During the five years study period, a total of 9000 patients sustained traumatic injuries admitted to the HTC. One hundred and seventy-five patients underwent angioembolization (1.9% of total trauma admissions). The majority were males (90%), and the mean age was 32.6±12.2 years. The most common mechanism of injury was blunt trauma in 95.4% of patients (Table 1).
The average ISS was 28±12.3. The majority presented initially with pulse rate 96.0±25.0 beat/min and the mean SI was 0.86±0.31. The median follow-up period was 215 days.
Endovascular angioembolization was used in SOI (liver, spleen, kidney, pancreas and adrenals) , for musculoskeletal injuries (pelvic , lumbar , retroperitoneal and others) and 2 cases of hollow viscus related bleeding (Gastric and superior mesenteric artery). The most common involved arteries were the splenic (31%), internal iliac artery (29%), and hepatic artery (25%). The rest of the places were sporadic or just a few.
Table 2 shows details of arterial embolization, timing, indication, location , type of embolic agent,complications and outcomes. Seventy-three percent of cases had successful NOM. In contrast, the pre-surgery angioembolization used in 10% and post-surgery in 15% and 2% had angioembolization before and after surgical interventions. The primary indication of angioembolization was based on CT findings i.e., active bleeding (51.7%) and blush (19.1%), presence of pseudo-aneurysm (12.6%) , and true aneurysm (1.7%) or intraoperative finding (active bleeding (14.9%).
Non-selective embolization (catheter placed in the main trunk) embolization in 23% , selective (catheter placed in 1st order) embolization of in 30% , superselective (catheter placed in 2nd or 3rd order) embolization in 34% and combined approach in 12%. In terms of the proximity to a given artery: proximal emboliztion was done in 47% and distal in 39% and both proximal and distal in 7%. Figure 1 shows examples of selectivity and proximity of angioembolization.
Table 2 shows the materials used for angioembolisation. Temporary material most commonly used in 57% (Gelfoam),while permanent materials such as coils was used in 23.1% .
The technical success rate was 93.7% correspond to the clinical success of 94.9% with a rebleeding rate of 5% ( in 9 cases) .
The angioembolization complications included infarction (extensive necrosis) in 6 patients (16%) and requied surgical debridement, infection in 7 cases (3 had an abscess), one case developed gall bladder necrosis and gangrene demanded subsequent cholecystectomy, and 2 cases had bowel gangrene (Table 2).
Massive transfusion protocol was activated in 34% of the cases, while blood transfusion use reported in 75% of the cases, with an average of 8 (1-79) units transfused. The average length of stay in ICU was 6 (1-57) days and in hospital was 13 (1-106) days. The overall mortality was 15% (26 cases), and there was no reported angiography related mortality.
Table3 and 4 compare the demography, clinical characteristics, and outcomes based on the anatomical arteries angio-embolized (hepatic , splenic, renal and pelvic). The hepatic cases had highr ISS, higher need for surgery (laparotomy) and blood transfusion. Also, the hepatic group was more likely to be embolized prior to surgery and had prolonged ICU and hospital stay in comparison to other groups (p=0.001). On the other hand, one-third of the patients in renal group underwent embolization after surgery (p=0.001).
The splenic artery cases were the larger group but with lower ISS, only 2 needed laparotomy, 40% received blood and only 2 (4%) needed MTP. The pelvic group were the second lareger group, older in age, had lower male percentrage compared to others, laparotomy needed in12 (23.5%), MTP was needed in 49% and blood transfusion was used in 96% .
While the renal embolization was performed in 6 young male patients with higher blood unit usage, active bleeding on CT scan was the only indication for the angioembolization with higher mortality (33%) among the groups.
Technical failure reported in 3 of the hepatic (7.3%), and one of the splenic (1.9%), non reported in the pelvic or renal angioembolized patients. Shock index ≥0.80 was more evident with hepatic (63%), pelvic (58.5%), renal (50%) and splenic group (32%); p=0.04.
Single session of angioembolization was the most common in the cohort. The Absorbable embolic agent (Gelfoam) was the most commonly used material for embilization .
The technical and clinical success were 86% for hepatic cases, 100% for pelvic and 83.3% for renal injury cases. Few cases had a rebleed mainly in the hepatic group (6 cases), two patients in the splenic and one in the renal group.
Time to angioembolization in SOI and pelvic injury was given in Table 5.
Overall complications were rare; one case had femoral pseudoaneurysm and the procedure was well tolerated. Infarction demanding surgical intervention was noticed in 4 hepatic cases and one splenic case. All infarcted cases had a sort of infection and one of them had liver abscess. Only one case of hepatic angioemolization had gall bladder necrosis and needed open cholecystectomy and one case had bowel ischemia following mesenteric angioembolization. The open abdomen (Damage control surgery; DCS) approach was used in 9 of the hepatic cases , 8 of the pelvic cases and 2 of the renal while the splenic group had zero DCS. During the follow-up period (median 215 days), there was no reported mortality.