Utility of Angioembolization in Patients with Abdominal and Pelvic Traumatic Bleeding: Descriptive Observational Analysis from a Level 1 Trauma Center

Figures & data

Table 1 Demographics, Associated Injuries and Clinical Characteristics of Trauma Patients Requiring Angioembolization (n=175)

Variables	Values	Variables	Values
Age (mean±SD)	32.6±12.2	Arterial embolization
Males	158 (90.3%)	Facial	3 (1.7%)
Mechanism of injury		Gastric	1 (0.6%)
Motor vehicle crash	60 (34.3%)	Hepatic	43 (24.9%)
Motor cycle crash	8 (4.6%)	Splenic	54 (31.2%)
All-terrain vehicle	4 (2.3%)	Internal Iliac	50 (28.9%)
Pedestrian	36 (20.6%)	Intercostal	2 (1.2%)
Fall from height	49 (28.0%)	Lumber	6 (3.5%)
Fall of heavy object	10 (5.7%)	Renal	6 (3.5%)
Others	8 (4.6%)	Retroperitoneal	1 (0.6%)
Injuries		Superior mesenteric artery	1 (0.6%)
Head	54 (30.9%)	Subclavian artery	1 (0.6%)
Chest	135 (77.1%)	Sacral	1 (0.6%)
Abdomen	151 (86.3%)	Others	4 (2.3%)
Injury severity score	28.0±12.3	Follow-up days	101 (1–365)
ISS>15	154 (88.0%)
Initial vitals
Pulse rate	96.0±25.2
Systolic blood pressure	117.4±26.9
Diastolic blood pressure	75.4±21.7
Glasgow Coma Scale	12±3.0

Table 2 Details of Arterial Embolization, Complications and Outcomes

Variables	Values	Variables	Values
Timing of embolization		- Polyvinyl alcohol	1 (0.6%)
No surgical intervention	128 (73.1%)	- Onyx	1 (0.6%)
Embolization before surgery	18 (10.3%)	Gel foam and coil (both)	28 (16.2%)
Embolization after surgery	26 (14.9%)	Stents	1 (0.6%)
Before and after surgery	3 (1.7%)	Number of sessions	1 (IQR 1–2)
Indications for embolization*		Number of arteries/branches embolized^b	1 (IQR 1–4)
Active bleeding on CT	90 (51.7%)	Technical success	164 (93.7%)
Blush on CT scan	33 (19.1%)	Clinical success	166 (94.9%)
Pseudoaneurysm	22 (12.6%)	Re-bleed	9 (5.1%)
True aneurysm	3 (1.7%)	Complications and management	38 (21.7%)
Intraoperative active bleeding	12 (6.9%)	Infarction needs surgical intervention	6 (15.8%)
Active bleeding and pseudoaneurysm	14 (8.0%)	Hepatic failure	0 (0.0%)
Embolization type**		Abscess	3 (7.9%)
Failure of angioembolization	1 (0.6%)	Infection	4 (10.5%)
Non-selective	39 (22.7%)	Gallbladder infarction needs cholecystectomy	1 (2.6%)
Selective	53 (30.8%)	Bowel Ischemia	2 (5.3%)
Highly selective	59 (34.3%)	Dislodgement of coil in the common femoral artery repaired by snare	1 (2.6%)
Combination	20 (11.6%)	Pseudoaneurysm of common femoral artery treated with thrombin injection	1 (2.6%)
Location of embolization***
No embolization due to technical failure	5 (2.9%)	Exploratory laparotomy	47 (26.9%)
Proximal	79 (46.2%)	Damage control with open abdomen	20 (42.6%)
Distal	68 (39.8%)	MTP activation	59 (33.7%)
Proximal and distal	12 (7.0%)	Blood transfusion	131 (74.9%)
Embolization to more than one area	5 (2.9%)	Number of blood units	8 (IQR 1–79)
Embolization to more than site in different organs	2 (1.2%)	ICU length of stay	6 (IQR 1–57)
Embolic agents^a		Ventilatory says	9 (IQR 1–53)
No embolization due to technical failure	5 (2.9%)	Hospital length of stay	13 (IQR 1–106)
Temporary		Mortality	26 (15%)
- Gel foam	98 (56.6%)	Follow-up days	215 (IQR 1–365)
Permanent
Coils (pushable/injectable/detachable)	40 (23.1%)

Notes: *Data available for 174 cases; **data available for 172 cases; ***data available for 171 cases; ^adata available for 173 cases; ^bdata available for 167 cases IQR: interquartile range.

