Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3599_Библиотеки_им_академика_М_И_Перельмана
.pdf
164 Interventional radiology and endovascular procedures
14. Kessel D, Robertson I. Interventional Radiology: A Survival Guide (2nd edn)
(Amsterdam:Elsevier); 2005.
15. Padia SA, Geisinger MA, Newman JS, et al. Effectiveness of coil embolization in angiographically detectable versus non-detectable sources of upper gastrointestinal hemorrhage. J Vasc Interv Radiol 2009; 20(4): 461–6.
16. d’Othée BJ, Surapaneni P, Rabkin D, et al. Microcoil embolization for acute lower gastrointestinal bleeding. Cardiovasc Inter vent Radiol 2006; 29(1): 49–58.
17. Lee MJ. Evidence-based review of embolization of upper GIH. GEST 2007; 2 0 0 7.
CASE
19
Endovascular approach to the
trauma patient
Athanasios Diamantopoulos
Expert commentary Konstantinos Katsanos
Case history
A 34-year-old male was admitted to the A&E department 30 minutes after a motorcycle accident. The patient was in a good general state, complaining only of mild left
upper quadrant abdominal pain. His blood pressure was 135/70mmHg with a heart
rate of 75 beats/minute. The Glasgow coma scale (GCS) was 15/15. His haemoglobin
(Hb) count on admission was 13.5g/dl. No relevant past medical history was mentioned by either the patient or his close relatives who escorted him to the hospital.
As per institute protocol he underwent focused abdominal ultrasonography (US)
(also known as FAST), which at the time showed no signs of intra-abdominal free
uid or site-specic organ injury.
The patient remained in the A&E department under close observation. An hour
later he started complaining of worsening abdominal pain on the left side. A second
haemoglobin count showed a drop of 2.1g/dl (Hb = 11.4g/dl) although he remained
haemodynamically stable. A decision was made to perform a CT scan in order to
identify any potential solid organ injury or other source of bleeding. The patient
was transferred to the CT department for a contrast-enhanced CT scan in order to
identify the cause of the continuing pain. A non-contrast-enhanced CT scan demonstrated a high-density free uid collection in the lower abdomen and pelvis, suggesting haemorrhage in the abdomen (Figure 19.1a,b). Contrast-enhanced CT scans
in both the arterial phase (Figure 19.1c) and the portal venous phase (Figure 19.1d)
identied an active bleeding site in the lower pole of the spleen.
Expert comment
CT is very useful for assessing trauma patients as it can accurately detect free intra- and retroperitoneal
fluid, bone, vascular, and solid organ injuries as well as classify the degree and severity of solid organ
injuries, thus altering their clinical management [1]. Contrast-enhanced multidetector CT is very precise
for both recognition and localization of acute bleeding, even for bleeding rates as low as 0.02ml/
min [2]. However, in acute trauma CT should always follow initial clinical assessment and patient
resuscitation, and it may not be appropriate for patients who require immediate lifesaving interventions
(e.g. pelvic fixation, surgical laparotomy, etc.).
Because of the persistence of abdominal pain and the drop in the Hb level a
decision was made to immediately transfer the patient to the angiographic suite
for embolization in order to control the bleeding. The patient was haemodynamically stable during the whole process, complaining solely of abdominal pain.
As expected, selective angiography of the splenic artery veried the presence of
Learning point
Focused abdominal
ultrasonography is considered
a reliable imaging method for
detection of free intra-abdominal
fluid in poly-trauma patients. In
addition, it is a valid method for
assessing possible specific organ
injury [1]. However, US may fail to
detect injuries within solid organs,
and failure to identify free intraabdominal fluid must not always
be assumed to indicate absence
of significant organ injury. In cases
of uncertainty, clinical observation
or a CT of the abdomen is
mandatory [1].
166 Interventional radiology and endovascular procedures
(a) (b)
(c)(d)
Figure 19.1 (a, b) Non-contrast-enhanced CT scans show a high-density free fluid collection in the
pelvis (curved arrow) with no obvious traumatic injuries in the upper abdominal solid organs. (c, d)
Contrast-enhanced arterial and venous phase axial images at the level of the spleen demonstrate a site of
intraparenchymal active bleeding from the lower pole of the spleen (straight arrows).
an intraparenchymal active bleeding site (Figure 19.2a). A small peripheral branch
of the splenic artery was identied as the culprit-feeding vessel (Figure 19.2b).
