Percutaneous transcatheter embolization for arterial trauma

Percutaneous transcathcter embolization for arterial trauma T h o m a s Panetta, M.D., Salvatore J. A. Sclafani, M.D., Alan S. Goldstein, M.D., and T h o m a s F. Phillips, M.D., Brooklyn, N.Y. With increasing technologic advances in interventional radiology, the vascular surgeon should be well versed in the indications, limitations, complications, and results of percutaneous transcatheter embolization for arterial trauma. Three hundred twenty-eight angiographically determined arterial injuries occurred in 242 patients from 1977 to 1984 in a major city hospital trauma center and were studied prospectively. Transcatheter embolizations performed for I07 arterial injuries in 100 patients were successful in 82.2% of injuries. Gelfoam, minicoils, microcoils, intimal dissections, or a combination of modalities was utilized. Anterior and posterior element pelvic fractures associated with hypotension and transfusion of 6 units or more of blood required embolization in 28 patients.i Bleeding was controlled in 85.7% of patients. Percutaneous transcatheter embolization was also effective in controlling 84.2% of arteriovenous fistulas, 88.9% of penetrating neck arterial injuries, and 73.3% of postoperative intra-abdominal hemorrhage. Therapeutic transcatheter embolization is a valuable adjunct to the vascular surgeon dealing with the spectrum o f vascular trauma. (J VASC SURG 1985; 2:54-64.)

Interventional radiologic techniques arc a valuable adjunct to the vascular surgeon for both the diagnosis and treatment o f vascular injurics. Recent technologic advances, including catheter modifications and microcoils, in conjunction with increasing skill and experience, havc widened the radiologist's scope in the management o f arterial trauma. ~.2Thcrcfbre it is imperative that the vascular surgcon bc well versed in the indications, limitations, complications~ and results o f percutaneous transcathetcr embolization (PTE). IYI'E has expanded from its initial indication in trauma, controlling major rctropcritoncal hcmorrhagc sccondao' to pelvic fractures, to a variety o f othcr uses. s-s Virtually the entire cardiovascular system is currently accessible to the cxpcrienced intcrventional radiologist, and the vascular surgeon must use discretion in determining which vascular injurics may be radiologically treated. This decision should be based on an understanding o f thc current "state

From the Departments of Surgery (Drs. Panetta, Goldstcm, and Phillips) and Clinical Radiology' (Dr. Sclat:hni), Downstate Medical Center. Presented at the Thirty-secondScientificMeeting of the North American Chapter, International Socict~, for Cardiovascular Surgery, Atlanta, Ga., June 8-9, 1984. Reprint requests: Thomas Panetta, M.D., Louisiana Statc UniversityMedical Center, Sectionof Vascular Surgcu, 1542 Tulane Ave., New Orleans, LA 70112. 54

o f thc art" in conjunction with the individual cxpcrienccs o f both the vascular surgeon and the intcrventional radiologist. Therapeutic cmbolization has become an established part o f the armamcntarium o f many trauma centers, having demonstrated its usefiflness in thc management o f major pelvic retropcritoneal hemorrhage, selected arteriovenous (AV) fistulas, pcnetrating neck injuries, postoperative intra-abdominal hcmorrhagc, muscular artcrial bleeding, and multiple bleeding sites in the hypotcnsive patient undergoing angiography." In our scries o f patients FFE has becn continuously rccvaluatcd and modified prospectively with regard to technique and indications. Mthough still in evolution, the current scrics is presented as a reference to the vascular surgeon involved in the management o f vascular trauma. MATERIAL AND METHODS Between Januaw 1977 and Februa W 1984, 328 angiographically determined arterial injuries wcre documented in 242 patients at the Kings CounD, Hospital Trauma Service. One hundred patients were evaluated prospectively and underwent PTE fbr 107 arterial injuries. Ninety-five patients had single arterial injuries, five patients had two injuries~ and one patient had three injurics. Thoracic, abdominal, and pelvic aortography wcre performed either individually or in combination

