Clinical Research
Unstable Patients With Retroperitoneal Vascular Trauma: An Endovascular Approach

https://doi.org/10.1016/j.avsg.2010.09.008Get rights and content

Background

In hemodynamically unstable patients, the management of retroperitoneal vascular trauma is both difficult and challenging. Endovascular techniques have become an alternative to surgery in several trauma centers.

Methods

Between 2004 and 2006, 16 patients (nine men, mean age: 46 years, range: 19-79 years) with retroperitoneal vascular trauma and hemodynamic instability were treated using an endovascular approach. The mean injury severity score was 30.7 ± 13.1. Mean systolic blood pressure and the shock index were 74 mm Hg and 1.9, respectively. Vasopressor drugs were required in 68.7% of cases (n = 11). Injuries were attributable to road traffic accidents (n = 15) and falls (n = 1). The hemorrhage sites included the internal iliac artery or its branches (n = 12) with bilateral injury in one case, renal artery (n = 2), abdominal aorta (n = 1), and lumbar artery (n = 1).

Results

In all, 14 coil embolizations and three stent-grafts were implanted. The technical success rate was 75%, as early re-embolization was necessary in one case and three patients died during the perioperative period. Six patients died during the period of hospitalization (37.5%). No surgical conversion or major morbidity was reported.

Conclusion

In comparison with particulates, coil ± stent-graft may provide similar efficacy with regard to survival, and thus may be a valuable solution when particulate embolization is not available or feasible.

Introduction

Management of retroperitoneal vascular trauma, especially in unstable patients, is both difficult and very challenging, and it requires multidisciplinary protocols.1 Control of bleeding can be accomplished by either surgical or endovascular approaches.

Surgical hemostasis can be achieved either through surgical exploration of bleeding arteries and veins or through packing. The results of surgical exploration and primary repair in hemodynamically unstable patients are well known and associated with a high mortality rate, ranging from 30 to 80%,2 regardless of the localization of the lesions. The main explanation for this high mortality rate is linked to the opening of the retroperitoneum space, which leads to suppression of the tamponade effect, disruption of the hematoma, and destabilization of the patient.3

In stable patients, arteriographic embolization (AE) is being increasingly used in primary intention and has been shown to be effective for achieving hemostasis in intraperitoneal, retroperitoneal, or pelvic injuries;4, 5 stent-grafting has also been used to control bleeding.6 However, for patients with unstable hemodynamics, management is more challenging, and only a few series advocate the role and benefits of AE.7, 8, 9

The present retrospective study analyzes the results of coil embolization and stent-graft repair for these patients

Section snippets

Patients and Methods

Since 2004, we have defined a protocol for all patients with abdominal trauma admitted at our regional trauma center (Fig. 1). First, we determine the hemodynamic status of the patient by evaluating blood pressure and the amount of fluid resuscitation. Second, if the patient is hemodynamically unstable, abdominal sonography is performed to determine the best surgical approach; a laparotomy is used for cases in which a free intraperitoneal effusion is detected and an endovascular approach in its

Results

Arteriography was performed using a femoral access in all patients, except one with severe shock and a faint pulse, for whom a surgical groin cutdown was performed. Five patients (31%) were initially admitted to another hospital and then transferred to our trauma center. Only six patients (37.5%) underwent the hemostatic procedure within 3 hours of getting injured. After localizing the source of bleeding by selective or supraselective catheterization, we achieved hemostasis with coil

Discussion

The management of hemodynamically compromised patients with abdominal and/or pelvic trauma still remains challenging.1 Surgical repair in these conditions is difficult; first, because the dissection of the retroperitoneal space may lead to the release of tamponade effect and, second, because of the difficulty in controlling the often diffuse branch injuries coupled with the lack of efficacy of proximal ligation. This kind of surgical repair in hemodynamically unstable patients is associated

Conclusion

The current therapeutic management of posttraumatic retroperitoneal or pelvic bleeding in hemodynamically unstable patients is largely based on arterial embolization using particulates and coils. This study showed that coil and stent-graft approaches for these patients may have comparable efficacy with regard to survival. Therefore, these results suggest that the use of coils ± stent-graft may be a valuable solution when flow-directed particulate embolization is not available or feasible.

References (18)

  • A.T. Drooz et al.

    Quality improvement guidelines for percutaneous transcatheter embolization

    J Vasc Interv Radiol

    (2003)
  • G.C. Velmahos et al.

    Angiographic embolization for arrest of bleeding after penetrating trauma to the abdomen

    Am J Surg

    (1999)
  • M.F. Rotondo et al.

    The damage control sequence and underlying logic

    Surg Clin North Am

    (1997)
  • W. Ertel et al.

    Control of severe hemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption

    J Orthop Trauma

    (2001)
  • R. Ciombra et al.

    The ongoing challenge of retroperitoneal vascular injuries

    Am J Surg

    (1996)
  • Y.C. Wong et al.

    Mortality after successful transcatheter arterial embolization in patients with unstable pelvic fractures: rate of blood transfusion as a predictive factor

    J Trauma

    (2000)
  • G.C. Velmahos et al.

    A prospective study on the safety and efficacy of angiographic embolization for pelvic and visceral injuries

    J Trauma

    (2002)
  • G.C. Velmahos et al.

    Angiographic embolization for intraperitoneal and retroperitoneal injuries

    World J Surg

    (2000)
  • R. White et al.

    Results of a multicenter trial for the treatment of traumatic vascular injury with a covered stent

    J Trauma

    (2006)
There are more references available in the full text version of this article.

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