The branch was selectively catheterized and embolized using a microcatheter and
microcoils. Although the nal selective angiogram showed effective arrest of bleeding (Figure 19.2c), a second, initially invisible, small peripheral branch contributing
to the bleeding was identied on a further angiogram from the origin of the splenic
artery (Figure 19.3a). This branch was also superselectively catheterized and embolized with microcoils (Figures 19.3b,c).
(a) (b) (c)
Figure 19.2 (a) Selective angiography of the splenic artery demonstrating the site of intraparenchymal
active bleeding (black arrows). (b,c) The branch was selectively catheterized with a microcatheter and
several microcoils were deployed to occlude it as demonstrated on completion angiography.
(a) (b) (c)
Figure 19.3 (a) Further angiography from the proximal trunk of the main splenic artery demonstrated
active bleeding from another small branch (black arrow). (b,c) The branch was subsequently catheterized
and occluded with additional placement of microcoils (black arrows).
Learning point
The spleen is the most frequently injured solid organ as a result of either blunt or penetrating
trauma [3]. Transcatheter embolization plays an important role in the non-operative management
of these cases. Embolization can be performed either proximally or distally. In the case of
proximal embolization, coils are usually deployed approximately 2cm distal to the origin of
the dorsal pancreatic artery, but ideally proximal to the origin of the pancreatica magna artery
[3]. Distal embolization or superselective embolization can be applied when the patient is
haemodynamically stable and time allows it, especially if there is a small peripheral vessel or
single arterial injury [3]. When superselective embolization is performed, as in the case described
here, it is important to remember to obtain a completion angiogram from the proximal splenic
artery in order to identify any additional culprit branches that may have been missed on the initial
angiograms.
167Case 19 Endovascular approach to the trauma patient
Expert comment
Use of endovascular techniques in order to control active haemorrhage originating from the spleen as
a consequence of either blunt or penetrating trauma has been a major contributor to the conservative
management of allowing preservation of the spleen. The aim of endovascular embolization is to
improve the results of the non-operative management of patients with splenic injury and to reduce
the rates of splenectomy [4,5]. Splenic vascular trauma management usually consists of proximal
embolization of the splenic artery resulting in decreased perfusion of the spleen which controls the
bleeding and in addition prevents secondary rupture by reducing the overall pressure. Alternatively,
more distal superselective embolization of the suspect arterial branch may be performed. Both
management methods are currently considered acceptable [5]. The same principles apply to other
solid organs such as liver and kidney. Superselective embolization techniques, if applicable, can be
used in order to minimize organ injury and preserve most of the target organ function. Nevertheless,
superselective techniques must only be used in cases where the clinical condition of the patient allows
sufficient time for this procedure. A proposed principle for trauma patient may be: ‘Try to embolize as
selectively as time allows’
After the successful embolization procedure the patient was admitted to a surgical ward for observation. There were no further signs of pain or embolization-related
complications (post-embolization syndrome). He had an otherwise uneventful recovery and was discharged from hospital three days later.
168 Interventional radiology and endovascular procedures
Learning point
Transcatheter embolization to
treat splenic arterial injuries is
likely to salvage the organ in up
to 94% of the cases without the
need for any surgical treatment
[6,7]. Complications of splenic
artery embolization include
splenic artery injury, non-targeted
embolization, infraction of
splenic parenchyma, and most
importantly abscess formation
and sepsis.
Expert comment
The aim of transcatheter embolization for management of splenic artery injuries is to preserve the spleen,
which is a key solid organ in the immunological system. Complications of transcatheter embolization
can be avoided with experience or, if present, can usually be managed conservatively. Non-target
embolization may be the result of improper sizing of the coils or failure to successfully recognize the
responsible arterial branch. Abscess formation may occur either immediately after the procedure or in a
delayed manner. Abscesses can be managed using standard percutaneous drainage techniques.