\ rO[UlYl¢ 2

Number 1 January 1985

PTE for arterial trauma

55

Table I. Technical guide for embolization Inju~

Technique

Comments

Rctroperitoneal hematoma (pelvic fractures) AV fistula Spleen~

Selectivesmall particle Gclfoam

Presacral hcmorrhage is subtle

Proximal and distal coils Proximal splenic artery coil

Liver"

Selective small particle Gelfbam

End vessels require only proximal coils Selective branch embolizationwith Gelfoam Portal vein must bc intact; embolize distal to cystic artery

Ki&aey~ Pancreas~ Peripheral large vessels Peripheral small vessels~

Selective small particle Gclfoam Proximal and distal coils Selectivesmall particle Gelfbam

~Except in cascs of AV fistulas; refer to technique mentioned abovc.

using 76% diatrizoate meglumine. Peripheral arteriography required 60% diatrizoate meglumine. Selective catheterization including the vessel distal to the arterial injury was facilitated by guide wire insertion under fluoroscopic control and the use o f coaxial catheters. Selective runs were routinely performed. Adequate collateral circulation was identified prior to embolization. SLxtv embolizations were performed with the use o f Gelfoam. Gelatin cakes were soaked in contrast medium and then sliced into 1 to 3 mm cubes. Increments o f 0.1 to 0.2 ml volumes o f small pledgers were placed in a tuberculin syringe and flushed through the catheter with contrast medium. The procedure was fluoroscopically monitored and embolization was stopped when flow slowed and before reflux occurred. Steel/cotton mini- and microcoils o f 2 to 8 mm helical diameter were utilized in 28 patients for control o f hemorrhage from larger vessels, or when proximal and distal control o f isolated injuries were required (Table I). A combination o f Gelfbam and coils was necessary, in 12 patients. Intentional intimal dissection with subsequent thrombosis was effective in controlling hemorrhage in three patients. Arteriography was repeated immediately after embolization. If no extravasation was seen, the procedure was terminated. Persistent bleeding because o f either incomplete embolization or collateral pathways required additional embolizations. RESULTS Overall. PTE was performed successfully in 82.2% o f the 107 arterial injuries for which it was selected. Three hundred twenty-eight angiographically determined arterial injuries were identified in over 1100 arteriograms. There were 13 diagnostic

Table II. Embolization o f AV fistulas Fistula

No.

Profunda femoral Vertebral External carotid Posterior tibial Internal mammary Circumflex humeral Hepatic Rcnal Pelvic

5 3 2 2 1 1 2 2 __[1 19

Success rate = 84.2%; complications = 3; deaths = 0.

errors (1.2%). These included eight false negative, two truc positivc with incorrect interpretations, two truc positive with misidentificd vessels, and one false positive study. T w o thirds o f these errors wcrc made by radiologists inexpericnccd in trauma angiography. R e t r o p e r i t o n e a l hematomas. Twcnty-cight cmbolizations were performed in 28 patients (19 male and 9 female). Twenty-six patients had Malgaigne fractures, and two patients had isolated anterior clement fractures. Twcnw-four patients underwent successful embolization (85.7%), and fbur patients died from massive uncontrollablc pelvic hemorrhage. There was a total o f 11 deaths (39.3% mortality rate) in patients with rctropcritoncal hcmatomas. However, seven o f the deaths occurrcd from associatcd injuries aftcr adcquatc control o f pclvic hemorrhage. One complication occurred in this group: an external iliac artc~, was dissected, but the intimal flap did not requirc trcatmcnc Arteriovenous fistulas. Nineteen embolizations were performed in 19 male patients with AV fistulas. Mechanisms o f i n j u u included gunshot wounds in 12 patients, stab wounds in six patients, and one

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56 Panetta et al.

Table III. Embolization fbr penetrating neck injuries A rte,w

Arterial inl'uries

AV fistulas

Total

Vcrtebral Internal maxillary Intcrnal carotid Extcrna/carotid IntcrnaI mammary

2 5 3 2 0

3 0 0 2 1

5 5 3 4 1

Success rate = 88.9%; complications = 3; d c a t h s =

3.

Table IV. Embolizations tbr peripheral vascular injuries A rter),

No.

Profunda femoral Branch supcrticial femoral artery Superior gluteal Inferior glutcal Circumflex femoral Circumflex humeral Branch brachial

7 2 2 2 2 2 1 18

Success rate = 83.3%; complications = 0; deaths = 0.

