Transcatheter arterial embolization for severe blunt liver injury in hemodynamically unstable patients: a 15-year retrospective study

Background Transcatheter arterial embolization (TAE) is the first-line nonsurgical treatment for severe blunt liver injury in patients, whereas operative management (OM) is recommended for hemodynamically unstable patients. This study investigated the comparative efficacy of TAE in hemodynamically unstable patients who responded to initial infusion therapy. Methods This retrospective study enrolled patients with severe blunt liver injuries, which were of grades III–V according to the American Association for the Surgery of Trauma Organ Injury Scale (OIS). Patients who responded to initial infusion therapy underwent computed tomography to determine the treatment plan. A shock index > 1, despite undergoing initial infusion therapy, was defined as hemodynamic instability. We compared the clinical outcomes and mortality rates between patients who received OM and those who underwent TAE. Results Sixty-two patients were included (eight and 54 who underwent OM and TAE, respectively; mean injury severity score, 26.6). The overall in-hospital mortality rate was 6% (13% OM vs. 6% TAE, p = 0.50), and the hemodynamic instability was 35% (88% OM vs. 28% TAE, p < 0.01). Hemodynamically unstable patients who underwent TAE had 7% in-hospital mortality and 7% clinical failure. Logistic regression analysis showed that the treatment choice was not a predictor of outcome, whereas hemodynamic instability was an independent predictor of intensive care unit stay ≥7 days (odds ratio [OR], 3.80; p = 0.05) and massive blood transfusion (OR, 7.25; p = 0.01); OIS grades IV–V were predictors of complications (OR, 6.61; p < 0.01). Conclusions TAE in hemodynamically unstable patients who responded to initial infusion therapy to some extent has acceptable in-hospital mortality and clinical failure rates. Hemodynamic instability and OIS, but not treatment choice, affected the clinical outcomes.

Transcatheter arterial embolization of severe blunt liver injury in hemodynamically unstable patients: a retrospective 15-year study

Background Non-operative management with Transcatheter arterial embolization(TAE) was the first line of treatment for severe blunt liver injury in hemodynamically stable patients, but in the case of hemodynamically unstable, Operative management(OM) was recommended. We evaluated the efficacy of TAE in our hospital where intervention radiology was available 24 hours a day if the patient responds to initial infusion therapy even unstable.Methods We conducted a retrospective study of severe blunt liver injury of AAST Organ Injury Scale(OIS) grade 3–5 transported to our hospital between 2005 and 2019. If the patient responded to initial infusion therapy, even though hemodynamically unstable(Shock Index ≧ 1), CT was taken and initial treatment was decided. We compared patients who underwent OM or TAE on initial treatment.Results 62 patients were included (8 OM, 54 TAE), with a mean ISS of 26.6, in hospital mortality of 6%(13% OM VS 6% TAE, p = 0.50), hemodynamically unstable of 35% (88% OM VS 28% TAE, p < 0.01) and Time from Door to start OM/TAE 81.8 min(120.0 OM VS 76.1 TAE, p = 0.02). Unstable patients who undergo TAE were associated with 7% in hospital mortality and 7% clnical failure. After logistic regression the choice of treatment was not a predictor of outcome, the predictor of in-hospital mortality death was GCS on arrival(OR0.48, P < 0.01), hemodynamically unstable was independent predictor of duration of ICU ≧ 7 days(OR 3.80, p = 0.05) and massive blood transfusion(OR 7.25, p = 0.01). the predictor of complication was OIS grade4-5(OR 6.61 p < 0.01).Conclusions The strategy of performing TAE even in the presence of hemodynamically unstable in a facility where TAE can be performed promptly was acceptable mortality and clinical failure. The choice of treatment did not affect the outcome, and hemodynamically unstable and OIS affected the prognosis.

Reversing Dabigatran Anticoagulation with Prothrombin Complex Concentrate versus Idarucizumab as Part of Multimodal Hemostatic Intervention in an Animal Model of Polytrauma

Background Although idarucizumab is the preferred treatment for urgent dabigatran reversal, it is not always available. Prothrombin complex concentrate (PCC) may be an alternative and, with bleeding in trauma, additional hemostatic therapy may be required. The authors investigated multimodal treatment in a preclinical polytrauma model. Methods Dabigatran etexilate (30 mg/kg twice daily) was given orally to 45 male pigs for 3 days. On day 4, animals received a dabigatran infusion before blunt liver injury and bilateral femur fractures. After injury, animals were randomized 1:1:1:1:1 to receive placebo (control), tranexamic acid (TXA; 20 mg/kg) plus human fibrinogen concentrate (FCH; 80 mg/kg) (TXA–FCH group), PCC (25 U/kg or 50 U/kg) plus TXA plus FCH (PCC25 and PCC50 groups), or 60 mg/kg idarucizumab (IDA) plus TXA plus FCH (IDA group). Animals were monitored for 240 min after trauma, or until death. Results The degree of injury was similar in all animals before intervention. Control and TXA–FCH animals had the highest total postinjury blood loss (3,652 ± 601 and 3,497 ± 418 ml) and 100% mortality (mean survival time 96 and 109 min). Blood loss was significantly lower in the PCC50 (1,367 ± 273 ml) and IDA (986 ± 144 ml) groups, with 100% survival. Thrombin–antithrombin levels and thrombin generation were significantly elevated in the PCC50 group. Conclusions Idarucizumab may be considered the optimal treatment for emergency reversal of dabigatran anticoagulation. However, this study suggests that PCC may be similarly effective as idarucizumab and could therefore be valuable when idarucizumab is unavailable. (Anesthesiology 2017; 127:852-61)

Traumatic Intraparenchymal Pseudoaneurysm on Initial Imaging Predicts Injury Progression in Patients with Nonoperative Major Blunt Liver Injury

Objective: Identify factors that would predict which patients would benefit from repeat imaging after major blunt liver injury. Summary of Background Data: Most patients who present with hemodynamic stability and no evidence of peritonitis after blunt liver injury are successfully managed nonoperatively. Little information is available regarding the utility of reimaging major blunt liver injuries for patients who are managed nonoperatively. Methods: A retrospective review of patients admitted to a level I trauma center with major blunt liver injuries (AAST grades 3-5) was conducted. Inclusion criteria were those admitted from July 2012 to June 2014 with blunt liver trauma who survived the first 24 hours and underwent repeat imaging. Data included demographics, procedures performed and computerized tomography (CT) scan findings. Findings on the second CT scan were categorized as Unchanged, Worse, Improved, or Negative. Results: 128 patients had blunt major liver injuries; 66 patients underwent repeat imaging. The mean time to repeat CT was 1.95 days. On repeat CT 47 were "Unchanged", 3 "Worse", 14 "Improved" and 2 "Negative". Three patients underwent angiography. One required embolization of a pseudoaneurysm. In 63 patients (95%), the second CT did not change the management plan. The presence of a pseudoaneurysm was significantly related to a worsening of the second CT (p=0.0475). Patients with admission hematocrit (Hct) below 32% were more likely to have a worsened second CT (p=0.0370). Conclusions: A pseudoaneurysm on admission CT and Hct &lt;32% predict major liver injury progression suggesting that routine reimaging is warranted in this group.