Discussion
Trauma is a major healthcare problem as it is the primary cause of death in young
patients. Interventional radiology plays an increasing role in management of
trauma patients, especially via percutaneous transcatheter treatment of sites of
active haemorrhage that contribute to haemodynamic instability. Patients eligible for endovascular management of traumatic arterial injuries are those who are
haemodynamic stable or sufciently resuscitated to allow enough time for both
cross-sectional imaging evaluation and angiographic identication and arrest of
the bleeding site.
Endovascular treatment for haemorrhage control was rst described in the early
1970s [8]. Since then, the increasing experience of interventional radiologists in
the delivery of transcatheter therapies, together with developments in endovascular instruments, has expanded the role of minimally invasive options in the polytrauma patient. This approach is applicable to almost all vascular territories of the
human body that may be injured by either blunt or penetrating trauma, including
the thoracic or abdominal aorta, the pelvic and upper or lower extremity arteries,
the lumbar arteries, and the major visceral branches feeding the spleen, liver, and
kidneys [3,9]. Endovascular techniques can be applied to manage bleeding in all
these arterial territories.
The following endovascular options are applicable to the poly-trauma patient:
balloon occlusions, embolization using all available embolic agents, and implant of
covered metal stents or stent grafts [3,9]. Each of these techniques has its advantages
and disadvantages, and the nal choice must be individualized based on the specic
clinical scenario, availability, and the operator’s experience and personal preference. It is essential that the operator involved must have the appropriate catheter
skills and knowledge to carry out an effective and safe percutaneous embolization
procedure. Knowledge of the arterial anatomy, including the collateral networks, is
essential for a successful embolization procedure. The most widely used embolic
agents in the trauma setting are coils and Gelfoam [3,9]; coils are more precise but
Gelfoam produces quicker arrest of ow.
A final word from the expert
Over the last few decades the role of endovascular treatment of traumatic arterial
injuries has emerged and evolved to allow non operative management of such cases. By
using embolic agents, occlusion balloons, and stent grafts radiologists have produced a
paradigm shift in the management of such cases. No matter where the injury is located,
radiologists can often offer a less invasive therapeutic option. The spleen, which is the
most frequently injured solid organ [3], is being preserved in an increasing number of
cases (up to 94%) thanks to application of modern imaging and endovascular techniques
[6,7]. Liver injuries can involve the hepatic arteries, the portal venous system, or the
hepatic veins. Surgical repair of liver injuries can have than mortality rates in excess of
33%, making transcatheter management a more appealing approach [10]. The technical
success rate of embolization ranges from 88% to 100% [11,12]. In kidney injuries
embolization must be performed as selectively as possible in order to minimize the extent
of organ infarction. Gelfoam is preferred because it offers the option of recanalization;
however, coils can also be used [3].
Pelvic haemorrhage can be the result of fractured bones or disrupted pelvic veins,
and in about 10–20% of cases the source of bleeding is severe arterial injury [13].
Arterial bleeding usually comes from branches of the hypogastric artery. Transcatheter
embolization is a highly effective procedure to control bleeding with success rates ranging
from 85% to 100%. Nonetheless, corresponding mortality rates are between 17.6% and
47% despite successful transcatheter embolization [14]. Aortic trauma and extremity
arterial injuries are also very common. The introduction and widespread use of a variety
of endografts and stent grafts have altered the management of such cases, favouring the
transcatheter endovascular approach whenever this is possible mainly because of its
inherent advantages over open surgery.
169Case 19 Endovascular approach to the trauma patient
References
1. McGahan JP, Wang L, Richards JR. From the RSNA refresher courses: focused abdominal
US for trauma. Radiographics 2001; 21(Spec. No.): S191–9.
2. Yoon W, Jeong YY, Shin SS, et al. Acute massive gastrointestinal bleeding: detection and
localization with arterial phase multi-detector row helical CT. Radiology 2006; 239(1):
16 0–7.
3. Gould JE, Vedantham S. The role of interventional radiology in trauma. Semin Intervent
Radiol 2006; 23(3): 270–8.
4. Wahl WL, Ahrns KS, Chen S, et al. Blunt splenic injury: operation versus angiographic
embolization. Surgery 2004; 136(4): 891–9.
