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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3733_Библиотеки_им_академика_М_И_Перельмана.pdf
both describe gallbladder-related complications, all of which occurred in
patients who underwent selective right hepatic artery embolization. This can
be avoided with judicious use of particles and superselective embolization
distal to the cystic artery origin when treating injuries to branches of the right
hepatic artery.
Hepatic necrosis after trauma often requires open debridement, but
bilomas and abscesses can be effectively managed using interventional
radiology techniques.51 In the patients who undergo hepatic artery
embolization, the risk of these complications can be mitigated with more
selective technique. Bile leaks complicated 23% of cases in the series by
Mohr et al.43 and were managed by interventional radiologists with
percutaneous drainage for a median of 1 month. Carrillo and colleagues
51
brought attention to the importance of interventional radiologic techniques
for management of these more common complications.
TIPS AND TRICKS
• Microcoils should be used for superselective embolization to limit
necrosis.
• If there is a large territory with multifocal arterial injuries, realize that
particles or gelfoam may be necessary for hemostasis but will
increase the risk of liver failure and may lead to necrosis requiring
operative debridement.
• When embolizing the right hepatic artery, the catheter should be
positioned distal to the cystic artery to avoid gallbladder necrosis.
KIDNEY
In comparison with hepatic and splenic injuries, renal injuries are less
common, occurring in 1% to 5% of all traumas.52 Hemorrhagic renal injuries
requiring intervention are more commonly iatrogenic, that is, related to
percutaneous nephrostomy, biopsy, nephrostolithotomy, etc., than
traumatic.53 As in all solid organ injuries, conservative management with
selective angioembolization is now the standard in patients with grades I to
IV injuries who are hemodynamically stable. A common theme throughout
this chapter is organ preservation; patients with renal injuries who undergo
laparotomy are more likely to have a nephrectomy, the implications of which
may ultimately be severe, particularly in the event of future trauma,
nephrolithiasis, malignancy, or other renal insult.
54
In one series of patients
with renal trauma, 28% of patients undergoing nephrectomy developed renal
failure.
55
Grades I and II injuries are managed conservatively (observationonly), with near 100% success rate.54 In grades III and IV injuries,
management depends on imaging findings and clinical status.
The optimal management of grade V lesions is uncertain, and published
results are variable. Many surgeons advocate nephrectomy in grade V,
particularly renovascular lesions. Breyer et al.
56
reported a failure rate of
100% (5/5) for angioembolization of grade V injuries. Brewer et al.
57
reported 100% success rate of angioembolization for grade V injuries in
unstable patients. These differences in outcomes may be due to
inhomogeneity of grade V injuries, with renal pedicle avulsion, for example,
likely requiring surgery.58 Hagiwara et al.59 reported on his success with
angioembolization in all grade III through grade V renal injuries in which it
was attempted. Eight of the patients in this series were grade IV or grade V,
and each of these was successfully embolized.59 In the study by Brewer et
al.,57 nine hemodynamically unstable patients with grade V parenchymal and
renovascular injuries were successfully embolized with no further
interventions required. Most of these patients, however, underwent main
renal artery occlusion with coils. Follow-up after a mean of 2.7 years
revealed no adverse effects of the embolizations.
60
Complete renal embolization is an alternative to nephrectomy in patients
who may be poor surgical candidates, with low complication rates and few
long-term sequelae. In a 1999 paper by Hom et al.,61 eight patients underwent
complete renal embolization for various reasons including recurrent bleeding
from tumor or angiomyolipoma, none of which related to trauma. Most of the
patients required narcotics for pain control for up to 48 hours, but in mean
follow-up of 30 months, no abscess, hypertension, or renal failure
developed.61 Main renal artery embolization for trauma, however, is
essentially a nonoperative nephrectomy with the benefits limited to avoidance
of exploratory laparotomy. Optimal management of grade V vascular renal
injury remains uncertain and for now depends on individual trauma center
expertise and availability of interventional radiologists.
