Acute Vascular Interventional Radiology Technique Procedures
In this study, we inserted the artery sheath into the femoral artery for all cases. For the AVIRT procedures, 4 Fr gauge sheathless guide catheters (Parent, Medikit, Tokyo, Japan) and 6 Fr sheaths (Terumo, Tokyo, Japan) were used for torso vessel injuries, and 4 Fr Shepherd hook catheters (Terumo, Tokyo, Japan) were used in patients with chest vessel injuries. In patients with a single pelvic injury, internal artery injuries, and retroperitoneal hemorrhage, we used 4 Fr Cobra catheter (Gadelius Medical, Tokyo, Japan) and 5 Fr sheaths. In head trauma, 6 Fr guiding catheters (Fubuki, Asahi Intecc, Aichi, Japan, or Launcher, Medtronic Inc, Minneapolis, USA) and 6 Fr sheaths were used.
In stroke patients, 8 or 9 Fr. balloon guiding catheters (Optimo, Tokai Medical Products, Aichi, Japan) and 9 Fr femoral artery sheaths (Medikit, Tokyo, Japan) were used in 12 cases, and 6 Fr sheathless guide catheters (Fubuki, Asahi Intecc, Aichi Japan) were used in three cases.
The treatment materials included detachable microcoils, gelfoam (Serescue, Nihonkasei, Tokyo, Japan), and N-butyl-2-cyanoacrylate (NBCA) (Histoacryl, Braun, Melsungen, Germany) for trauma cases, and detachable microcoils, gelfoam, NBCA, and polyvinyl alcohol particles (Embosphere, Nihonkasei, Tokyo Japan) for nontrauma cases. For other vessel occlusions, we performed balloon angioplasties for severe iliac artery stenosis, drug infusions for intestinal ischemia, and thrombectomies for radial artery emboli. We routinely performed selective catheterization with microcatheters using a coaxial or triaxial system, and our treatment materials were introduced via the microcatheters. For mechanical thrombectomies, we used the Penumbra MAX System (Penumbra Inc, Alameda, CA) in all stroke patients.
No major device-related complications were encountered, but one patient who had a splenic injury had an arterial dissection at a branch of the splenic artery caused by microguidewire handling; this patient also required endovascular coil embolization. We also identified one case of mild necrosis (gluteal) that occurred after embolization in a patient with an unstable pelvic fracture. The overall mortality rate at 60 days was 8% (trauma, 10%; and nontrauma, 6%), with death causes by exsanguination (n = 2), pneumonia (n = 2), sepsis (n = 1), or brain death (n = 1).
Active hemorrhage is a major cause of death among patients admitted to emergency centers and intensive care units, and initial resuscitation is a high priority for acute hemorrhage in hemorrhagic shock. In this context, interventional radiology with minimally invasive catheter-based techniques is becoming an increasingly essential part of modern medicine.
A single well-trained acute care surgeon can manage both general surgery and trauma surgery in the EDs of hospitals in the United States and, if trained, could also perform endovascular emergency care.15 However, in Japanese emergency centers, acute care surgeons are not always available, and it can be impractical to wait for general surgeons. Furthermore, if in-house radiologists are performing scheduled endovascular treatments, AVIRT may not be available immediately, and there can be a significant delay in receiving acute endovascular procedures. This is also complicated by the long time required to contact and wait for radiologists, especially when requested out of hours. In our center, approximately 50% of therapeutic AVIRT procedures were performed out of hours, which is consistent with the reported rate by Ono et al.16 In a study by Ashleigh et al.17 in Manchester, 70% of emergency endovascular procedures took place at the weekend. The improvement of workflow in acute care and the growing role of catheter-based techniques in AMS is a matter of continual worldwide development.18 Thus, by necessity, we have adopted an approach that allows diagnostic and therapeutic AVIRT procedures to be performed by trained acute care specialists for both trauma and nontrauma patients.1,2
Brenner et al.15 reported that they were concerned that interventionalists who were unfamiliar with AMS and injury dynamics may persist in treating clinically insignificant injuries in patients who need other therapy more urgently or who may be best served by stopping the interventional procedure and resuming resuscitation. Matsumoto et al.18 suggested the importance of radiologists with trauma experience in the initial acute care of hemodynamically unstable trauma patients. This supports our concept that AVIRT should be performed by trained acute care specialists in AMS.
