Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (65 page)

Non-operative management (NOM) of blunt liver injuries in haemodynamically stable or stabilised patients has become standard practice. The introduction of AE has been reported to increase the success rate of NOM to well above 80%.
⁸¹

Operative treatment of liver injuries, even in experienced hands, still carries a high mortality and morbidity risk. AE seems to be a valuable adjunct to operative management since most patients are haemodynamically abnormal at the end of a damage control laparotomy, and ongoing arterial bleeding is difficult to rule out clinically.

The indications for AE should include CT evidence of ongoing bleeding with contrast extravasation outside or within the liver, a drop in haemoglobin, tachycardia and haemoperitoneum, as well as formation of pseudoaneurysm. The risk of bleeding with NOM in OIS grade 4 and 5 liver injuries is significant, and operative intervention, with packing, followed by AE is preferable.
⁸²

Indications for AE include CT evidence of ongoing bleeding with contrast extravasation outside or within the spleen, a drop in haemoglobin, tachycardia and haemoperitoneum, as well as formation of pseudoaneurysm. Selective catheterisation of the splenic artery is performed, followed by superselective catheterisation of the bleeding arteries or feeders to the pseudoaneurysm.
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Severe pelvic fractures, particularly with disruption of the sacroiliac joints, are associated with a high risk of severe arterial and venous bleeding. The application of a sheet or external fixation may control the venous bleeding, which constitutes about 85% of all pelvic bleeding. However, arterial bleeding often requires AE, which has become the first line of treatment in patients stable enough to reach angiography.
⁸⁵
Established indications are CT evidence of ongoing bleeding such as contrast extravasation and pelvic haematoma with bladder compression and ongoing transfusion requirements without evidence of other extrapelvic bleeding sources.

There is also a possibility in this subgroup of patients of severe venous bleeding. The patient in shock refractory to resuscitation should be considered for damage control with (extraperitoneal) pelvic packing before AE.

AE is carried out after performing an abdominal aortography followed by selective catheterisation of the internal iliac arteries. When contrast extravasation is demonstrated, the bleeding vessels are catheterised superselectively and embolised with coils, or a combination of coils and gelfoam particles.

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