Table V. Embolization for abdomen and chest injuries Site

No.

Spleen Liver Kidney Paa~creas Left gastric Gastroduodenal Intercostal

13 9 3 1 1 1 _22

30 Success rate = 73.3%; complications = 2; deaths = 2.

patient with a pclvic fracture sccondaq, to blunt trauma. The specific vessels involved arc listed in Table II. Sixteen o f 19 AV fistulas werc successfully embolized (84.2%). There wcre three treatment failures. A profunda femoral AV fistula required surgical ligation aftcr inadequate occlusion. A vertebral AV fistula required craniotomy for distal ligation after adequate proximal control o f hemorrhage had becn obtained by the insertion o f minicoils at the time o f angiography. Inability to successihlly catheterize a circumflex humeral AV fistula precluded embolization. There were three complications and no dcaths among the patients with AV fistulas. A coil that was too small embolized to the lung o f a paticnt with a

profunda fkmoral AV fistula. Thc patient rcmained asymptomatic and thc coil did not require removal. A small intimal flap was disscctcd in a subclavian artc O' during cmbolization o f an internal mammary AV fistula. Thc patient remained asymptomatic and did not require opcrativc intcrvcntion. A transicnt Brown-Sdquard syndrome dcvclopcd in one paticnt with a vertebral AV fistula aftcr cmbolization. This paticnt was ambulaton7 at timc o f discharge from thc hospital. Penetrating neck injuries. Eightecn cmbolizations were performed in 17 male patients with pcnetrating neck injuries. There were 14 zone III and fbur zonc I injuries. Six o f thc 18 cmbolizations (Table III) were in patients with AV fistulas, and these paticnts are also included in the prcvious group. The mechanisms of inju W were gunshot wounds in 16 patients, a shotgun wound m one patient, and a stab wound in one patient. There werc five vertebral, five internal maxillaB,, tbur external carotid, thrcc internal carotid, and one internal malrmlaB~ arterial injuries. Sixtcen of 18 embolizations were successful (88.9%). The two embolization failures include the previously described vertebral AV fistula that rcquired craniotomy fbr distal control. The second failure was in a patient who sustained an intimal dissection o f the opposite vcrtebral artery while collateral flow was being studied. This patient had a shotgun pellet lodged in thc wall o f his left vcrtcbral arteo~, and it was decided to observe the patient without fhrther intervention after his right vertebral atte D, was dissected, rather than cmbolize the left vertebral artery and risk bilateral occlusion. Follow-up arteriography 2 wceks later showed healing o f the intimal flap in the arteD, injured bv the pellct and stenosis o f the artery injured bv the catheter. There were three deaths in this group (17.6% mortality rate) and m'o complications. Onc death was secondary to a respiratoD' arrest unrclatcd to the embolization. The Bvo other deaths occurred after massive strokes tbllowing internal carotid injurics. Both patients were comatose and embolization was perfbrmcd subsequent to thc neurologic insult. There were three complications in this group. The subclavian artery intimal flap from cmbolization o f the internal mammary AV fistula is also included as a complication o f AV fistula embolizations (Tablc II). The contralateral vertebral dissection that precluded embolization is considered both a treatment failure and a complication. The third complication was an air embolism that resulted in a strokc. This

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PTE )br meerial trauma

57

Fig. 1. A, AV fistula between internal mammaDT artery and subclavian vein was misdiagnosed as aortic arch pseudoaneuwsm (arrows). Note absence of internal mammary artery on left. B, Selective internal mammary angiogram demonstrating fistula (arrow) subsequently obliterated with coils. occurred after Gelfbam embolization o f a contralateral external carotid injury during control arteriography o f the normal carotid artery after embolization. The neurologic sequelae o f the stroke resolved completely. Peripheral vascular injuries. Eighteen embolizations were performed in 18 patients (17 male and one female) with peripheral vascular trauma. All injuries were secondary to penetrating trauma, includ ing 12 gunshot wounds and six stab wounds. The injured vessels are listed in Table IV. There were no deaths and 15 (83.3%) o f the embolizations were successful.

