Trauma angiography and embolization in IR
Barbara Wilkey, MD
Bob Ryu, MD
Purpose: The purposes of this document are
1)To provide education pertaining to the process of trauma angiography and embolizationin IR and this population’s common peri-procedure management concerns.
2)To provide peri-procedure management suggestions.
Content: This content is a combination of published literature and peer recommendation (Interventional Radiology and Anesthesiology).
The procedure
Most common indications:arteriographic diagnosis and embolization for cessation/control of acute abdominal or pelvic hemorrhage after trauma
Length of procedure: 1-2 hours of IR MD time
Antibiotic prophylaxis: yes, choice is dependent upon targeted area
Imaging: ultrasound, fluoroscopy
Contrast agents: intravenous iodinated contrast
Ancillary procedures: central venous access, diagnostic paracentesis/thoracentesis, chest tube placement.
Preprocedural testing: CT/CTA/CXR, routine laboratory tests including comprehensive blood chemistries (Cr, etc), hematology (Hgb, plt >50K), coagulation parameters (INR<2), type and screen, cross match blood for bleeding patients.
Patient positioning: supine, mostly performed from right or left femoral artery; transradial approach is very rarely used (morbidly obese).
Procedural details: Ultrasound guided femoral artery access, selective catheterization/arteriography of targeted vessel (hepatic, splenic, renal, pelvic etc), embolization of targeted bleeding branch, completion arteriography of potential collateral pathways after embolization, removal or arterial access sheath and deployment of hemostasis device.
The patient severity of bleeding will vary significantly from case to case. Specific management should be tailored to the needs of the individual patient.From a procedure standpoint this can be done under sedation if the patient is hemodynamically stable and cooperative. The decision for general anesthesia versus MAC based on patient factors will be made at the discretion of the attending anesthesiologist.
The pre-anesthesia assessment starts with a standard evaluation, with careful attention to the following:
1)Hemodynamic stability.
2)Transfusion requirements.Massive Transfusion Protocol isinitiated if the patient likely will require 10U PRBCs in 12 hours, greater than 4u PRBCs in 4 hours, has active bleeding or hemodynamic instability(Blood Bank 8-4444). Use emergency release (uncrossmatched Type O) PRBCs if crossmatched PRBCs are not ready then switch to crossmatched PRBCs when available (as guided by UCH Blood Bank policy). Please also see CVC document entitled regarding how to get blood products in the CVC.
3)Amount of blood product available for the patient.
4)TRALI, TACO or other complication of transfusion.
5)Coagulopathy. Consider baseline TEG.
6)Presence or absence of acidosis from hypoperfusion.
7)IV access, both actual and potential.
8)Co-existent injuries from the inciting trauma.
9)Is there need for C-Spine precautions?
Room Setup standard set up plusan additional large bore peripheral IV, pumps for any necessary infusions, and a Level One if there is active bleeding. Invasive arterial blood pressure monitoring is appropriate if there is active bleeding or transfusion. Central venous access may be necessary if not already present and/or the patient does not have adequate peripheral access.
Anesthesia induction:
-For patients who require general anesthesia, consider indications for a rapid sequence induction, such as inadequate NPO status.
-Consider avoiding propofol in patients who have evidence of volume depletion pre-operatively.
-Consider placement of a pre-induction arterial line for patients who have evidence of intravascular depletion.
Maintenanceof general anesthesia with inhaled anesthetics is generally appropriate. If patient is to have MAC medications are at the discretion of the attending anesthesiologist.
Emergence/extubation/disposition is at the discretion of the anesthesia team. Patients received from the ICU generally go back to the ICU. Patients may also dispo back to the trauma suite.
Procedural Risks
-Access site hematoma (<2%)
-Continued bleeding with hemodynamic instability
- Contrast induced nephropathy
- Instability related to other unrelated injuries (neuro trauma, etc)