In our experience, GIB is one of the most common nontrauma indications for AVIRT. Although endoscopic treatment is generally acceptable for GIB, it can be difficult to achieve complete success in some patients, and severe hemorrhage can be rapidly fatal. Indeed, it is reported that in 5% to 10% of patients with nonvariceal GIB, it is impossible to achieve hemostasis endoscopically. A recent study indicated that arterial embolization had become a first-line option when managing acute GIB that is refractory to endoscopic hemostasis and surgery.7,8 Furthermore, a recent systematic review reported that REBOA successfully elevated central blood pressure in patients with hemorrhagic shock in various clinical settings.13 In this study, three patients (one trauma and two nontrauma patients) underwent REBOA in the ED that was performed by residents trained in femoral sheath insertion by trained acute care specialists. Resuscitative endovascular balloon occlusion of the aorta is an important adjunct procedure designed to sustain the circulation until definitive hemostasis can be obtained. This procedure is a newer catheter-based technique, and we previously reported that our trained acute care physicians could complete REBOA procedures with a high degree of technical success.12
There has been marked progress in the development of embolic agents over the past decade, with a variety of materials now available, including metallic coils, gelatin sponge particles, liquids, and nitinol plugs. Patients with hemorrhage often develop coagulopathy, and the resulting uncontrolled hemorrhage is often associated with poor outcomes, regardless of whether the case is of traumatic or nontraumatic in origin. Recently, NBCA has been used as a liquid embolic agent in various nontraumatic situations, where it has been shown to have a high technical success rate and low recurrent bleeding rate, especially in patients with coagulopathy.19 Although the use of gelatin sponge particles remains popular because of its easier handling, a recent study reported that NBCA was more effective in an animal model of hemorrhage-induced coagulopathy.20 There have also been a few case reports of successful use of NBCA in trauma patients, and it seems to be the most effective method in cases of severe trauma.16 However, some training is needed for the use of NBCA because of the risk of ischemic complications or reflux, and the need to handle it safely. Thus, we conduct training in our radiology department to practice handling these embolic agents, who may help achieve successful hemostasis in future trauma resuscitation.
Device-related complications were caused during the insertion of the catheter or artery sheath. Those complications typically associated with catheter insertion are vessel injury (e.g., arterial dissection, rupture, and perforation), embolization, air emboli, and peripheral ischemia, and those associated with sheath insertion are arterial injury (e.g., pseudoaneurysm, arteriovenous fistula, and dissection) and lower limb ischemia at the same site. Despite the acute care setting, we must ensure that we inform patients or their guardians about these complications. In this study, we encountered an iatrogenic splenic artery injury, which was caused by a handling error of a microguidewire that required endovascular coil embolization. We also encountered one case of mild gluteal necrosis after an AVIRT in a patient with an unstable pelvic fracture (traumatic). This was caused by either NBCA embolization or ischemia after catheterization for uncontrolled bleeding from a lateral sacral artery. There were considered device-related complications. We routinely inserted the artery sheath at the femoral artery, except in the case of abdominal aortic aneurysm or other aortic disease, when we used the brachial artery. We also routinely used a calcium alginate hemostasis pad (Tricell, Alliance Medical Group, Tokyo, Japan) for sheath removal to prevent groin hematoma. Trained acute care specialists or trauma surgeons who perform angiography should also be aware of the need to minimize radiation exposure and prevent associated complications, as previously reported.1,2
In Japan, the JAAM is committed to residents having to complete at least three clinical years in JAAM-accredited education programs, which are different from those in other developed countries. However, there is a recognition of the need to incorporate training for catheter-based techniques among acute care specialists or trauma surgeons, consistent with the recommendation of Brenner et al.,15 and we have been practicing these at high-volume trauma or emergency centers. Although the optimal interval for radiology training is difficult to assess, our experience is that 6 months or more are sufficient in high-volume centers. We would also recommend that interventional radiology be performed weekly for at least 6 months with radiologists from the current hospital to ensure continued competency after training has been completed, especially in low-volume emergency centers. The use of catheter-based techniques in the management of whole-body vessel injuries has increased in AMS; there is a role for the training of acute care specialists, trauma surgeons, or intensivists in AVIRT. In Japan, trained acute care specialists recently organized the Society of Diagnostic and Interventional Radiology in Emergency, Critical Care, and Trauma to expand the training on the appropriate use of diagnostic and interventional radiology in emergency and critical care not only to acute care physicians but also to trauma surgeons, cardiovascular surgeons, and intensivists.21 In our department, all acute care specialists have trained in critical care medicine through a Japanese Society of Intensive Care Medicine–accredited education program for at least 3 months, and one trained acute care specialist completed one of the Japanese Society for Neuroendovascular Therapy–accredited education programs after the completion of AVIRT training. Some trained acute care specialists have started an acute care surgery training program. We believe that there may be advantages for acute care specialists having significant knowledge about catheter-based techniques in AMS before beginning their training for acute care surgery or critical care medicine.
There are several limitations to this study, most notably the retrospective design and relatively small number of cases. The most notable weaknesses were the use of a post hoc hypothesis, and that AVIRT by trained acute care specialists was not assessed in a randomized trial against controls. In addition, patients were allocated to treatments at the discretion of the attending acute care specialist, so we cannot exclude the possibility of bias.
Acute vascular interventional radiology technique performed by trained acute care specialists produced good technical success, making it useful and advantageous for acute on-site care. We recommended these techniques be added to the training requirements of acute care physicians and surgeons.
T.J. conceived of this study. T.J. and H.H. contributed to the study's design. T.J., O.E., and A.I. performed data collection. T.J., M.S., O.J., and O.S. contributed to data analysis. T.J., O.E., A.I., H.H., M.S., O.J., O.S., and Y.T. participated in data interpretation. T.J., H.H., and O.S. wrote the manuscript. All authors read and approved the final manuscript, the final version of which Y.T. gave final approval for submission.
The authors thank Enago (www.enago.jp) for the English language review.
The authors declare no conflicts of interest. This manuscript has not been published previously and is not under consideration for publication elsewhere.
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Keywords:© 2017 Lippincott Williams & Wilkins, Inc.
Endovascular treatment; embolization; trauma surgeon; emergency department; training