Three irI'E attempts in this group were unsuccessful. T w o patients were embolized and continued to bleed. A superior gluteal arteqT required surgical ligation, and an arterial inju W in a branch o f a superficial femoral arte W was inadequately controlled preoperatively in a hypotensive patient during aortic angiography. Difficulty in cannulating a branch o f a superficial femoral artery precluded embolization in the third patient. Chest and abdomen. Thirty embolizations were performed in 28 patients (23 male and five female) with thoracoabdominal trauma. Sixteen patients sustained injuries secondary to blunt trauma, and 12

58

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Panetta et al.

Fig. 2. A, Subtle presacral hemorrhage (a,wo~t,s) ovcr postcrior clcment pelvic fracture was treated bv Gclfoam cmbolization. B, Multiple blccding sites (a~v'oll,s) in patient with Malgaignc fracture were treated with Gcltbam embolization. were the result o f penetrating trauma (sevcn gunshot wounds and five stab wounds). Sites of injuries arc listed in Table V. Twenty-two o f 30 embolizations were successful (73.3%). O f the eight trcatmcnt fhilures, seven were for splenic injurics that required splenectomy subsequent to embolization. This represents 54% o f splenic cmbolizations. Thc eighth treatment failure was a gastroduodcnal arterial injur T that required surgical ligation after continued hcmorrhagc l~bllowing embolization. Both patients with intercostal embolizations died fi-om associated nonthoracic injuries alter thc intercostal bleeding was successfullv controlled. Subphrcnic absccsscs devcloped in two patients after postoperativc embolization o f hepatic vessels.

DISCUSSION When vascular disruption results t'rom blunt or penetrating trauma, the decision must bc made whether the injury is best managed by surgical intervention or PTE. Obvious arterial injuries with significant extcrnal, intra-abdominal, or intrathoracic blood loss or arterial injuries resulting in ischemic organs or limbs usually mandate immediate exploration without preoperative angiography. Howcver, once an arterial injuD~ is discovered by angiography, . the choicc betwcen surgical repair or ligation vs. PTE exists. Treatment decisions must be individualized and no universally applicable algorithm can be constructcd bccausc of the many factors that must bc considcred.

Vo~tlnlc 2 Numbcr 1 January 1985

PTE fi~r arterial trauma

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Fig. 3. A, Hepatic artery (arrow) to hepatic vein (arrowhead) AV fistula was subsequently treated by FFE with coils. B, Vertebral AV fistula was subsequently obliterated with coils.

A varie D" of angiographic findings mav be associated with arterial injuries, ranging from the subtle presacral hemorrhage of some pelvic fractures to gross extravasation of contrast. AV fistulas, pseudoaneuDTsms, intimal flaps, arterial occlusion, or cxtravasation are not difficult to diagnose. However, subtle presacral hemorrhage associated with certain pelvic fractures, irregular arterial wall contour, or even smooth tapering arterial spasm may be the only evidence of significant arterial injuries that otherwise remain occult. 7 Follow-up angiography, in selected cases, may be necessary to reduce the incidence of false negative studies. The greater accuracy of selective angiography is helpful in decreasing the incidence of tn~e positive misdiagnoses. One patient referred to us with the diagnosis of an aortic pseudoaneurysm (Fig. 1, A) was fbund on selective angiography to have a fistula originating from the internal mammary arte~.~ (Fig. 1, B). PTE was successful and the patient did not require sternotomv. PTE is the treatment of choice l~br controlling massive or persistent retroperitoneal hemorrhage from pelvic fractures. In our institution angiography is performed in patients with pelvic fractures requiring transfusions of 4 units or more of blood within

the first 24 hours, 6 units or more within 48 hours, in patients who have unstable vital signs with negative or borderline peritoneal tap and lavage, and in patients with large expanding retropcritoncal hcmatomas discovered at the time of celiotomy. High (supraumbilical) peritoneal tap and lavage arc performed in all patients with pelvic fractures to rulc out concomitant intra-abdominal hemorrhagc. If thc tap or lavage reveals positive findings, laparotomy is performed prior to PTE. However, pelvic rctropcritoneal hematomas are not disturbed at the timc of abdominal exploration. Selective catheterization of the injured pelvic vessels followed by small-particle embolization with Gclfoam is superior to surgeu in controlling hemorrhage in this area. The rich nem'ork of collateral pathways in the pelvis is responsible for the failure of proximal internal iliac ligation to control pclvic hemorrhage. 8 Furthermore, injudicious exploration of pelvic retroperitoneal hematomas may increase hemorrhage by releasing the tamponadc effect of the rctroperitoneum on both venous and small artcrial bleeding. Presacral hemorrhage and bilatcral cxtravasation require bilateral selective embolization with Gclfbam (Fig. 2). Tissue slough or neurologic deficits