OIS grade and clinical status are important but imperfect indicators for
the need for intervention, particularly with regard to OIS grades III and IV
injuries. Several retrospective studies have helped to clarify this issue by
identifying specific CT findings indicative of the need for intervention, either
angiographic or surgical.
6,62,63
Contrast extravasation and perirenal
hematoma rim distance (PRD) were found to be significant predictors of
intervention in the studies by Dugi et al.6 and Nuss et al.62 In the study by
Dugi et al.,6 medial as opposed to lateral laceration site was also found to be
a significant predictor of the need for intervention. Most recently, Lin et al.
63
found that the combination of contrast extravasation and extent of hematoma
“remarkably increased the predictive value of the need for intervention.”
Dugi et al.6 recommended substratifying the OIS grade IV into grades IVa
(low risk) and IVb (high risk: PRD >3.5 cm, contrast extravasation, and
medial renal laceration), with IVb indicating the need for angioembolization
or surgery. These CT findings could also be used to upgrade grade III injuries
with two or more risk factors to IVb injuries.
6
Technique
Arterial lacerations and pseudoaneurysms in the kidney, like those in the liver
or spleen, are preferably treated with coil embolization of the artery as close
as possible to the site of injury (Fig. 22.4). Given the variability in arterial
supply to the kidney, flush aortography is typically necessary. A Cobra or
reverse curve (Sos or Mikaelsson, for example) catheter is most commonly
used to select the renal artery. If extravasation, pseudoaneurysm, or AVF is
present, the injured artery is selected using a microcatheter, and embolization
with microcoils is performed as close to the injury as possible. In cases of
extravasation from the main renal artery, a covered stent may be deployed. If
this is suspected based on CT findings or clinical status, starting with a longer
6-Fr or 7-Fr sheath or shaped guiding catheter, which can be advanced to the
renal artery ostium for stent delivery, will save time. As described earlier,
main renal artery embolization may be required in renal hilar injuries; close
communication between the interventional radiologist and trauma surgeon is
particularly important in these cases to determine the optimal course of
action.
Results
Reported outcomes of transarterial embolization for renal vascular injury are
excellent and demonstrate the effectiveness of this therapy in fulfilling the
dual goals of hemostasis and preservation of renal function. In a series of five
patients with nontraumatic arterial injury and pseudoaneurysm who
underwent transarterial coil embolization, Poulakis et al.53 demonstrated
100% success rate in cessation of bleeding and return to preinjury creatinine
values. Average estimated area of renal infarct in follow-up CT was 5%.
53
Segmental renal arteries are considered end arteries, so infarcts typically
occur after renal angioembolization, but they tend to be subclinical and are
reported to decrease in size over time.
64,65
This process may represent
collateral blood flow restoring perfusion to initially ischemic parenchyma
(i.e., these may not actually be true end arteries) or contraction of scar
tissue.65 There is a significant association between OIS grade based on initial
CT and decrease in renal function in patients managed expectantly with or
without embolization, with overall poor functional outcome in grade V as
well as certain grade IV injuries.
66,67
One may therefore conclude that
embolization in grade V injuries is unlikely to significantly affect the degree
of renal function preservation. Several studies have demonstrated that
superselective angioembolization of renal arterial injuries does not result in a
clinically significant long-term decrease in renal function.
53,64,65
Huber et al.68 analyzed 26 studies of renal embolization for traumatic
and nontraumatic hemorrhage and found 89% primary success rate and 82%
success rate in repeat angioembolization for those who failed the initial
therapy. In patients who failed angioembolization and did not undergo repeat
attempt, 100% underwent nephrectomy. Based on this data, they concluded
that patients who fail angioembolization should undergo a repeat session
instead of laparotomy.68 In the largest such study of renal trauma patients to
date, Hotaling et al.69 analyzed NTDB data of renal injuries from 2002 to
2007 and also found high success rates for repeat angioembolization.
