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Erschienen in:
13.06.2018 | Editorial
The role of interventional radiology in the management of hemodynamically compromised patients
Erschienen in: Intensive Care Medicine | Ausgabe 8/2018
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The minimally invasive nature of interventional radiology (IR), supported by the advances in imaging and improvements in endovascular techniques, has resulted in expansion of its role as an alternative option for medical, endoscopic, or surgical interventions. While IR procedures are currently incorporated in several medical, oncological, and surgical practice guidelines, the levels of recommendations mainly depend on low-quality evidence lacking long-term outcomes and comparison to other treatment options. In this editorial, we provide an overview of the emerging role of IR procedures in management of hemodynamically compromised patients based on current clinical practice guidelines, with a focus on life-threatening bleeding, massive and submassive pulmonary embolism (PE), and sepsis. A summary of the related clinical practice guidelines is presented in Table 1. Angiographic images of selected representative cases are shown in Online Supplement Fig. 1.
Table 1
Summary of clinical practice guidelines regarding the possible role of IR procedures in management of different conditions in critically ill patients
|
Condition
|
Clinical practice guideline
|
Recommendation
|
|---|---|---|
|
Peptic ulcer bleeding
|
American College of Gastroenterology (2012)
|
If bleeding occurs after a second endoscopic therapeutic session, surgery or IR procedures with transcatheter arterial embolization is generally employed (conditional recommendation, low-quality evidence)
|
|
Acute lower gastrointestinal bleeding
|
American College of Gastroenterology (2016)
|
IR procedures should be considered in patients with high-risk clinical features and ongoing bleeding who have a negative upper endoscopy and do not respond adequately to hemodynamic resuscitation efforts and are therefore unlikely to tolerate bowel preparation and urgent colonoscopy (strong recommendation, very low quality evidence)
|
|
Acute variceal bleeding
|
American College of Gastroenterology (2007)
|
1. Esophageal varices: transjugular intrahepatic portosystemic shunt (TIPSS) is indicated in patients in whom hemorrhage from esophageal varices cannot be controlled or in whom bleeding recurs despite combined pharmacological and endoscopic therapy (recommendation class I, level of evidence C)
2. Gastric varices: TIPSS should be considered in patients in whom hemorrhage from fundal varices cannot be controlled or in whom bleeding recurs despite combined pharmacological and endoscopic therapy (recommendation class I, level of evidence B)
|
|
Blunt hepatic injury
|
Eastern Association for the Surgery of Trauma (2012)
|
1. Angiography with embolization may be considered as a first-line intervention for a patient who is a transient responder to resuscitation as an adjunct to potential operative intervention (recommendation level 2)
2. Angiography with embolization should be considered in a hemodynamically stable patient with evidence of active extravasation (a contrast blush) on abdominal CT scan (recommendation level 2)
|
|
Blunt splenic injury
|
Eastern Association for the Surgery of Trauma (2012)
|
1. Angiography should be considered for patients with American Association for the Surgery of Trauma (AAST) grade of greater than III injuries, presence of a contrast blush, moderate hemoperitoneum, or evidence of ongoing splenic bleeding (recommendation level 2)
2. Angiography may be used either as an adjunct to nonoperative management for patients who are thought to be at high risk for delayed bleeding or as an investigative tool to identify vascular abnormalities such as pseudoaneurysms that pose a risk for delayed hemorrhage (recommendation level 3)
|
|
Genitourinary trauma
|
Eastern Association for the Surgery of Trauma (2004)
|
The success of nonsurgical management may be enhanced by the use of angiographic embolization (recommendation level 3)
|
|
Pelvic trauma
|
Eastern Association for the Surgery of Trauma (2011)
|
1. Patients with pelvic fractures and hemodynamic instability or signs of ongoing bleeding after nonpelvic sources of blood loss have been ruled out should be considered for pelvic angiography/embolization (recommendation level 1)
2. Patients with evidence of arterial intravenous contrast extravasation (ICE) in the pelvis by CT may require pelvic angiography and embolization regardless of hemodynamic status (recommendation level 1)
3. Patients with pelvic fractures who have undergone pelvic angiography with or without embolization, who have signs of ongoing bleeding after nonpelvic sources of blood loss have been ruled out, should be considered for repeat pelvic angiography and possible embolization (recommendation level 2)
4. Patients older than 60 years with major pelvic fracture (open book, butterfly segment, or vertical shear) should be considered for pelvic angiography without regard for hemodynamic status (recommendation level 2)
|
|
The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition (2016)
|
In patients with ongoing hemodynamic instability despite adequate pelvic ring stabilization, early pre-peritoneal packing, angiographic embolization, and/or surgical bleeding control are recommended (recommendation grade 1B)
|
|
|
Blunt traumatic aortic injury
|
Eastern Association for the Surgery of Trauma (2015)
|
The use of endovascular repair in patients who do not have contraindications to endovascular repair is strongly recommended (grade framework)