]~itl1nal ~1i

60

Panetta ct al.

Fig. 4. A, This profunda fi:moral AV fistula was sccondarv to a gunshot wound. B, Sdectivc angiogram o f superficial tkmoral artery m same paticnt dcmonstrates patent distal profimda fkmoris arte W fkeding AV fistula through collateral pathways (an'on,). C, Fistula was isolated by proximal and distal coil embolization.

VAS(l TI \ P, SURGFRY

VoIunlc 2 Number 1 ] almatw 1985

did not occur in our patients t~bllowing unilateral or bilateral embolization. Large-vessel hemorrhage is controlled with micro- or minicoils. This protocol was effective in controlling hemorrhage in 85.7% of the patients in our series. Only four of the 11 deaths wcre related to uncontrollable hemorrhagc. All patients with penetrating zone I and zone III neck injuries who have stable vital signs, patients with injuries in proximity to extremity, vessels, and postoperative patients with significant central liver injuries undergo routine angiography to identify early AV fistulas. Our indications for angiography have been liberalized to include injuries in proximity to vascular structures even in the absence of clinical indications of arterial injuD,. AV fistulas can present without a histo W of significant arterial bleeding, as the arterial injury is sometimes decompressed into the low-pressure venous svstem. Delayed diagnosis of an AV fistula that presents after maturation or development of symptoms complicates either operative or PTE treatment. Indications fbr embolization in our series of AV fistulas included (1) surgically inaccessible AV fistulas (pelvic, central hepatic, renal parenchymal, and distal vertebral); (2) nonreconstructable AV fistulas that would require surgical ligation (internal mammary and distal profunda f~moral); and (3) selected cases in which vesscls were considered "expendable" (external carotid, isolated proximal vertebral, and posterior tibial arterics) (Fig. 3). The prerequisites for effective obliteration of AV fistulas bv PTE include arterial occlusion proximal and distal to the fistula and arteriography after embolization to rule out collateral filling (Fig. 4). The placement of microcoils through coaxial catheters is an effective technique for distal control in small-caliber vessels. Penetrating neck injuries in our institution arc managed by a protocol of selective exploration. 9 Stable patients without clinical evidence of visceral or vascular inju~ in the neck are evaluated with csophagography and angiography. Revascularization was attempted in patients with surgically accessible vascular injuries of the arch and major vessels, unless the patients were comatose.m Indications for PTE in penetrating neck injurics included (1) surgically inaccessible zone III arterial . injuries (Fig. 5), (2) selected "expendable" vessels, and (3) comatose patients with internal carotid injuries who were not candidatcs for revascularization. Prior to embolization of vertebral injuries, adequate collateral flow must be documented by selective con-

PTE Jbr arterial trauma

61

Fig. 5. High internal carotid injuD, (arrow) was treated with coil cmbolization. tralateral angiography. Approximately 10% of patients do not have adequate collateral pathways. 1~We are currently investigating the use of metal alloys with thermal memow-shape characteristics that will allow percutaneous placement of intra-arterial endoprostheses. Potentially this will allow percutaneous reconstruction of surgically inaccessible arterial trauma as in the case of zone III internal carotid injuries. Patients with penetrating extremity trauma undergo routine angiography for indications including decreased or absent distal pulses, expanding hematomas, excessive or pulsatile external blood loss, thrills, and bruits. In addition, patients with a histoD, of exccssive or pulsatile bleeding, and patients with injuries in close proximi~ to vascular structurcs also undergo routine angiography. In thc absence of clinical indications of arterial injury., angiography is done electivelv. PTE is indicated to control muscular blecding

