Selective Angioembolization in Blunt Solid Organ Injury in Children and Adolescents: Review of Recent Literature and Own Experiences

 

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Abstract

Nonoperative management (NOM) is considered the standard therapy for clinically stable children with blunt solid organ injuries (SOI) grade I to IV. The capability of angioembolization (AE) to decrease the NOM failure rate in adults with blunt SOI has been demonstrated. The inclusion of AE in the pediatric SOI management is rarely reported. The aim of this review is to evaluate the recent literature surrounding trauma-related AE in children focusing on criteria for patient selection for AE and on the success rates including the greater experience in adults and on our own little series with splenic and renal injuries at a Level 1 Trauma Center. The technique will be described in detail. Although already added to some institutional treatment protocols patient selection for AE is still without full consent. High-grade injury, active bleeding with contrast blush on computed tomography, threatening, or ongoing hemodynamic instability and pseudoaneurysm represent the most common criteria to admit AE. Patients' characteristics are often similar to those of NOM failure groups in trauma managements protocols without AE. The impact of this interventional approach is situated between the possibility for NOM in the obvious stable child and the need for open surgery in the obvious unstable patient with grade IV to grade V SOI. There is evidence that AE is capable to decrease the failure rate and complications in the NOM. Although available data are based on cohort studies rather than prospective randomized-controlled trials, we conclude, AE represents a safe and effective therapy and should be part of the interdisciplinary trauma management protocol for SOI in children and adolescents.

• References

• 1 Upadhyaya P, Simpson JS. Splenic trauma in children. Surg Gynecol Obstet 1968; 126 (4) 781-790
  PubMedGoogle Scholar
• 2 Upadhyaya P, Nayak NC, Moitra S. Experimental study of splenic trauma in monkeys. J Pediatr Surg 1971; 6 (6) 767-773
  CrossrefPubMedGoogle Scholar
• 3 Moore EE, Shackford SR, Pachter HL , et al. Organ injury scaling: spleen, liver, and kidney. J Trauma 1989; 29 (12) 1664-1666
  CrossrefPubMedGoogle Scholar
• 4 Stylianos S ; The APSA Trauma Committee. Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury. J Pediatr Surg 2000; 35 (2) 164-167 , discussion 167–169
  CrossrefPubMedGoogle Scholar
• 5 Margenthaler JA, Weber TR, Keller MS. Blunt renal trauma in children: experience with conservative management at a pediatric trauma center. J Trauma 2002; 52 (5) 928-932
  CrossrefPubMedGoogle Scholar
• 6 Umbreit EC, Routh JC, Husmann DA. Nonoperative management of nonvascular grade IV blunt renal trauma in children: meta-analysis and systematic review. Urology 2009; 74 (3) 579-582
  CrossrefPubMedGoogle Scholar
• 7 Jacobs MA, Hotaling JM, Mueller BA, Koyle M, Rivara F, Voelzke BB. Conservative management vs early surgery for high grade pediatric renal trauma—do nephrectomy rates differ?. J Urol 2012; 187 (5) 1817-1822
  CrossrefPubMedGoogle Scholar
• 8 Saltzherr TP, van der Vlies CH, van Lienden KP , et al. Improved outcomes in the non-operative management of liver injuries. HPB (Oxford) 2011; 13 (5) 350-355
  CrossrefPubMedGoogle Scholar
• 9 van der Wilden GM, Velmahos GC, Joseph DK , et al. Successful nonoperative management of the most severe blunt renal injuries: a multicenter study of the research consortium of new England centers for trauma. JAMA Surg 2013; 148 (10) 924-931
  CrossrefPubMedGoogle Scholar
