Hsein-Jar Chiang

Emergent Transcatheter Arterial Embolization in Hemodynamically Unstable Patients With Blunt Splenic Injury

RATIONALE AND OBJECTIVES Splenic preservation is currently the trend for treatment of patients with splenic trauma to avoid complications of splenectomy. This study aimed to evaluate the feasibility of emergent transcatheter arterial embolization (TAE) for hemodynamically unstable patients with blunt splenic injury. MATERIALS AND METHODS In a period of 2 years, 65 patients of blunt splenic trauma were studied. Patients with initial systolic blood pressure < 90 mmHg and showed initial response including rapid response and transient response to the emergent fluid resuscitation were included. Angiography and TAE was undertaken if contrast medium extravasation or pseudoaneurysm formation was noted in the computed tomography (CT) images, according to the criteria of American Association for the Surgery of Trauma. All patients who underwent TAE were admitted for observation of the possibility of delayed rupture. RESULTS Thirteen hemodynamically unstable patients who were responsive to initial fluid resuscitation received angiography due to abnormal CT findings including contrast agent extravasation in 12 patients, 2 patients with arteriovenous fistula, and 8 patients with pseudoaneurysm formation. TAE was successfully performed in all of these 13 patients, including 2 patients with associated left renal injuries and 1 patient associated with bilateral internal mammary arteries injuries, without complications. CONCLUSIONS TAE is a safe and effective procedure for treating blunt splenic injury even in hemodynamically unstable patients who responded to initial fluid resuscitation.

Transarterial Embolization for Control of Bleeding in Patients with Head and Neck Cancer

OBJECTIVE: This study evaluated the efficacy of transarterial embolization for the treatment of tumor bleeding in neck tumors following radiation or chemotherapy. STUDY DESIGN: We performed a case series with chart review of 25 patients with clinically suspected tumor bleeding that occurred in the period between August 2003 and April 2007. SETTING: All patients were admitted to and accepted treatment at China Medical University Hospital, Taiwan, R.O.C. SUBJECTS AND METHODS: Twenty-five male patients (aged 32 to 88 years) with pathologically verified malignant carcinomas of the neck received radiotherapy (n = 6), radiotherapy and chemotherapy (n = 7), or initial surgery and palliative radiotherapy or chemotherapy (n = 12). Carotid artery angiography was performed to detect tumor bleeding, and affected vessels were embolized using either Gelfoam sponge (or cubes), coils, microcoils, or a combination of these methods. RESULTS: By angiography, patients showed tumor vessels with tumor stain (n = 13), extravasation of the contrast agent (n = 7), stenotic vessels (n = 5), pseudoaneurysm (n = 4), and arteriovenous shunt (n = 1). Transarterial embolization was performed with catheter insertion through the branches of the external carotid artery (n = 18), the external carotid artery (n = 5), or the internal carotid artery (n = 1). All patients showed dramatic clinical improvement following embolization. Patients with tongue cancer had the longest average post-transarterial embolization hospital stay (21 days) and the highest incidence of aspiration pneumonia (3/9). After two months of follow-up, five patients had experienced rebleeding. CONCLUSION: Specific vessel injuries following radiation or chemotherapy require different kinds of endovascular treatment. Patients with tongue cancer should be carefully monitored for aspiration pneumonia.

Transcatheter arterial embolization in the treatment of maxillofacial trauma induced life-threatening hemorrhages.

BACKGROUND Life-threatening hemorrhages with hemodynamic instability are uncommon in patients with sustained maxillofacial trauma, but when they occur, require immediate surgical intervention if conservative treatment fails. This study assessed the effects of transcatheter arterial embolization (TAE) in the treatment of maxillofacial trauma-induced life-threatening hemorrhages. METHODS From January 2004 to January 2007, eight ambulatory patients admitted for maxillofacial injuries with life-threatening hemorrhaging and hemodynamic instability (systolic blood pressure < or = 90 mm Hg) caused primarily by intractable oronasal bleeding who subsequently underwent TAE were included in this study. RESULTS Maxillofacial trauma was caused by motorcycle traffic injuries (6 cases), motor vehicle injury (1 case), and fall injury (1 case). All patients exhibited documented Le Fort III fractures. The average Glasgow Coma Scale score was 4.7. TAE was successfully performed and hemorrhaging arrested in all patients. Three deaths occurred (38%) from severe traumatic brain injury. The other five patients (62%) survived without development of systemic or neurologic complications post-TAE. CONCLUSIONS Conservative treatment consisting of packing of the nares, compression, and blood transfusion should always precede TAE as the primary protocol. When conservative treatment fails, as shown either by the need for continued blood product replacement exceeding 1,500 mL and a systolic blood pressure < or = 90 mm Hg, TAE intervention should immediately be considered as an alternative recourse before other surgical interventions.

Reappraisal of the Management and Outcome of Emphysematous Pyelonephritis

This study compared the management, prognostic factors and outcomes of patients with emphysematous pyelonephritis (EPN). Twenty‐one patients with EPN were studied between September 1996 and August 2005, and were assigned to two groups. Patients in Group 1 received conservative treatment with/without percutaneous catheter drainage (PCD) while patients in Group 2 underwent nephrectomy following medical treatment and PCD. A post hoc analysis of the prognostic factors was performed between survivors and nonsurvivors, and between the survivors in Group 1 and Group 2. There were 14 patients in Group 1, and seven in Group 2. The mortality in Group 1 was 35.7% (5/14) and in Group 2 was 0% (p = 0.12). There were no statistically significant differences in prognostic factors between the two groups, though patients in Group 1 had relatively lower platelet counts (p = 0.07) and Group 2 patients had a higher incidence of dialysis after nephrectomy (p = 0.03). Comparing the survivors and nonsurvivors, patients with comorbid congestive heart failure and patients initially presenting with consciousness disturbances had higher mortalities (p = 0.02 and p < 0.01, respectively). Nonsurvivors also had lower platelet counts (p = 0.06). In conclusion, medical treatment with/without PCD can be used to manage patients with EPN. More aggressive drainage is needed in patients with congestive heart failure who initially present with consciousness disturbances or thrombocytopenia.

Arterial Embolization for Controlling Life-threatening Traumatic Pelvic Hemorrhage

Background/Purpose. To evaluate the effectiveness of transcatheter arterial embolization (TAE) for controlling arterial hemorrhage due to pelvic trauma. Methods. In this retrospective study, we analyzed the surgical outcomes of 40 hemodynamically unstable patients who underwent pelvic angiography for traumatic pelvic hemorrhage during the period January 2004 to July 2007. TAE was performed when direct signs (eg, contrast extravasation and pseudoaneurysm) or indirect signs (eg, vasospasm and vessel tortuosity) of vascular injury were noted. Results. Embolization was required in 36 (90%) patients. Indications included active contrast extravasation in 31 (86%) and indirect signs of vascular injury in 5 (13.9%). Repeated TAE for recurrent pelvic arterial hemorrhage during the same admission was necessary in 5 (13.9%) of the 36 patients. The success rate of embolization was 94.4%. All patients had been followed for at least 3 months. There were no complications directly associated with the embolization procedures during the follow-up period. Conclusion. TAE is a safe and effective method for controlling life-threatening traumatic pelvic hemorrhage.