Finally, the type of renal vascular injury, penetrating versus blunt, may
play a role in outcomes of expectant management and influence the decision
to intervene. Specifically, penetrating renal trauma may require a more
aggressive approach due to the higher likelihood of arterial laceration. This
was the conclusion of Muir et al.70 who reported a 20% failure of observation
in penetrating renal trauma and support the use of early angiography in this
setting. In a study by Bjurlin et al.71 reviewing 98 penetrating renal injuries,
selective NOM resulted in lower mortality rate, shorter mean intensive care
unit and hospital stays, and fewer blood transfusions compared with
nephrectomy; angioembolization was not a part of the protocol at their
institution. Most of the cited studies of renal trauma did not substratify
patients based on mechanism of injury.
TIPS AND TRICKS
• Microcatheters should be used for superselective coil occlusion to
preserve renal function.
THORACIC TRAUMA
BACKGROUND AND PATIENT SELECTION
Blunt and penetrating thoracic trauma often results in persistent intrathoracic
hemorrhage and hemothorax, for which exploratory thoracotomy has
historically been the “gold standard” treatment.72 However, many patients are
poor candidates for surgery due to associated injuries or comorbidities. In
patients with slow or intermittent arterial bleeding, thoracotomy may fail to
identify and control the source.
72,73
Excluding injuries to the aorta and great
vessels, which are also often treated endovascularly with stent grafts, a
common cause of hemothorax is intercostal arterial injury, which is well
suited to transcatheter embolization. Compared with the literature regarding
solid organ injury, embolization for thoracic trauma has received little
attention. Several case reports and small retrospective series have
demonstrated its safety and effectiveness.
72–75
Up to 85% of patients who survive blunt or penetrating thoracic trauma
require only conservative measures, including tube thoracostomy, adequate
volume resuscitation, and serial chest radiographs.72 Chest tube output of
between 500 and 1,000 mL over a defined period is considered a threshold
for thoracotomy.74 In keeping with the theme of this chapter, transarterial
embolization is an effective alternative in the hemodynamically stable patient
and can obviate the need for thoracotomy.
According to Hagiwara et al.,
74
common causes of hemothorax after
thoracic trauma are intercostal arterial lacerations and pulmonary lacerations.
Differentiating between the two is important in the patient with significant
chest tube output (>200 mL per hour) because embolization would not be
helpful if the bleeding is secondary to pulmonary laceration. In their study of
154 patients who underwent contrast-enhanced CT, contrast extravasation
and large displacement of a fractured rib were associated with intercostal
arterial injury, and 5 out of 5 of these patients were successfully embolized.
74
Their findings support CT in patients with chest tube output of greater than
200 mL per hour and embolization if there is contrast extravasation on CT.
74
Other authors rely on chest tube output or hemoglobin and less on CT
findings.
72,73
TECHNIQUE
Intercostal arteries as well as bronchial arteries are not typically well seen
with aortography given their small size. Reverse curve catheters such as
Mikaelsson are often used. The intercostal arteries are small, and at times, 5Fr may be too large to actually select the artery; in these cases, a microwire
and microcatheter may be advanced coaxially into the artery. If extravasation
or pseudoaneurysm is identified, superselective catheterization with microcoil
embolization and/or particles is performed. Achieving hemostasis may be
difficult because of collateral flow via internal mammary, musculophrenic,
inferior phrenic, and adjacent intercostal arteries that can cause rebleeding.
73
Thus, if there is injury to the intercostal artery with extravasation or
pseudoaneurysm, coils should be placed distal (Fig. 22.5) and proximal to the
injury and consideration should be given to occluding the adjacent intercostal
artery as well.73 If the source of bleeding is ventral, then the internal
mammary artery should be interrogated; this will also allow imaging of the
musculophrenic artery, which is a branch of the internal mammary. The
inferior phrenic artery may also anastomose with lower anterior intercostal
arteries. The use of particles should be reserved for cases in which
superselective catheterization is unsuccessful. This also requires particular
caution because anterior segmental medullary arteries arise from various
posterior intercostal arteries and supply portions of the anterior spinal cord. If
these arteries are occluded, paralysis will likely result, the extent of which
depends on the level of the spinal cord affected. The largest, or major,
anterior segmental medullary artery (artery of Adamkiewicz) is typically
present at the level of T10 on the left, but it may arise anywhere from T8 to
T12, and embolization of this artery will cause anterior spinal cord ischemia
and bilateral lower extremity paralysis.
