Sue E. Hanks

Angiographic Embolization for Intraperitoneal and Retroperitoneal Injuries

Abstract. Angiographic embolization (AE) has been used extensively for bleeding control after injuries to the face and neck. Its role in abdominal trauma requires further exploration. We reviewed the medical records of 137 consecutive patients who underwent angiography with the intent to embolize bleeding sites within the abdomen. Of them, 97 (71%) had blunt and 40 (29%) had penetrating trauma. AE was performed for hemorrhage associated with pelvic fractures (97 patients), liver lacerations (n= 26), renal lacerations (n= 12), splenic lacerations (n= 5), other injuries (n= 9), and multiple injuries (n= 12). On angiography, 102 patients were found to have bleeding sites and underwent AE, with angiographic and clinical bleeding control in 93 (91%). The rate of successful hemostasis by AE was identical in blunt and penetrating trauma patients. There was no major morbidity after AE. No factors predicted patients with a high likelihood to have a positive angiogram. Patients who had AE before or after a period of attempted hemodynamic stabilization in the intensive care unit were no different with respect to hemodynamic parameters immediately before AE or effectiveness of AE for bleeding control. AE is a safe and effective method for controlling bleeding after blunt and penetrating intra- and retroperitoneal injuries. Early AE may be used in selected patients as a front-line therapeutic intervention that offers expeditious hemostasis and prevents delays in definitive bleeding control.

N-butyl cyanoacrylate embolization for control of acute arterial hemorrhage.

PURPOSE To report the initial clinical experience with the use of n-butyl cyanoacrylate (NBCA) for embolization of acute arterial hemorrhage from varied etiologies and at varied anatomic sites. MATERIALS AND METHODS Sixteen patients who demonstrated active extravasation of contrast material and/or arterial abnormality underwent NBCA embolization. Sites of embolization included the gastrointestinal tract, kidney, liver, uterus, adrenal gland, extremity, and chest wall. Standard coil or particulate embolization had previously failed in 10 patients. NBCA was used as the initial embolic agent in the remaining six patients. After treatment, serial hematocrit levels, transfusion requirements, and clinical signs and symptoms were monitored for stabilization. Patients were evaluated for signs and symptoms of end-organ damage. RESULTS NBCA embolization was successful in 12 of 16 patients (75%), who exhibited complete cessation of bleeding. In four patients (25%), NBCA embolization was of no benefit. Embolization failed in two of 16 patients (12.5%), who showed evidence of recurrent bleeding after use of NBCA. The remaining two patients (12.5%) died within 24 hours of the procedure. None of the 16 patients developed clinical signs of end-organ damage or iatrogenic ischemia attributable to NBCA. CONCLUSIONS In this initial limited series, NBCA embolization was shown to be a feasible and effective method to control acute arterial hemorrhage. NBCA embolization was able to stop arterial bleeding even when previous coil or particulate embolization had failed.

Angiographic embolization for arrest of bleeding after penetrating trauma to the abdomen

BACKGROUND Angiographic embolization is an effective technique to control bleeding after blunt trauma to the liver or pelvis. Its role in penetrating trauma to the abdomen has not been studied. METHODS From January 1992 to May 1998, 40 patients underwent angiography for bleeding resulting from intra-abdominal penetrating injuries (33 gunshot wounds, 7 stab wounds). Angiographic embolization of intraperitoneal or retroperitoneal vessels was performed by standard angiographic techniques with gelatin sponge and/or coils. Data were extracted from medical records, radiology data bank, trauma registry, and morbidity/mortality records, and compared by Students t test and chi-square test. The main outcome measures were failure of angiographic embolization to control bleeding and complications of angiographic embolization. RESULTS Angiography was performed during a course of nonoperative management in 6 patients (group A), because of failure to control bleeding surgically in 23 (group B), and because of late vascular complications after an initially successful operation in 11 more (group C). In 32 patients, angiography revealed active bleeding; 29 (91 %) underwent successful angiographic embolization. Of the remaining 3 patients, 2 were successfully managed surgically (1 each from groups A and B) and 1 died despite multiple surgical maneuvers (group B). One patient who developed postoperatively a large, bleeding superior mesenteric artery pseudoaneurysm, suffered extensive bowel necrosis after angiographic embolization. No other significant complication was related to angiographic embolization. CONCLUSIONS Angiographic embolization after penetrating injuries to the abdomen is safe and effective for a small number of selected patients. It is a valuable tool for bleeding control when surgery has failed. It may be ideal for control of late vascular complications when reoperation is not desirable. It may prove to be a useful adjunct in the nonoperative treatment of selected injuries.

Percutaneous retrieval of a misplaced titanium greenfield filter

Vena caval filters are considered permanent indwelling devices. Occasionally, malposition of a filter prompts a desire for its removal. We report a method of percutaneous retrieval of a titanium Greenfield filter by snare.

Admixture of Heparin with Urokinase to Decrease Thrombolysis Time and Urokinase Dose in Polytetrafluoroethylene Dialysis Graft Recanalization

PURPOSE To determine whether the addition of heparin to urokinase during dialysis graft thrombolysis can lower urokinase dose and shorten procedure time. PATIENTS AND METHODS Patients who underwent dialysis graft thrombolysis during an 18-month period were studied retrospectively. Twenty patients were treated with urokinase alone, and 19 patients were treated with urokinase and heparin. Thrombolysis was performed in the angiography suite by using a crossed-catheter technique. Urokinase was administered directly into the thrombus. In patients receiving heparin, 5,000 IU was added directly to the initial urokinase solution. RESULTS In patients who received urokinase alone, an average of 750,000 U of urokinase was used, and the average procedure time was 2 hours 42 minutes. When heparin was added, an average of 435,000 U of urokinase was used, and the average procedure time was 2 hours. CONCLUSION The addition of heparin to urokinase can decrease both urokinase dose and thrombolysis time in the recanalization of dialysis grafts.