Selective Angioembolization in Blunt Solid Organ Injury in Children and Adolescents: Review of Recent Literature and Own Experiences

Abstract

Nonoperative management (NOM) is considered the standard therapy for clinically stable children with blunt solid organ injuries (SOI) grade I to IV. The capability of angioembolization (AE) to decrease the NOM failure rate in adults with blunt SOI has been demonstrated. The inclusion of AE in the pediatric SOI management is rarely reported. The aim of this review is to evaluate the recent literature surrounding trauma-related AE in children focusing on criteria for patient selection for AE and on the success rates including the greater experience in adults and on our own little series with splenic and renal injuries at a Level 1 Trauma Center. The technique will be described in detail. Although already added to some institutional treatment protocols patient selection for AE is still without full consent. High-grade injury, active bleeding with contrast blush on computed tomography, threatening, or ongoing hemodynamic instability and pseudoaneurysm represent the most common criteria to admit AE. Patients' characteristics are often similar to those of NOM failure groups in trauma managements protocols without AE. The impact of this interventional approach is situated between the possibility for NOM in the obvious stable child and the need for open surgery in the obvious unstable patient with grade IV to grade V SOI. There is evidence that AE is capable to decrease the failure rate and complications in the NOM. Although available data are based on cohort studies rather than prospective randomized-controlled trials, we conclude, AE represents a safe and effective therapy and should be part of the interdisciplinary trauma management protocol for SOI in children and adolescents.

Splenic trauma: WSES classification and guidelines for adult and pediatric patients

“…Mortality and major complications are rarely reported following AG/AE [ 180 , 184 , 186 , 187 ]. Nevertheless, a post-embolization syndrome (PES), consisting of abdominal pain, nausea, ileus, and fever, seems to occur in 90% of children undergoing AG/AE.…”

Transcatheter embolization in pediatric blunt renal trauma: Case report and review of the literature

“…It has been reported that vascular injuries in the setting of blunt renal traumas can be treated effectively by TAE. [2,[19][20][21][22][23][24][25][26] This procedure can be performed in children whose hemodynamic status is either stable or nearly stable and who have active bleeding due to renal parenchymal bleeding, contrast extravasation or perirenal hematoma detected in computerized tomography scan. In addition, it can be utilized in patients with late bleeding following conservative treatment, arterial pseudoaneurysm or arteriovenous fistula.…”

Therapeutic strategies for pseudoaneurysm following blunt liver and spleen injuries: a multicenter cohort study in the pediatric population.

“…A total of 79 patients (5.6% of the entire cohort) underwent OM, of whom 53 (3.8% of the whole cohort) underwent OM within 48 hours of admission. Among the overall cohort, 22 patients (1.6%) underwent combined OM and IR intervention within 48 hours of admission, of whom 13 underwent IR intervention followed by OM, while 9 patients underwent OM 27 37 29 28 [20- 15 [14][15] 15 [14][15] 15 [14][15] 13 [8][9][10][11][12][13][14][15] 13 [6][7][8][9][10][11][12][13][14][15] followed by IR. The most common indication for first surgical intervention was acute hemorrhage (90%), followed by peritonitis (9%).…”

“…Highly selective use of interventional radiology (IR) has been recommended for pediatric trauma patients as a better balance of risk, benefit, and resource utilization. 3,8 Although angioembolization has been proved as safe in pediatric patients as in adults, with few complications, 1,[9][10][11][12] its use in children remains controversial because of insufficient evidence on the association between the use of IR and clinical outcomes. 8 In the real world, where there is often no clear consensus on indications for IR intervention in the acute phase and late phase, individual institutions develop their own empirical indications for hemostatic interventions based primarily on the availability and preferences of the surgeons and interventional radiologists involved.…”