5. Madoff DC, Denys A, Wallace MJ, et al. Splenic arterial interventions: anatomy,
indications, technical considerations, and potential complications. Radiographics 2005;
25(Suppl 1): S191–211.
6. Sclafani SJ, Shaftan GW, Scalea TM, et al. Nonoperative salvage of computed tomographydiagnosed splenic injuries: utilization of angiography for triage and embolization for
hemostasis. J Tr auma 1995; 39(5): 818–27.
7. Haan J, Scott J, Boyd-Kranis RL, et al. Admission angiography for blunt splenic injury:
advantages and pitfalls. J Tra u ma 2001; 51(6): 1161–5.
8. Margolies MN, Ring EJ, Waltman AC, et al. Arteriography in the management of
hemorrhage from pelvic fractures. N Engl J Med 1972; 287(7): 317–21.
9. Nicholson AA. Vascular radiology in trauma. Cardiovasc Intervent Radiol 2004; 27(2):
105–20.
10. Schwartz RA, Teitelbaum GP, Katz MD, Pentecost MJ. Effectiveness of transcatheter
embolization in the control of hepatic vascular injuries. J Vasc Intervent Radiol 1993;
4(3): 359 – 65.
170 Interventional radiology and endovascular procedures
11. Hagiwara A, Yuk ioka T, Ohta S, et al. Nonsurgical management of patients with blunt
hepatic injury: efcacy of transcatheter arterial embolization. AJR Am J Roentgenol 1997;
169(4): 1151–6.
12. Monnin V, Sengel C, Thony F, et al. Place of arterial embolization in severe blunt hepatic
trauma: a multidisciplinary approach. Cardiovasc Intervent Radiol 2008; 31(5): 875–82.
13. Hak DJ. The role of pelvic angiography in evaluation and management of pelvic trauma.
Orthop Clin North Am 2004; 35(4): 439–43.
14. Yoon W, Kim JK, Jeong YY, et al. Pelvic arterial hemorrhage in patients with pelvic
fractures: detection with contrast-enhanced CT. Radiographics 2004; 24(6): 1591–6.
CASE
20
Uterine fibroid embolization:
can fertility be preserved?
Leto Maili and Aneeta Parthipun
Expert commentary Irfan Ahmed
Case history
A 40-year-old woman, who was previously t and well, presented to her
gynaecologist with a long-standing history of menorrhagia and dysmenorrhea.
She had a 12-year-old child and was concerned about preserving her fertility.
Magnetic resonance imaging (MRI) examination showed a broid uterus with
multiple intramural and subserosal broids. Following contrast administration,
there was avid enhancement of the majority of the broids (Figure 20.1). There
was no endometrial abnormality or additional supply to the uterus via the ovarian arteries.
Expert comment
Ideally, all women should have an MRI scan with IV contrast. MRI outperforms transvaginal
ultrasound in pre-embolization assessment of the number, size, and location of leiomyomas [1,2] and
detection of possible collateral ovarian artery supply to the fibroids. It is also beneficial in predicting
the outcome of uterine fibroid embolization (UFE) [3]. For example, leiomyomas with haemorrhagic
degeneration have a poor outcome following UFE [4,5]. MRI has the additional benefit of diagnosis
of adenomyosis and endometriosis. It is also used to exclude leiomyosarcoma or adnexal malignancy,
which are contraindications for UFE [6,7].
Figure 20.1 MR sagittal and axial images of the uterus following IV contrast administration reveal large
enhancing fibroids.
172 Interventional radiology and endovascular procedures
Evidence base HOPEFUL
trial [9]: safety and efficacy of UFE
●
UK multicentre retrospective
cohort trial comparing
hysterectomy and UFE for the
treatment of symptomatic
uterine fibroids.
●
UFE (n = 459) versus
hysterectomy (n = 649).
●
Average follow-up: 8.6 years for
hysterectomy cohort; 8.6 years
and 4.6 years in the UFE cohort.
●
85% of UFE patients reported
relief from fibroid symptoms
versus 95% of hysterectomy
patients.
●
23% of UFE patients required
further treatment for fibroids.