62

Journal oi VASCUI.A1L SURGERY

l'anetta ctal.

from vcsscls that would not bc reconstructed during a surgical cxploration. :2 In our series this includcd distal prothnda tkmoral, superior gluteal, infcrior glutcal, circumflex femoral, circumflex humeral, and muscular branches o f both the brachial and superficial fkmoral arteries (Table IV). Splenic salvage in combination with nonopcrativc management o f isolated splenic injuries is a theoretical possibiliD,. ~~The sensitivity o f abdominal tap and lavage in combination with the specificiD~ o f an abdominal CT scan theoretically can identit), patients who would be potential candidates tbr PTE of isolated splenic injuries. However, currcnt results of PTE for splenic injuries (46% success rate) must be improved betbre incorporating this tbrm o f therapy into the algorithm tbr managing blunt abdominal trauma. The indications tbr splenic artcriography in this series werc (1) delayed presentation o f patients who have stable conditions after blunt abdominal trauma but who are suspected o f having intra-abdominal bleeding after a peritoneal tap, lavage, or CT scan; (2) evaluation o f the role ofangiographic techniques in the management o f intra-abdominal hemorrhage in patients with stable conditions who have positive peritoneal lavage as part o f a protocol; and (3) associated injuries (widened mediastinum, peMc fi*actures, and liver injuries). Although 7 o f 13 patients underwcnt splenectomy after cmbolization and are considered treatment failures, considerable cxpericnce was gained from this series. T w o patients in w h o m lavagcs wcrc positive underwent Gcltbam cmbolization o f shattered splecns, which were removcd at the time o f laparotomy. It was bclieved that this maneuver considerably decreascd preopcrativc hcmorrhage, although splcnectomy was not avoided. Embolization o f thc splenic artery with Gclti)am in one case and coil migration into a hilar splcnic vessel in a second case resulted in either segmcntal or complete splenic infarction. Currently wc arc placing appropriately sized coils into splenic artcries and reserving Gelfbam tbr distal cmbolization o f small scgmcntal bleeding branches utilizing coaxial cathctcr placemcnt. This improved technique has allowcd nonopcrative splenic salvage in fi)ur o f our last five patients in this group. The indications tbr PTE in the remainder o f the intra-abdominal injuries wcre postoperative intra-abdominal hemorrhage in patients with coagulopathies, hematobilia, and pcrsistent gross hcmaturia. ' 4 0 n c patient had a persistent arteriocalyceal fistula that was successfully embolized. T w o patients with persistent

hemorrhage from chest tubes undcrwcnt PTE of intercostal vessels. In both o f these patients angiography was indicatcd for associated injuries, and PTE was indicated to control multiple bleeding sitcs in the hypotensivc paticnt. Intercostal artery embolization was an effective immediate means o f decreasing the patients' blood loss. PTE has a number o f distinct advantages ovcr surgeD, in treating selectcd types o f vascular trauma. Rctmperitoneal hemorrhage secondary to peMc ffacturcs reprcsents the prototype in which PTE is o f demonstrated superiority. The trcatmcnt o f ccrtain parenchymal organ injuries such as hematobilia, hcpatoportal fistulas, and intrarenal vascular disruption may also tall into this category. In other anatomic locations PTE precludes general ancsthesia, parenchvmal dissection, cosmetic deformity, and cxtensivc soft tissue dissection with thc potcntial tot cranial and pcriphcral nerve injuries. Furthermore, the skilled intc~cntional radiologist can rapidly control hcmorrhagc from multiple blceding sites at the timc angiography is pertbrmed tbr diagnostic purposes. Intcrventional radiologic tcchniqucs havc evolved to the point whcre they arc cxtremelv eft}zctivc in , trcating a variety o f vascular injuries. Success rates in our series ranged from 73.3% to 88.9%, depcnding on location and type o f injur T. Further cxperiencc, tcchnical advanccs, and proper patient selection will continue to improvc results and provide a vahlable assct to the surgeon dealing with the spectrum o f vascular trauma. One must consider multiple thctors in individualizing thc trcatmcnt o f vascular injurics, including thc location and t3,pc o f injury, the paticnts' surgical risk, and thc indMdual cxpcricncc o f both thc vascular surgeon and the intcrventional radiologist.