Figure 1 Examples of selectivity and proximity of angioembolization in different injured organs (A: liver, B: spleen, C: kidney, D: pelvis).

Figure 2 Algorithm for angioembolization in solid organ injury and pelvic injury.

Table 3 Cause of Death

	Overall (n=26)	Mortality ≤30 Days (n=14)	Mortality >30 Days (n=12)
Multiorgan failure post-cardiac arrest before arrival to the emergency department	10 (38.5%)	7 (50.0%)	3 (25.0%)
In-hospital multiorgan failure	4 (15.4%)	3 (21.4%)	1 (8.3%)
Head injury	7 (26.9%)	3 (21.4%)	4 (33.3%)
Multiorgan failure/preexisting Non-Hodgkin lymphoma/Hepatitis C virus with liver cirrhosis	1 (3.8%)	0 (0.0%)	1 (0.0%)
Gastrointestinal bleeding and pulmonary embolism	1 (3.8%)	0 (0.0%)	1 (8.3%)
Gastrointestinal bleeding	1 (3.8%)	0 (0.0%)	1 (8.3%)
Pulmonary embolism	1 (3.8%)	1 (7.2%)	0 (0.0%)
Cardiac arrest	1 (3.8%)	0 (0.0%)	1 (8.3%)

Table 4 Demographics, Clinical Characteristics and Outcome Based on Anatomical Location and Timing of Arterial Angioembolization*

Variables	Hepatic (n=43)	Splenic (n=54)	Pelvic (n=51)	Renal (n=6)	P value
Age	30.4±10.9	32.3±13.6	33.6±11.2	24.5±5.6	0.02
Males	40 (93.0%)	53 (98.1%)	40 (78.4%)	6 (100%)	0.007
Injury severity score	31.3±10.7	24.2±11.2	30.2±12.2	29.1±10.6	0.03
Shock index ≥0.80	63%	32%	58.5%	50%	0.04
Exploratory laparotomy	27 (62.8%)	2 (3.7%)	12 (23.5%)	2 (33.3%)	0.001
MTP Activation	21 (48.8%)	2 (3.7%)	25 (49.0%)	3 (50.0%)	0.001
Blood transfusion	38 (88.4%)	22 (40.7%)	49 (96.1%)	5 (83.3%)	0.001
Number of blood units	10 (1–73)	2 (1–18)	10 (1–42)	13 (2–26)	0.001
ICU length of stay	14 (2–57)	2 (1–41)	6.5 (1–47)	5 (2–15)	0.001
Hospital length of stay	25 (2–102)	8 (4–106)	22 (1–102)	8.5 (2–52)	0.001
Surgical intervention
No surgical intervention	19 (44.2%)	51 (94.4%)	37 (72.5%)	4 (66.7%)	0.001 for all
Embolization before surgery	9 (20.9%)	3 (5.6%)	4 (7.8%)	0 (0.0%)
Embolization after surgery	12 (27.9%)	0 (0.0%)	10 (19.6%)	2 (33.3%)
Both (pre and post-surgical intervention)	3 (6.9%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Follow-up (days)	126 (1–346)	109 (6–342)	102 (1–365)	6 (2–154)	0.24
Mortality	7 (16.3%)	1 (1.9%)	10 (19.6%)	2 (33.3%)	0.008

Note: *Other sporadic vessels were excluded from this comparative analysis (n=19 cases).

