with embolization is a very valuable tool in the management of complication pelvic fractures. Remember that a number of complications have been described:

  • Skin sloughing or necrosis
  • Buttock claudication, pain, paresthesias
  • Skin ulceration
  • Impotence

Other than an increase in paresthesias in the long-term, there did not appear that there was any difference in patients undergoing angiography with and without embolization. Although the numbers were small (100 patients total), this is the best study we have to date. Just keep in mind that complications are possible, and question your patients about them when they present for their followup visits.

Reference: Evaluation of Short-term and Long-term Complications after Emergent Internal Iliac Artery Embolization in Patients with Pelvic Trauma. J Vascular Interventional Rad 19(6):840-847, 2008.

Post-Embolization Syndrome In Trauma

A reader requested that I write about post-embolization syndrome. Not being an oncologist or oncologic surgeon, I honestly had never heard about this before, let alone in trauma care. So I figured I would read up and share. And fortunately it was easy; there’s all of one paper about it in the trauma literature.

Post-embolization syndrome is a constellation of symptoms including pain, fever, nausea, and ileus that occurs after angio-embolization of the liver or spleen. There are reports that it is a common occurrence (60-80%) in patients being treated for cancer, and there are a few papers describing it in patients with splenic aneurysm. But only one for trauma.

Children’s Hospital of Boston / Harvard Medical School retrospectively reviewed 12 years of their pediatric  trauma registry data. For every child with a spleen injury who underwent angio-embolization, they matched four others with the same grade of injury who did not. A total of 448 children with blunt splenic injury were identified, and (thankfully) only 11 underwent angio-embolization. Nine had ongoing bleeding despite resuscitation, and two had developed splenic pseudoaneursyms.

Here are the factoids:

  • More of the children who underwent embolization had extravasation seen initially and required more blood products.  They also had longer ICU (3 vs 1 day) and hospital stays (8 vs 5 days). Not surprising, as that is why they had the procedure.
  • 90% of embolized kids had an ileus vs 2% of those not embolized, and they took longer to resume regular diet (5 vs 2 days)
  • Respiratory rate and blood pressure were higher on days 3 and 4 in the embolized group, as was the temperature on day 5 (? see below)
  • Pain was higher on day 5 in the embolized group (? see below again)

Bottom line: Sorry, but I’m not convinced. Yes, I have observed increased pain and temperature elevations in patients who have been embolized. Some have also had an ileus, but it’s difficult to say if that’s from the procedure or other injuries. And this very small series just doesn’t have enough power to convince me of any clinically significant differences in injured children.

Look at the results above. “Significant” differences were only identified on a few select days, but not on the same days across charts. And although the authors may have demonstrated statistical differences, are they clinically relevant? Is a respiratory rate of 22 different from 18? A temp of 37.8 vs 37.2? I don’t think so. And length of stay does not reveal anything because the time in the ICU or hospital is completely dependent on the whims of the surgeon.

I agree that post-embolization syndrome exists in cancer patients. But the findings in trauma patients are too nondescript. They just don’t stand out well enough on their own for me to consider them a real syndrome. As a trauma professional, be aware that your patient probably will experience more pain over the affected organ for a few days, and they will be slow to resume their diet. But other than supportive care and patience, nothing special need be done.

Related posts:

Reference: Transarterial embolization in children with blunt splenic injury
results in postembolization syndrome: A matched
case-control study. J Trauma 73(6):1558-1563, 2012.