REFERENCES

1. Bcn-Mcnachcm Y, Handel SF, Thaggard Ill A, Carnovale RI,, Katragadda C, Glass TF. Therapeutic arterial embolization in trauma. J Trauma 1979; 19:944-51. 2. Walter JF, Bookstcin JJ, Kramcr RA, ct al. Therapeutic an giography: Its value to the surgical patients. Arch Surg 1978; 113:432 9. 3. Margolies MN, Ring EJ, Waltman AC, ct al. Artcriography in the managcmcnt of hcmorrhagc from pcMc fractures. N Engl I Med 1972; 287:317-21. 4. Matalon TSA, Athanasoulis CA, Margolics MN, ct al. Hcmorrhage with pelvic fractures: Efficacyof transcathctcr cmbolization. AIR 1979; 133:859-64. S. Ring EJ, Athanasoulis C, Waltman AC, ct al. Artcriographic management of hcmorrhage following pcMc t'racturc. Radiology 1973; 109:65-70. 6. SctafaniSIA, ShaffanGW, Mitchell WG, NayaranaswamyTS,

VoltllllC 2 Number 1 Janual 3' 1985

McAulcy J. Intcrvcntional radiology in trauma victims: Analysis of 51 consecutive patients. J Trauma 1982; 22:353-60. 7. Sclafani SJA, Bcckcr JA. The arteriographic diagnosis and management of traumatic presacral hemorrhage. AJR 1982; 138:123-6. 8. Brotman S, Sodcrstrom C, Oster-Granite M, Cisternino S, Browncr B, Cowlcv R. Managcmcnt of scvcrc bleeding in fractures of the pelvis. Surg Gvnccol Obstct 1981; 153: 823-6. 9. Elcrding SC, Manart FD, Moore EE. A reappraisal of penetrating neck injury management. I Trauma 1980; 20: 695-7.

DISCUSSION Dr. M a l c o l m O. Perry (New York, N.Y.). This is an omnibus report; it is a complete tour of the technical ability to enter and manage some o f these vessels, and I will have to confine mv remarks to just a few areas. The authors have quite correctly identified the most fkrtile area fbr this technique: the management of the canccllous fractures of the pelvis that are associated with such massive bleeding. It is important, o f course, that one must get the catheter directly to the site o f the injury, particularly if it is an AV fistula. Inadvertent discharge of the occluding device into the hypogastric arte W not only precludes treatment, but it precludes further studv and reembolization. I noticed that there were 19 AV fistulas. Can I assume that these were chronic rather than acute, because it would be remarkable to see 19 acute AV fistulas? O n occasion the occlusion can be accomplished via a venous approach. Thirteen splenic arteries with subsequent failure are a little more disturbing to me. We know we need to preservc the spleen, and I think it might be more appropriate in those patients to operatc on them. I am a little more comfortable in operating fbr penetrating trauma with known injuries in that area. I noticed you had one splenectomy and seven failures. It is interesting to speculate if they could have bccn saved had you operated. In addition, Dr. Donald Trunkey has shown us that the early use of a CT scan in these patients mav be hclpful in determining splenic damage. I am also a little less comfbrtable with the profunda fkmoral embolizations. 1 would have operated on those patients and repaired the profunda femoris arte U unless it was not feasible to do so. It is not an expendable artery, and many others that wm listed were expendable. Some might have stopped bleeding on their own. The prot~nda femoris is an important artery., and I think it should be operated on and repaired. These are fairly simple and straight~brward operations for the most part. I also would like to know about the time consumed in preparation. Somc of these patients are hemodynamically unstable, and we have fbund it unsafk to send them unattendcd to radiology.. I assume that thc vascular surgeon is in attendance not onh, in the event of cardiovascular