|
|
Society for Vascular Surgery (2011)
|
1. The clinical practice guidelines suggest that endovascular repair be performed preferentially over open surgical repair or nonoperative management (recommendation grade 2, level of evidence C)
2. The clinical practice guidelines suggest endovascular repair regardless of age if anatomically suitable (recommendation grade 2, level of evidence C)
|
|
|
Penetrating abdominal trauma
|
Eastern Association for the Surgery of Trauma (2010)
|
Angiography may be necessary as an adjunct to initial nonoperative management of penetrating abdominal trauma. Further study is needed on the use of angiography and angioembolization in this patient population before a formal recommendation can be made
|
|
Ruptured AAA
|
European Society for Vascular Surgery (2011)
|
Endovascular aortic repair (EVAR) should be considered as a treatment option for ruptured AAA, provided that anatomy is suitable, and the center is appropriately equipped and the team experienced in emergency endovascular aneurysm procedures (level of evidence 2b, recommendation B)
|
|
Acute occlusive arterial ischemia
|
American College of Cardiology/American Heart Association (2005)
|
Percutaneous interventions (including transcatheter lytic therapy, balloon angioplasty, and stenting) are appropriate in selected patients with acute intestinal ischemia caused by arterial obstructions. Patients so treated may still require laparotomy (recommendation class IIb, level of evidence C)
|
|
European society of trauma and emergency surgeons (ESTES) guidelines (2016)
|
Embolic acute mesenteric ischemia (EAMI): in cases where immediate surgical intervention is not required the decision to perform endovascular or open vascular surgery for EAMI should be determined by the personal experience and technical capabilities of the surgeon and the available resources (level IV)
Thrombotic acute mesenteric ischemia (TAMI): when bowel integrity has not been compromised, endovascular techniques should be performed as first-line treatment for TAMI (level of evidence III)
|
|
|
Acute non-occlusive mesenteric ischemia
|
American college of cardiology/American heart association (2005)
|
1. Arteriography is indicated in patients suspected of having non-occlusive intestinal ischemia whose condition does not improve rapidly with treatment of their underlying disease (recommendation class I, level of evidence B)
2. Transcatheter administration of vasodilator medications into the area of vasospasm is indicated in patients with non-occlusive intestinal ischemia who do not respond to systemic supportive treatment and in patients with intestinal ischemia due to cocaine or ergot poisoning (recommendation class IIa, level B)
|
|
ESTES guidelines (2016)
|
Non-occlusive mesenteric ischemia should be managed by correcting the underlying cause wherever possible and improving mesenteric perfusion by direct infusion of vasodilators. Infarcted bowel should be excised (level of evidence III)
|
|
|
Venous acute mesenteric ischemia
|
ESTES guidelines (2016)
|
Endovascular intervention should be offered to patients with venous acute mesenteric ischemia who deteriorate during medical therapy (level of evidence IV)
|
|
Acute massive (high-risk) pulmonary embolism
|
American Heart Association (2011)
|
Depending on local expertise, catheter embolectomy and fragmentation or surgical embolectomy is reasonable for patients with massive pulmonary embolism and contraindications to fibrinolysis or who remain unstable after fibrinolysis (recommendation class IIa; level of evidence C)
|
|
European Society of Cardiology (2014)
|
Percutaneous catheter-directed treatment should be considered as alternative to surgical pulmonary embolectomy for patients in whom full-dose systemic thrombolysis is contraindicated or has failed (recommendation class IIa, level of evidence C)
|
|
|
American College of Chest Physicians (2016)
|
In patients with acute PE associated with hypotension and who have (a) a high bleeding risk, (b) failed systemic thrombolysis, or (c) shock that is likely to cause death before systemic thrombolysis can take effect (e.g., within hours), if appropriate expertise and resources are available, we suggest catheter-assisted thrombus removal over no such intervention (recommendation grade 2, level of evidence C)
|
|
|
Acute submassive pulmonary embolism (intermediate)
|
American Heart Association (2011)
|
Catheter embolectomy or surgical embolectomy may be considered for patients with submassive acute PE judged to have clinical evidence of adverse prognosis (i.e., new hemodynamic instability, worsening respiratory failure, severe right ventricular dysfunction, or major myocardial necrosis) (recommendation class IIb; level of evidence C)
|
|
European Society of Cardiology (2014)
|
Percutaneous catheter-directed treatment may be considered in treatment of intermediate- to high-risk patients if the anticipated risk of bleeding under thrombolytic treatment is high (recommendation class IIb, level of evidence B)
|
|
|
Sepsis
|
Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock (2016)
|
1. Recommend that a specific anatomic diagnosis of infection requiring emergent source control be identified or excluded as rapidly as possible in patients with sepsis or septic shock, and that any required source control intervention be implemented as soon as medically and logistically practical after the diagnosis is made (best practice statement)
2. Recommend prompt removal of intravascular access devices that are a possible source of sepsis or septic shock after other vascular access has been established (best practice statement)
|