76
Catheterization of the internal mammary artery and other small branches
of the subclavian artery such as the pectoral or lateral thoracic arteries may be
difficult, often requiring placement of a 90-cm sheath or ipsilateral access via
the radial or brachial artery. If access is via the femoral artery, an arch
aortogram may be useful, particularly in older patients who may have
difficult arch anatomy.
RESULTS
There is a paucity of series examining arterial embolization after thoracic
trauma. Retrospective studies by Carrillo et al.72 and Chemelli et al.,73 cited
earlier, demonstrate feasibility and efficacy of embolization in blunt and
penetrating chest injuries, predominantly involving intercostal and internal
mammary arterial injuries. Injuries to other anterior thoracic arteries
originating from the subclavian artery, such as pectoral and lateral thoracic
arteries, may be considered in the same category. The larger study by
Chemelli et al.73 demonstrated 87.5% primary technical success rate of
arterial embolization in a combination of traumatic and iatrogenic thoracic
injuries. Other literature is largely limited to case reports involving, for
example, pulmonary artery pseudoaneurysms77 (which most commonly result
from iatrogenic injury), esophageal hematoma,78 and a report by Hagiwara
and Iwamoto75 of successful embolization of bleeding from thoracic vertebral
fractures via intercostal arteries.
These cases, relatively rare compared to solid organ injuries of the
abdomen, do not lend themselves well to large retrospective studies.
However, the basic principles and techniques of embolization are the same.
The most significant variables in thoracic cases are the location of injury and
presence of collateral vessels, which may cause rebleeding. When
superselective catheterization is possible, every attempt should be made to
exclude the injury by deploying coils across (distal and proximal to) the
injury.
TIPS AND TRICKS
Thorax
• For bronchial or intercostal artery embolization, look for branches
with the “hairpin turn” of the anterior segmental medullary arteries;
embolization proximal to these arteries must be avoided as it may
cause anterior spinal cord ischemia, which can lead to paralysis.
General
• When embolizing traumatic pseudoaneurysms, the injured artery
should be embolized from a point just distal to the pseudoaneurysm to
a point just proximal to the pseudoaneurysm to completely exclude
the area of injury.
REFERENCES
1. Tinkoff G, Esposito TJ, Reed J, et al. American Association for the
Surgery of Trauma Organ Injury Scale I: spleen, liver, and kidney,
validation based on the National Trauma Data Bank. J Am Coll Surg.
2008;207:646–655.
2. Esposito TJ, Tinkoff G, Reed J, et al. American Association for the
Surgery of Trauma Organ Injury Scale (OIS): past, present, and future. J
Trauma Acute Care Surg. 2013;74:1163–1174.
3. Moore EE, Cogbill TH, Jurkovich GJ, et al. Organ injury scale: spleen
and liver (1994 revision). J Trauma. 1995;38:323–324.
4. Barquist ES, Pizano LR, Feuer W, et al. Inter- and intra-rater reliability
in computed axial tomographic grading of splenic injury: why so many
grading scales? J Trauma. 2004;56:334–338.
5. Marmery H, Shanmuganathan K, Alexander MT, et al. Optimization of
selection for nonoperative management of blunt splenic injury:
comparison of MDCT grading systems. AJR Am J Roentgenol.
2007;189:1421–1427.
6. Dugi DD, Morey AF, Gupta A, et al. American Association for the
Surgery of Trauma grade 4 renal injury substratification into grades 4a