The interventional radiologist and the gynaecologist both accepted that the
patient was a valid candidate for a myomectomy, but also suggested that, because of
the presence of multiple broids, UFE would be a reasonable alternative. In view of
the current literature, the interventional radiologist stated that UFE was an effective
form of treatment for symptomatic broids. Several studies have also demonstrated
that UFE has short-term advantages of UFE over surgery, including less blood loss,
shorter hospital stay, and quicker resumption of work [8]. Both the gynaecology and
the interventional radiology consultants felt that the patient’s preference for a less
invasive procedure should be taken into account.
Evidence base EMMY trial and REST trial
EMMY Trial [10]:
●
Level 1 evidence
●
Prospective randomized controlled trial (RCT) (n = 177) comparing UFE with hysterectomy
●
UFE is an effective alternative to hysterectomy
●
Both procedures improved quality of life at two-year follow-up.
REST trial [11]:
●
Level 1 evidence
●
RCT comparing UFE (n = 106) with surgery (hysterectomy (n = 43) and myomectomy (n = 8))
●
9% of UFE patients required repeat UFE or hysterectomy because of inadequate symptom control
●
Symptom scores at one year were better in the surgical group
●
Significantly shorter hospital stay and faster return to regular activities in the UFE cohort.
The patient was provided with an information leaet detailing the procedure and the potential complications. She was also sent for routine blood tests
(full blood count, coagulation screen, and renal function tests), which were all
normal.
Learning point Complications of UFE [12]
●
Post-embolization syndrome: this is a common presentation defined by the presence of a low-
grade fever, nausea, vomiting, and malaise, which can last for several days after the procedure. It is
important that this entity is distinguished from infection.
●
Serious infection: a rare complication presenting in 0.5% of UFE patients [13]. It may
manifest with pelvic pain, pyrexia, leucocytosis, or vaginal discharge. Risk of hysterectomy is
less than 1%.
●
Transcervical expulsion of leiomyomas: this is the most common serious complication and is
defined as the detachment of fibroid tissue from the uterine wall and subsequent transvaginal
passage. The incidence is up to 3% [14–16] and presents with severe menstrual cramps, vaginal
discharge, tissue passage, or heavy bleeding. When fibroid impaction occurs in the cervix,
gynaecological intervention is mandatory [14].
●
Premature ovarian failure: this may occur following UFE and is age dependent. It is estimated that
5% of women over 45 years of age may have temporary or permanent amenorrhea following UFE.
The risk decreases to 1% after the age of 40 [17].
●
Pulmonary embolism: this is the most common life-threatening complication, with an incidence
of around 1 in 400 [18]. Women at significant risk should be anticoagulated; however, there is no
indication for routine anticoagulation therapy.
The overall periprocedural complication rate for UFE, including major and minor complications, is 8%.
The overall infection rate is 2% [14,19]. Pinto et al. [20] demonstrated that the major complication rate
following hysterectomy was 20% compared with 2.5% following UFE.
On the day of the UFE the patient was given a stat dose of diclofenac sodium
100mg PR, metronidazole 500mg IV, morphine sulphate 10mg IM, and ondansetron
4mg IV. This was in accordance with departmental guidelines. A right unilateral
common femoral artery approach was performed and a 4Fr sheath was introduced.
Both uterine arteries were selectively catheterized with a 4Fr cobra (C2) catheter
using a Waltman loop technique [21]. Subsequent embolization was performed
using three vials of non-spherical polyvinyl alcohol (PVA) particles of diameter
500–700μm (PVA-500; Cook Medical, Bloomington, IN, USA). The angiographic endpoint for embolization was ‘almost complete stasis of contrast’ in the uterine arteries
(Figures 20.2 and 20.3).
173Case 20 Uterine fibroid embolization
Figure 20.2 Selective angiogram of the left
uterine artery prior to embolization. Inset:
Stagnant flow of the left uterine artery with
occlusion of its distal branches.
Figure 20.3 Selective angiogram of the right
uterine artery prior to embolization following
Waltman loop formation of the catheter. Inset:
Stagnant flow of the right uterine artery with
occlusion of its distal branches.
Соседние файлы в папке Библиотека им академика М.И. Перельмана