Pseudoaneurysm after High-Grade Penetrating Solid Organ Injury and Utility of Delayed CT Angiography.

BACKGROUND: Leaving an injured solid organ in situ allows preservation of structure function but invites complications from the damaged parenchyma, including pseudoaneurysms (PSAs). Empiric PSA screening after solid organ injury is not yet established, particularly following penetrating trauma. The study objective was definition of delayed CT angiography (dCTA) yield in triggering intervention for PSA after penetrating solid organ injury. METHODS: Penetrating trauma patients at our American College of Surgeons-verified level 1 center with American Association for the Surgery of Trauma grade ≥3 abdominal solid organ injury (liver, spleen, kidney) were retrospectively screened (January 2017 to October 2021). Exclusions were age <18 y, transfers, death within <48 h, and nephrectomy/splenectomy within <4 h. Primary outcome was intervention triggered by dCTA. Statistical testing with ANOVA/chi-square compared outcomes between screened vs unscreened patients. RESULTS: A total of 136 penetrating trauma patients met study criteria: 57 patients (42%) screened for PSA with dCTA and 79 (58%) unscreened. Liver injuries were most common (n = 41, 64% vs n = 55, 66%), followed by kidney (n = 21, 33% vs n = 23, 27%) and spleen (n = 2, 3% vs n = 6, 7%) (p = 0.48). Median American Association for the Surgery of Trauma grade of solid organ injury was 3 (3 to 4) across groups (p = 0.75). dCTA diagnosed 10 PSAs (18%) at a median of hospital day 5 (3 to 9). Among screened patients, dCTA triggered intervention in 17% of liver patients, 29% of kidney patients, and 0% of spleen-injured patients, for an overall yield of 23%. CONCLUSIONS: Half of eligible penetrating high-grade solid organ injuries were screened for PSA with dCTA. dCTA identified a significant number of PSAs and triggered intervention in 23% of screened patients. dCTA did not diagnose any PSAs after splenic injury, although sample size hinders interpretation. To avoid missing PSAs and incurring their risk of rupture, universal screening of high-grade penetrating solid organ injuries may be prudent.

Recent trends in the management of isolated high-grade splenic injuries: A nationwide analysis.

BACKGROUND: The feasibility of nonoperative management for high-grade blunt splenic injuries (BSIs) has been suggested in recent studies. The purpose of this study was to assess nationwide trends in the management of isolated high-grade BSIs. We hypothesized that isolated high-grade BSIs are more frequently being managed nonoperatively. METHODS: The American College of Surgeons Trauma Quality Improvement Program database was queried to identify patients (16 years or older) with isolated high-grade BSIs (Abbreviated Injury Scale, ≥3) between 2013 and 2019. Patients were divided into two groups based on their hemodynamic status (hemodynamically stable [HS] and hemodynamically unstable [HU]). The primary outcome was the rate of total splenectomy each year, and the secondary outcome was the use of splenic angioembolization (SAE). Multiple regression models were created to estimate annual trends in splenectomy and SAE. RESULTS: A total of 6,747 patients with isolated high-grade BSIs were included: 5,714 (84.7%) and 1,033 (15.3%) in HS and HU groups, respectively. In the HS group, the rate of overall splenectomy was significantly decreased (from 22.9% in 2013 to 12.6% in 2019; odds ratio [OR] for 1-year increment, 0.850; 95% confidence interval [CI], 0.815-0.886; p < 0.001), and the use of SAE was significantly increased (from 12.5% in 2013 to 20.9% in 2019; OR, 1.107; 95% CI, 1.065-1.150; p < 0.001). In the HU group, the overall splenectomy rate was unchanged (from 69.8% in 2013 to 50.8% in 2019; OR, 0.931; 95% CI, 0.865-1.002; p = 0.071), whereas SAE was significantly increased (from 12.7% in 2013 to 28.8% in 2019; OR, 1.176; 95% CI, 1.079-1.284; p < 0.001). CONCLUSION: We observed significant trends toward more frequent use of nonoperative management in high-grade BSIs with hemodynamic stability. Further studies are warranted to define the role of SAE, especially in patients with hemodynamic instability. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Pseudoaneurysms after high-grade blunt solid organ injury and the utility of delayed computed tomography angiography.