• 10 Bhullar IS, Frykberg ER, Siragusa D , et al. Age does not affect outcomes of nonoperative management of blunt splenic trauma. J Am Coll Surg 2012; 214 (6) 958-964
  CrossrefPubMedGoogle Scholar
• 11 Sclafani SJ. The role of angiographic hemostasis in salvage of the injured spleen. Radiology 1981; 141 (3) 645-650
  CrossrefPubMedGoogle Scholar
• 12 van der Vlies CH, van Delden OM, Punt BJ, Ponsen KJ, Reekers JA, Goslings JC. Literature review of the role of ultrasound, computed tomography, and transcatheter arterial embolization for the treatment of traumatic splenic injuries. Cardiovasc Intervent Radiol 2010; 33 (6) 1079-1087
  CrossrefPubMedGoogle Scholar
• 13 Olthof DC, van der Vlies CH, Joosse P, van Delden OM, Jurkovich GJ, Goslings JC ; PYTHIA Collaboration Group. Consensus strategies for the nonoperative management of patients with blunt splenic injury: a Delphi study. J Trauma Acute Care Surg 2013; 74 (6) 1567-1574
  CrossrefPubMedGoogle Scholar
• 14 Stassen NA, Bhullar I, Cheng JD , et al; Eastern Association for the Surgery of Trauma. Selective nonoperative management of blunt splenic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012; 73 (5, Suppl 4): S294-S300
  CrossrefPubMedGoogle Scholar
• 15 Gross JL, Woll NL, Hanson CA. Embolization for pediatric blunt splenic injury is an alternative to splenectomy when observation fails. J Trauma Acute Care Surg 2013; 75 (3) 421-425
  CrossrefPubMedGoogle Scholar
• 16 Ben-Ishay O, Gutierrez IM, Pennington EC, Mooney DP. Transarterial embolization in children with blunt splenic injury results in postembolization syndrome: a matched case-control study. J Trauma Acute Care Surg 2012; 73 (6) 1558-1563
  CrossrefPubMedGoogle Scholar
• 17 Kiankhooy A, Sartorelli KH, Vane DW, Bhave AD. Angiographic embolization is safe and effective therapy for blunt abdominal solid organ injury in children. J Trauma 2010; 68 (3) 526-531
  CrossrefPubMedGoogle Scholar
• 18 Skattum J, Gaarder C, Naess PA. Splenic artery embolisation in children and adolescents-An 8 year experience. Injury 2012; Nov 5. pii: S0020-1383(12)00464-0. doi: 10.1016/j.injury.2012.10.015. [Epub ahead of print]
  PubMedGoogle Scholar
• 19 Moore HB, Vane DW. Long-term follow-up of children with nonoperative management of blunt splenic trauma. J Trauma 2010; 68 (3) 522-525
  CrossrefPubMedGoogle Scholar
• 20 Matsushima K, Kulaylat AN, Won EJ, Stokes AL, Schaefer EW, Frankel HL. Variation in the management of adolescent patients with blunt abdominal solid organ injury between adult versus pediatric trauma centers: an analysis of a statewide trauma database. J Surg Res 2013; 183 (2) 808-813
  CrossrefPubMedGoogle Scholar
• 21 Holmes IV JH, Wiebe DJ, Tataria M , et al. The failure of nonoperative management in pediatric solid organ injury: a multi-institutional experience. J Trauma 2005; 59 (6) 1309-1313
  CrossrefPubMedGoogle Scholar
• 22 Davies DA, Pearl RH, Ein SH, Langer JC, Wales PW. Management of blunt splenic injury in children: evolution of the nonoperative approach. J Pediatr Surg 2009; 44 (5) 1005-1008
  CrossrefPubMedGoogle Scholar
• 23 van der Vlies CH, Saltzherr TP, Wilde JC, van Delden OM, de Haan RJ, Goslings JC. The failure rate of nonoperative management in children with splenic or liver injury with contrast blush on computed tomography: a systematic review. J Pediatr Surg 2010; 45 (5) 1044-1049
  CrossrefPubMedGoogle Scholar
• 24 Dobremez E, Lefevre Y, Harper L , et al. Complications occurring during conservative management of splenic trauma in children. Eur J Pediatr Surg 2006; 16 (3) 166-170
  Article in Thieme ConnectPubMedGoogle Scholar
• 25 Martin K, Vanhouwelingen L, Bütter A. The significance of pseudoaneurysms in the nonoperative management of pediatric blunt splenic trauma. J Pediatr Surg 2011; 46 (5) 933-937
  CrossrefPubMedGoogle Scholar
