Clinical ResearchUnstable Patients With Retroperitoneal Vascular Trauma: An Endovascular Approach
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.
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Cited by (17)
The injury patterns, management and outcomes of retroperitoneal haemorrhage caused by lumbar arterial bleeding at a Level-1 Trauma Centre: A 10-year retrospective review
2023, InjuryCitation Excerpt :Due to anatomical complexities and concurrent traumatic injuries, RPH is often difficult to access and control surgically [6,7]. In particular, the lumbar arteries (1st to 4th) (LA), are prone to laceration and non-cavitary bleeding following injury, and these vessels can be difficult or impossible to access during laparotomy [8–11]. Early diagnosis and management can reduce mortality rates associated with RPH [12].
Management of complicated lumbar artery injury after blunt trauma
2011, Annals of Emergency MedicineCitation Excerpt :The mortality rate was 50% in our study, though the amount directly attributed to the lumbar artery injury is uncertain, given the multiple injuries. In the literature, the mortality rate of unstable traumatic retroperitoneal hemorrhage is approximately 17.6% to 47%.6,9 In this series, concomitant head injury was associated with mortality.
American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of abdominal vascular injuries
2020, Journal of Trauma and Acute Care SurgeryImpact of contrast extravasation on computed tomography of the psoas major muscle in patients with blunt torso trauma
2019, Journal of Trauma and Acute Care SurgeryEmbolization and its limits: Tips and tricks
2019, Journal of Endovascular Resuscitation and Trauma Management