PURPOSE: Pseudoaneurysms (PSA) can occur following high-grade solid organ injury. PSA natural history is unclear but risk for spontaneous rupture and exsanguination exist. The yield of delayed CT Angiography (dCTA) for PSA diagnosis is not well delineated and optimal timing is undefined. The study objective was definition of dCTA utility in diagnosing and triggering intervention for PSA after high-grade blunt solid organ injury. METHODS: All blunt trauma patients arriving to our ACS-verified Level 1 trauma center with AAST grade ≥ III liver, spleen, and/or kidney injury were included in this retrospective observational study (01/2017-10/2021). Exclusions were age < 18 year, transfers in, death < 48 h, and immediate nephrectomy/splenectomy. dCTA performance was not protocolized and pursued at attending surgeon discretion. Demographics, clinical/injury data, and outcomes were collected. Primary outcome was dCTA-triggered intervention. Statistical testing with ANOVA/Chi squared compared outcomes by type of solid organ. RESULTS: 349 blunt trauma patients with 395 high-grade solid organ injuries met study criteria. Median AAST grade of solid organ injury was 3 [3-4]. dCTA for PSA screening was pursued in 175 patients (44%), typically on hospital day 4 [3-7]. dCTA identified vascular lesions in 16 spleen, 10 liver, and 6 kidney injuries. dCTA triggered intervention in 24% of spleen, 13% of kidney, and 9% of liver injured patients who were screened, for an overall yield of 14%. Intervention was typically AE (n = 23, 92%), although two splenic PSA necessitated splenectomy. CONCLUSION: Delayed CTA for PSA screening after high-grade blunt solid organ injury was performed in half of eligible patients. dCTA identified numerous vascular lesions requiring endovascular or surgical intervention, with highest yield for splenic injuries. We recommend consideration of universal screening of high-grade blunt solid organ injuries with delayed abdominal CTA to avoid missing PSA.

Pseudoaneurysm Screening after Pediatric High Grade Solid Organ Injury.

BACKGROUND: High grade solid organ injuries carry risk of complications, including pseudoaneurysms (PSA). The optimal approach to PSA screening among pediatric patients is unknown and may include delayed Computed Tomography Angiography (dCTA) and/or contrast-enhanced ultrasound (CEUS). This study endeavored to define dCTA/CEUS yield in PSA diagnosis after pediatric high grade solid organ injury. METHODS: Patients <18y presenting to our ACS-verified Level 1 trauma center with ≥1 AAST grade ≥3 abdominal solid organ injury (kidney, liver, and spleen) were included (01/2017-10/2021). Transfers in, death <48h, and immediate nephrectomy/splenectomy were exclusions. PSA screening was pursued selectively based on attending discretion. Demographics, clinical/injury data, and outcomes were collected. Primary outcome was performance of dCTA or CEUS. RESULTS: Forty-two patients satisfied criteria, with median age 12.5y and ISS 22. Liver injuries were most frequent (48%), followed by spleen (33%) and kidney (19%). Initial management strategy was most commonly nonoperative (liver 60%, spleen 64%, kidney 75%). Overall, 26% underwent PSA screening at a median of hospital day 4, with dCTA (21%) or CEUS (5%). CEUS was only used among liver injuries (10%), with no PSA identified. One PSA was diagnosed on dCTA after splenic injury and was managed with observation. CONCLUSION: PSA screening occurs infrequently after pediatric high grade solid organ injury, potentially due to concerns about radiation exposure from dCTA which would be mitigated with CEUS. Further delineation of PSA incidence and yield of screening investigations are needed to avoid missing this important diagnosis and to determine the diagnostic accuracy of dCTA and CEUS.

Rectal arterio-venous malformation (AVM) with bleeding of an internal hemorrhoid.

A 38-year-old male with no past history of illnesses visited the out-patient clinic of Nerima Hikarigaoka Hospital complaining of dizziness and persistent anal bleeding. There was a significant anemia on a blood test and colonoscopy showed a thrombus in a markedly swollen internal hemorrhoid. Contrast-enhanced computed tomography (CT) showed a poorly demarcated area with early face enhancement on the right side of the rectum and anal canal. Based on these findings, an arterio-venous malformation (AVM) of the rectum was suspected. Abdominal angiography showed abnormal vessels receiving a blood supply from the bilateral superior rectal arteries. We suspected that the AVM in the rectum was the cause of the hemorrhage from the internal hemorrhoid, and therefore performed embolization of the AVM. Thereafter, the hemorrhage from the internal hemorrhoid stopped completely and the anemia improved to the normal level, without the need for treatment for the internal hemorrhoid. Colonoscopy performed 6 months after embolization showed shrinkage of the internal hemorrhoid. To the best of our knowledge, there are no reports stating a relationship between rectal AVM and internal hemorrhoids. However, we consider that contrast-enhanced CT can be used to detect vessel abnormalities related to severe bleeding of the internal hermorrhoids in patients with internal hemorrhoids and severe anemia.