ORIGINAL ARTICLE Hepatic Angioembolization in Trauma Patients: Indications and Complications Timothy S. Misselbeck, MD, Erik J. Teicher, MD, Mark D. Cipolle, MD, PhD, Michael D. Pasquale, MD, Kamalesh T. Shah, MD, Dale A. Dangleben, MD, and Michael M. Badellino, MD Background: Hepatic angiography (HA) and hepatic angioembolization (HAE) are increasingly used to diagnose and treat intrahepatic arterial injuries. This study was performed to review indications, outcomes, and complications of HA/HAE in blunt trauma patients who underwent HAE as adjunct management of hepatic injury. Methods: A retrospective review of consecutive cases of HA/HAE at a Level I trauma center during an 8-year period. Data include demographics, physiologic condition, liver injury grade, HA/HAE indications, outcomes, morbidity, and mortality. Results: Seventy-nine patients underwent diagnostic HA; 31 (39%) had subsequent HAE. Fifty-eight hemodynamically stable patients had comput- erized axial tomographic (CT) scan followed by HA. HA was performed for contrast blush on CT in 30 (52%) of 58 patients, high-grade liver injury in 4 (7%), subsequent hemodynamic instability in 15 (27%), and angiography planned for other purpose in 9 (17%). HA confirmed arterial injury and led to HAE in 50% of patients with contrast blush on CT or high-grade liver injury. HA was negative when performed for hemodynamic instability or for other primary purposes. Twenty-one hemodynamically unstable patients underwent emergent laparotomy followed by postoperative HA with 11 (50%) requiring HAE. Overall mortality in HAE group was 16%, and liver-related morbidity was 29% usually presenting as gallbladder or liver necrosis. Conclusion: HA/HAE should be used when CT scan suggests associated intrahepatic arterial or high-grade injury in the management of hepatic injuries and should also be considered after laparotomy and perihepatic packing to control inaccessible intrahepatic hemorrhage. Mortality related to HAE is uncommon, but morbidity occurs frequently. Key Words: Hepatic angioembolization, Hepatic angiography, Trauma, Parenchymal necrosis, Gallbladder ischemia. (J Trauma. 2009;67: 769 –773) N onoperative management of blunt hepatic injuries has become the treatment of choice in the hemodynamically stable trauma patient, with recent clinical series reporting success rates of 90%. 1–5 Even patients with high-grade liver injuries can be successfully managed without operation. 6 The benefits of nonoperative treatment include decreases in over- all mortality, abdominal complications, and transfusion re- quirements when compared with surgical management. 1–4 Indeed, the evolution to nonoperative or conservative man- agement of even complex hepatic wounds with associated vascular injuries is supported by a far more rational under- standing of anatomy and physiology than that proposed during the era of aggressive operative management. 7 The progression toward nonoperative management of hepatic injuries has been assisted by the development of more sensitive high-speed computerized axial tomographic (CT) scanners and advances in critical care. 8,9 Another innovation used in both operative and nonoperative management of these injuries involves the use of angiography and angioemboliza- tion techniques. Hepatic angiography (HA) has been increas- ingly used to diagnose intrahepatic arterial injuries, and hepatic angioembolization (HAE) has become an important interventional adjunct in the treatment of these injuries. 10,11 Although nonoperative management is an appropriate treatment choice in hemodynamically stable patients, opera- tive exploration is still indicated for the hemodynamically unstable patient. Even after resuscitative laparotomy, postop- erative HA has been shown to be useful by allowing embo- lization to control arterial bleeding in inaccessible areas deep in the liver parenchyma. 12 Recently, there have been reports of HAE being used before or to obviate surgery in transient responders. 13,14 The purpose of this study was to review the indications, outcomes, and complications of HA and HAE in a series of predominantly blunt trauma patients who underwent HAE as an adjunct to the management of hepatic injury. PATIENTS AND METHODS A retrospective review of prospectively collected data during an 8-year period from 1997 to 2005 at a Level I trauma center was performed on all patients who sustained liver injuries. Data were collected on patients who underwent HA and included demographics, presenting physiologic condi- tion, hepatic injury grade, transfusion requirements, and he- modynamic parameters within the first 24 hours, indications for and results of HA or HAE, liver-related morbidity, and Submitted for publication January 29, 2009. Accepted for publication June 25, 2009. Copyright © 2009 by Lippincott Williams & Wilkins From the Division of Trauma/Surgical Critical Care (T.S.M., E.J.T., M.D.P., K.T.S., D.A.D., M.M.B.), Department of Surgery, Lehigh Valley Health Network, Allentown, Pennsylvania; and Division of Trauma/Surgical Critical Care (M.D.C.), Department of Surgery, Christiana Care Health System, Newark, Delaware. Presented, in part, at the American College of Surgeons Pennsylvania Committee on Trauma (COT) Resident Paper Competition, Harrisburg, Pennsylvania, October 21, 2005; Regional COT Competition, Baltimore, Maryland, December 3, 2005; and as a poster at the 66th Annual Meeting of the American Association for the Surgery of Trauma, September 27–29, 2007, Las Vegas, Nevada. Address for reprints: Michael M. Badellino, MD, Department of Surgery, Lehigh Valley Health Network, Cedar Crest & I-78, PO Box 689, Allentown, PA 18105-1556; email: sally.lutz@lvh.com. DOI: 10.1097/TA.0b013e3181b5ce7f The Journal of TRAUMA ® Injury, Infection, and Critical Care • Volume 67, Number 4, October 2009 769