• 26 Nellensteijn D, Porte RJ, van Zuuren W, ten Duis HJ, Hulscher JB. Paediatric blunt liver trauma in a Dutch level 1 trauma center. Eur J Pediatr Surg 2009; 19 (6) 358-361
  Article in Thieme ConnectPubMedGoogle Scholar
• 27 Fitzgerald CL, Tran P, Burnell J, Broghammer JA, Santucci R. Instituting a conservative management protocol for pediatric blunt renal trauma: evaluation of a prospectively maintained patient registry. J Urol 2011; 185 (3) 1058-1064
  CrossrefPubMedGoogle Scholar
• 28 Nance ML. Abdominal trauma. In: Mattei P, ed. Fundamentals of Pediatric Surgery, 1st ed. New York, NY: Springer; 2011: 135-143
  CrossrefGoogle Scholar
• 29 Requarth JA, D'Agostino Jr RB, Miller PR. Nonoperative management of adult blunt splenic injury with and without splenic artery embolotherapy: a meta-analysis. J Trauma 2011; 71 (4) 898-903 , discussion 903
  CrossrefPubMedGoogle Scholar
• 30 Cloutier DR, Baird TB, Gormley P, McCarten KM, Bussey JG, Luks FI. Pediatric splenic injuries with a contrast blush: successful nonoperative management without angiography and embolization. J Pediatr Surg 2004; 39 (6) 969-971
  CrossrefPubMedGoogle Scholar
• 31 Velmahos GC, Toutouzas KG, Radin R, Chan L, Demetriades D. Nonoperative treatment of blunt injury to solid abdominal organs: a prospective study. Arch Surg 2003; 138 (8) 844-851
  CrossrefPubMedGoogle Scholar
• 32 Chen IC, Wang SC, Shih HC , et al. Spleen artery embolization increases the success of nonoperative management following blunt splenic injury. J Chin Med Assoc 2011; 74 (8) 341-344
  CrossrefPubMedGoogle Scholar
• 33 van der Vlies CH, Hoekstra J, Ponsen KJ, Reekers JA, van Delden OM, Goslings JC. Impact of splenic artery embolization on the success rate of nonoperative management for blunt splenic injury. Cardiovasc Intervent Radiol 2012; 35 (1) 76-81
  CrossrefPubMedGoogle Scholar
• 34 Banerjee A, Duane TM, Wilson SP , et al. Trauma center variation in splenic artery embolization and spleen salvage: a multicenter analysis. J Trauma Acute Care Surg 2013; 75 (1) 69-74 , discussion 74–75
  CrossrefPubMedGoogle Scholar
• 35 Sabe AA, Claridge JA, Rosenblum DI, Lie K, Malangoni MA. The effects of splenic artery embolization on nonoperative management of blunt splenic injury: a 16-year experience. J Trauma 2009; 67 (3) 565-572 , discussion 571–572
  CrossrefPubMedGoogle Scholar
• 36 Skattum J, Naess PA, Eken T, Gaarder C. Refining the role of splenic angiographic embolization in high-grade splenic injuries. J Trauma Acute Care Surg 2013; 74 (1) 100-103 , discussion 103–104
  CrossrefPubMedGoogle Scholar
• 37 Schnüriger B, Inaba K, Konstantinidis A, Lustenberger T, Chan LS, Demetriades D. Outcomes of proximal versus distal splenic artery embolization after trauma: a systematic review and meta-analysis. J Trauma 2011; 70 (1) 252-260
  CrossrefPubMedGoogle Scholar
• 38 Letoublon C, Morra I, Chen Y, Monnin V, Voirin D, Arvieux C. Hepatic arterial embolization in the management of blunt hepatic trauma: indications and complications. J Trauma 2011; 70 (5) 1032-1036, discussion 1036–1037 [discussion 1036–7]
  CrossrefPubMedGoogle Scholar
• 39 Lynch TH, Martínez-Piñeiro L, Plas E , et al; European Association of Urology. EAU guidelines on urological trauma. Eur Urol 2005; 47 (1) 1-15
  CrossrefPubMedGoogle Scholar
• 40 van der Vlies CH, Olthof DC, van Delden OM , et al. Management of blunt renal injury in a level 1 trauma centre in view of the European guidelines. Injury 2012; 43 (11) 1816-1820
  CrossrefPubMedGoogle Scholar
• 41 Stewart AF, Brewer Jr ME, Daley BJ, Klein FA, Kim ED. Intermediate-term follow-up of patients treated with percutaneous embolization for grade 5 blunt renal trauma. J Trauma 2010; 69 (2) 468-470
  CrossrefPubMedGoogle Scholar
