Objectives : The aims of this study were to determine if angiographic findings can be used to predict successful nonoperative therapy of splenic injury and to determine if coil embolization of the proximal splenic artery provides effective hemostasis. Methods : Splenic injuries detected by diagnostic imaging between 1981 and 1993 at a level I trauma center were prospectively collected and retrospectively reviewed after management by protocol that used diagnostic peritoneal lavage, computed tomography (CT), angiography, transcatheter embolization, and laparotomy. Computed tomography was performed initially or after positive diagnostic peritoneal lavage. Angiography was performed urgently in stabilized patients with CT-diagnosed splenic injuries. Patients without angiographic extravasation were treated by bed rest alone ; those with angiographic extravasation underwent coil embolization of the proximal splenic artery followed by bed rest. Results : Patients (172) with blunt splenic injury are the subject of this study. Twenty-two patients were initially managed operatively because of associated injuries or disease (11 patients) or because the surgeon was unwilling to attempt nonoperative therapy (11 patients) and underwent splenectomy (17 patients) or splenorrhaphy (5 patients). One hundred fifty of 172 consecutive patients (87%) with CT-diagnosed splenic injury were stable enough to be considered for nonoperative management. Eighty-seven of the 90 patients managed by bed rest alone, and 56 of 60 patients treated by splenic artery occlusion and bed rest had a successful outcome. Overall splenic salvage was 88%. It was 97% among those managed nonoperatively, including 61 grade III and grade IV splenic injuries. Sixty percent of patients received no blood transfusions. Three of 150 patients treated nonoperatively underwent delayed splenectomy for infarction (one patient) or splenic infection (two patients). Conclusions : (1) Hemodynamically stable patients with splenic injuries of all grades and no other indications for laparotomy can often be managed nonoperatively, especially when the injury is further characterized by arteriography. (2) The absence of contrast extravasation on splenic arteriography seems to be a reliable predictor of successful nonoperative management. We suggest its use to triage CT-diagnosed splenic injuries to bed rest or intervention. (3) Coil embolization of the proximal splenic artery is an effective method of hemostasis in stabilized patients with splenic injury. It expands the number of patients who can be managed nonoperatively.

Nonoperative salvage of computed tomography-diagnosed splenic injuries: utilization of angiography for triage and embolization for hemostasis.

PURPOSE: To evaluate superselective embolization therapy for the management of arterial damage in patients with severe renal trauma. MATERIALS AND METHODS: Nine consecutive patients with renovascular injuries after blunt trauma underwent superselective embolization. Six patients had pseudoaneurysms or traumatic arteriovenous fistulas. Three patients had frank, uncontained extravasation (two shattered kidneys, one complete pedicle avulsion) and were treated immediately after admission. Two patients were hemodynamically unstable. All patients underwent embolization with 3-F coaxial microcatheters and polyvinyl alcohol particles (n = 2) or 0.018-inch platinum microcoils (n = 7). Procedural and medical success and complications (eg, postembolization syndrome, abscess, permanent serum creatinine elevation, hypertension) were retrospectively assessed from the patients’ records. Mean clinical follow-up was 11.9 months (range, 1–50 months). RESULTS: In all cases bleeding was effectively controlled with superselec...

Blunt Renal Trauma: Minimally Invasive Management with Microcatheter Embolization—Experience in Nine Patients

Historical accounts of small bowel injuries from blunt abdominal trauma are numerous and date from as early as Aristotle in 350 b.c. [1,2]. The majority of reports of gastrointestinal tract injuries (GITIs) relate experiences dominated by penetrating trauma. Injuries to the gastrointestinal tract resulting from penetrating trauma are common, with 80% of gunshot wounds to the abdomen and 30% of fully penetrating stab wounds causing significant injury to the GIT [3–5]. GITIs are much less common following blunt trauma. There are few reports in the literature which describe reports of the management and outcome from these injuries [6–14]. Nevertheless, the GIT is the third most commonly injured abdominal organ in blunt trauma [6,15–17] with major GITIs found in 5–17% of laparotomies for blunt trauma [7,9,16,18–24] and 0.35–2% of blunt trauma admissions having a major GITI [9,15,23,25,26]. The incidence of GITIs rose steeply with the introduction of high speed travel after World War II [16,27] and was then documented to increase further with the introduction of seat belts [15]. The mechanism involved with seat belts is believed to be the creation of closed loops of bowel as a result of compression and subsequent rupture from increased intraluminal pressure [7,15,16]. Blunt GITIs are undoubtedly injuries of young males [6,8,10,12,19,20,22,25,8–31]. The incidence of major blunt GITIs amongst paediatric admissions for blunt abdominal trauma has been reported to be greater than for adults [32–34]. Motor vehicle occupants account for rates of 70–85% of patients with major GITIs [6,10,12,19,30,34,35]. In such cases, the rapid deceleration results in multiple serious injuries. The reported incidence of non-vehicular blunt trauma as a cause of GITI is 5–32% [6,9,10,19,36]. Non-vehicular trauma includes assaults, falls, industrial accidents, blasts,

The pathophysiology and management of bowel and mesenteric injuries due to blunt trauma

Ultrasonography for the initial evaluation of blunt abdominal trauma: A review of prospective trials.

Background Severe pelvic fractures continue to be a major problem for trauma surgeons. Early identification of patients who would benefit from therapeutic angiographic embolization (AE) of pelvic bleeding would be beneficial. We hope to identify simple risk factors that would pinpoint patients who would benefit from therapeutic AE. Study Design This is a prospective observational study at an academic Level I trauma center. All blunt trauma patients with a pelvic fracture admitted from December 2003 to February 2007 were included. AE was performed for hemodynamic instability (systolic blood pressure Results One hundred thirty-seven (23%) of 603 patients with pelvic fractures had angiography. Therapeutic AE was performed in 85 patients (62%). Indications for angiography included hemodynamic instability (58%), fracture pattern (26%), and CT findings (9%). Nineteen patients (22%) with therapeutic AE had no hypotension or tachycardia. Independent predictors for therapeutic AE were SIJ disruption (odds ratio [OR]: 4.5; 95% CI, 1.6 to 12.6; p=0.005), female gender (OR: 3.9; 95% CI, 1.5 to 10.0; p=0.005), and duration (in minutes) of systolic blood pressure Conclusions Presence of SIJ disruption, female gender, and duration of hypotension can reliably predict patients who would benefit from AE. This predictive model can help early identification of patients who would benefit from pelvic angiography.

https://www.journalacs.org/article/S1072-7515(08)00584-X/pdf

Ernst E Vieux

Papers

Nonoperative management of blunt abdominal trauma: The role of sequential diagnostic peritoneal lavage, computed tomography, and angiography