PTE fi)r arterial trauma

63

10. Lickwcg WG, Grccnficld LF. Managcmcnt of pcnctrating carotid arterial injury. Ann Surg 1978; 188:887-92. 11. Wiener I, Flyc MW. Traumatic fZalscaneurvsm of the vcrtcbral artctT. J Trauma 1984; 24:346-9. 12. Sclat~aniSJA, Shaffan GW. Angiographic treatment of injuries to the profunda tEmoris artery. AIR 1982; 138:463-6. 13. Sclafani SJA. ,Mlgiographic hcmostasis: Its role m the salvage of the injurcd spleen. Radiok)g3, 1981; 141:648-50. 14. Sclafhni SJA, Stein K. Artcriographic management of traumatic artcriocalyccal fistula. Urol Radiol 1981; 3:177-9.

collapse but also to direct the radiologist to a method of action. Dr. Erich W. Pollak (Los Angeles, CaliE). If pcrcutaneous transcatheter embolization is, as stated bv Dr. Panetta, the treatment o f choice fbr massive pelvic fracture hemorrhage, it should be safer and better than standard therapy. We believe that this has not been proved. O f his 28 patients with pelvic hemorrhage, six died o f unrelated causes. O f the remaining 22, fbur (18%) died because of therapeutic f]ailure o f his method. In the absencc o f a control series, any statement regarding Dr. Panetta's treatment value is debatable. Historic controls do not support his contention cither. In our last 22 patients with massive hemorrhage duc to pelvic fractures, two ofeveD, three patients stopped bleeding with nonoperative measures. The remaining ones werc operated on with the use of standard techniques. Two needed reoperation within 48 hours. Bleeding was controlled in all 22 and there were no deaths. I am not implying that Dr. Panetta's method should be condemned. It may eventually find its niche in the treatment of selected patients. Whether it will ever be the method of choice is questionable and should be determined by carefully planned randomized prospective studies instead of sweeping cnthusiastic statements. I have one question: What was the incidence of pulmona D, embolism fbllowmg the transcatheter injection? Patients with pelvic fractures alreadv have a high (up to 50%) incidence of pulmona U embolism. Because of this, wc have performed inferior vena cava clipping at the time of the initial laparotomy in selected patients. Dr. P a n e t t a (closing). Dr. PerD*, all of our AV fistulas were acute, and the reason fbr the high incidence of identifi,ing these injuries is that we perfbrm angiography on our patients tbr proximity injuries. As far as the splenic injuries, this was initially done as part of a protocol to evaluate angiography for blunt abdominal trauma. The 13 splenic injuries were a result o f blunt abdominal trauma, and in the initial part of the series PTE was used to control hemorrhage at the time the angiogram was done. In a later part of the series, fbur of five embolizations resulted in

64

Panetta et al.

splenic salvage as a result of using proximal coils. As far as saving splenic tissue, thc initial failures were all operated on and the majoriD, of those were shattcrcd spleens. If we thought that the spleens were repairable at that time, we would have done splenorrhaphy. As far as the distal profunda fcmoral injuries, the decision whether to repair or embolize is based on thc judgment of thc individual surgeon and our interventional radiologists. Thc decision is made as to whether the particular surgcon has the capabiliDT to repair those profunda f~moral arteries. I agree that any proximal and any rcpairablc profimda femoral artery should bc repaired. We monitor our patients m the angiography suitc with arterial lines and with a cardiac monitor. Wc have a vascular surgeon, the interventional radiologist, and the resident on call in the suite with the patient. Dr. Pollak, if you havc such a low mortality rate, I

]OtlrnaI ot V A S C U L A I ~. SURGERY

think that is reportable and I would likc to congratulatc vou on that. None of our patients was studied fbr pulmonary emboli. The majoriD* of deaths occurred in our patients who had massive crushing injuries and was caused by associated injuries. We evaluate our patients with chest, cervical spine, and pelvic x-ray films at the time the patient comes into the emergency department and do a high supraumbilical tap and lavage. If the tap and lavage arc positive, the patient is operated on fbr intra-abdominal injuries first. If the tap and lavagc arc negative, he is scnt to the angiographic suitc fbr angiography and therapeutic cmbolization. We have found this cffi:ctivc in controlling hcmorrhagc; the four patients who died of uncontrollable hemorrhage had massive crushing injuries. Two patients had jumped from scvcn- or eight-stoo~ buildings, and two patients had massive pelvic hemorrhagc afYerbeing crushed by a brick wall and steel girders.