Table 5 Timing, Indication, Type and Location of Embolization Based on Anatomical Location*

	Hepatic (n=43)	Splenic (n=54)	Pelvic (n=51)	Renal (n=6)	P value
Indications for embolization
Active bleeding on CT	17 (39.5%)	21 (38.9%)	36 (72.0%)	4 (66.7%)	0.001 for all
Blush on CT scan	9 (20.9%)	14 (25.9%)	6 (12.0%)	0 (0.0%)
Pseudoaneurysm	8 (18.6%)	11 (20.4%)	1 (2.0%)	0 (0.0%)
True aneurysm	0 (0.0%)	3 (5.6%)	0 (0.0%)	0 (0.0%)
Intraoperative active bleeding	6 (14.0%)	0 (0.0%)	6 (12.0%)	0 (0.0%)
Active bleeding and pseudoaneurysm	3 (7.0%)	5 (9.3%)	1 (2.0%)	2 (33.3%)
Embolization type
Non-selective	6 (14.3%)	26 (49.1%)	3 (5.9%)	2 (33.3%)	0.001 for all
Selective	12 (28.6%)	4 (7.5%)	24 (47.1%)	2 (33.3%)
Highly selective	18 (42.9%)	12 (22.6%)	22 (43.1%)	1 (16.7%)
Combination	5 (11.9%)	11 (20.8%)	2 (3.9%)	1 (16.7%)
Location of embolization
Proximal	13 (31.7%)	22 (41.5%)	30 (58.8%)	2 (33.3%)	0.005 for all
Distal	18 (43.9%)	21 (39.6%)	20 (39.2%)	3 (50.0%)
Proximal and distal both	3 (7.3%)	8 (15.1%)	1 (2.0%)	0 (0.0%)
Embolization to more than one area	3 (7.3%)	1 (1.9%)	0 (0.0%)	0 (0.0%)
Embolization to more than site in different organs	1 (2.4%)	0 (0.0%)	0 (0.0%)	1 (16.7%)
No embolization due to technical failure	3 (7.1%)	1 (1.9%)	0 (0.0%)	0 (0.0%)	0.001 for all
Temporary agent	25 (59.5%)	14 (26.4%)	45 (88.2%)	4 (66.7%)
Permanent agent	4 (9.5%)	31 (58.5%)	1 (2.0%)	0 (0.0%)
Both agents	10 (23.8%)	7 (13.2%)	5 (9.8%)	2 (33.3%)
Stents	0 (0.0%)	1 (1.9%)	0 (0.0%)	0 (0.0%)	0.68
Number of sessions	1 (1–2)	1 (1–2)	1 (1–1)	1 (1–2)	0.02
Number of embolized vessel	1 (1–4)	1 (1–3)	1 (1–2)	1.5 (1–3)	0.71
Technical success	37 (86.0%)	51 (94.4%)	51 (100%)	5 (83.3%)	0.06
Clinical success	37 (86.0%)	53 (98.1%)	51 (100%)	5 (83.3%)	0.01
Re-bleed	6 (14.0%)	2 (3.7%)	0 (0.0%)	1 (16.7%)	0.01

Note: *Other sporadic vessels were excluded from this comparative analysis (n=19 cases).

Figure 3 Time of angioembolisation in relation to surgical intervention.

Table 6 Time to Angioembolization

	SOI (n=56)	Pelvis (n=32)	P value
Hospital arrival to intervention time (min)	273 (46–1259)	220 (79–997)	0.12
Hospital arrival to intervention time <180	15 (27.3%)	10 (31.3%)	0.69 for all
Hospital arrival to intervention time ≥180	40 (72.7%)	22 (68.8%)
Injury to intervention time (min)	418 (96–1397)	275.5 (168–1057)	0.01
Injury to intervention time <180	4 (9.8%)	3 (13.6%)	0.64 for all
Injury to intervention time ≥180	37 (90.2%)	19 (86.4%)
Intervention time (min)	67 (11–185)	59 (29–165)	0.67