• 42 Huber J, Pahernik S, Hallscheidt P , et al. Selective transarterial embolization for posttraumatic renal hemorrhage: a second try is worthwhile. J Urol 2011; 185 (5) 1751-1755
  CrossrefPubMedGoogle Scholar
• 43 Morita S, Inokuchi S, Tsuji T , et al. Arterial embolization in patients with grade-4 blunt renal trauma: evaluation of the glomerular filtration rates by dynamic scintigraphy with 99mTechnetium-diethylene triamine pentacetic acid. Scand J Trauma Resusc Emerg Med 2010; 18: 11-16
  CrossrefPubMedGoogle Scholar
• 44 Stassen NA, Bhullar I, Cheng JD , et al; Eastern Association for the Surgery of Trauma. Nonoperative management of blunt hepatic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012; 73 (5, Suppl 4) S288-S293
  CrossrefPubMedGoogle Scholar
• 45 Harbrecht BG, Ko SH, Watson GA, Forsythe RM, Rosengart MR, Peitzman AB. Angiography for blunt splenic trauma does not improve the success rate of nonoperative management. J Trauma 2007; 63 (1) 44-49
  CrossrefPubMedGoogle Scholar
• 46 Ekeh AP, Khalaf S, Ilyas S, Kauffman S, Walusimbi M, McCarthy MC. Complications arising from splenic artery embolization: a review of an 11-year experience. Am J Surg 2013; 205 (3) 250-254 , discussion 254
  CrossrefPubMedGoogle Scholar
• 47 van der Vlies CH, Saltzherr TP, Reekers JA, Ponsen KJ, van Delden OM, Goslings JC. Failure rate and complications of angiography and embolization for abdominal and pelvic trauma. J Trauma Acute Care Surg 2012; 73 (5) 1208-1212
  CrossrefPubMedGoogle Scholar
• 48 Fallon SC, Coker MT, Hernandez JA , et al. Traumatic hepatic artery laceration managed by transarterial embolization in a pediatric patient. J Pediatr Surg 2013; 48 (5) E9-E12
  PubMedGoogle Scholar
• 49 Ong CC, Toh L, Lo RH, Yap TL, Narasimhan K. Primary hepatic artery embolization in pediatric blunt hepatic trauma. J Pediatr Surg 2012; 47 (12) 2316-2320
  CrossrefPubMedGoogle Scholar
• 50 Saad DF, Gow KW, Redd D, Rausbaum G, Wulkan ML. Renal artery pseudoaneurysm secondary to blunt trauma treated with microcoil embolization. J Pediatr Surg 2005; 40 (11) e65-e67
  CrossrefPubMedGoogle Scholar
• 51 Safavi A, Beaudry P, Jamieson D, Murphy JJ. Traumatic pseudoaneurysms of the liver and spleen in children: is routine screening warranted?. J Pediatr Surg 2011; 46 (5) 938-941
  CrossrefPubMedGoogle Scholar
• 52 Skattum J, Loekke RJ, Titze TL , et al. Preserved function after angioembolisation of splenic injury in children and adolescents: A case control study. Injury 2012; Dec 13. pii: S0020-1383(12) 00485-8. doi: 10.1016/j.injury.2012.10.036. [Epub ahead of print]
  PubMedGoogle Scholar
• 53 Pirasteh A, Snyder LL, Lin R , et al. Temporal assessment of splenic function in patients who have undergone percutaneous image-guided splenic artery embolization in the setting of trauma. J Vasc Interv Radiol 2012; 23 (1) 80-82
  CrossrefPubMedGoogle Scholar
• 54 Charbit J, Manzanera J, Millet I , et al. What are the specific computed tomography scan criteria that can predict or exclude the need for renal angioembolization after high-grade renal trauma in a conservative management strategy?. J Trauma 2011; 70 (5) 1219-1227 , discussion 1227–1228
  CrossrefPubMedGoogle Scholar
• 55 Fu CY, Wu SC, Chen RJ , et al. Evaluation of need for operative intervention in blunt splenic injury: intraperitoneal contrast extravasation has an increased probability of requiring operative intervention. World J Surg 2010; 34 (11) 2745-2751
  CrossrefPubMedGoogle Scholar
• 56 Tinkoff G, Esposito TJ, Reed J , et al. American Association for the Surgery of Trauma Organ Injury Scale I: spleen, liver, and kidney, validation based on the National Trauma Data Bank. J Am Coll Surg 2008; 207 (5) 646-655
  CrossrefPubMedGoogle Scholar