Gaining or wasting time? Influence of time to operating room on mortality after temporary hemostasis using resuscitative endovascular balloon occlusion of the aorta.

BACKGROUND: The optimal candidates for resuscitative endovascular balloon occlusion of the aorta (REBOA) remains unclear. We hypothesized patients with delayed transfer to operating room (OR) would benefit from REBOA. METHODS: Using the 2016-2017 ACS-TQIP database, patients were divided based on the transfer time to OR: ≤1 h (early) and >1 h (delayed). In each group, patients who underwent REBOA in emergency department (ED-REBOA) were matched with those without REBOA (non-REBOA) using propensity scores, and survival to discharge was compared. RESULTS: Among 163,453 patients, 114 and 138 patients (38 and 46 ED-REBOA) were included in the early and delayed groups, respectively. Survival to discharge was comparable between ED-REBOA and non-REBOA patients in the early group (39.5% vs. 48.7%, p = 0.35), whereas it was higher in ED-REBOA patients in the delayed group (39.1% vs. 12.0%, p < 0.01). CONCLUSIONS: Patients with delayed transfer to OR >1 h benefited from REBOA.

Contemporary management and natural history of aberrant right subclavian artery.

OBJECTIVE: An aberrant right subclavian artery (ARSA) is the most common congenital anomaly of the aortic arch. A paucity of reported studies is available regarding the treatment of these patients. The purpose of the present study was to evaluate the contemporary management strategies and natural history of ARSA in these patients. METHODS: A single-center retrospective review of patients with a diagnosis of ARSA from 2009 to 2019 was performed. Computed tomography scans were analyzed, and the aortic and ARSA diameters were measured at 10 different segments. The demographic data, comorbidities, and operative interventions were collected. The patients were categorized into those who had undergone intervention and those who had undergone expectant management. Linear mixed effect models were used to estimate the annual ARSA diameter changes. RESULTS: A total of 30 patients with ARSA were identified, 17 (57%) of whom were women. The average age for the cohort was 54.5 ± 14.6 years. Of the 30 patients, 20 (67%) had undergone operative repair at presentation and 10 (33%) were initially observed. The most common presenting symptom was dysphagia (30%). Of the 10 patients who had been initially treated expectantly, 4 had subsequently required intervention. Of the 24 operative interventions, 13 (54%) were hybrid procedures involving right carotid-subclavian bypass or transposition and thoracic endovascular aortic repair. The mean diameter of ARSA at its origin was 20.4 ± 5.7 mm, and the mean cross-sectional aortic diameter at the level of the ARSA was 31.8 ± 8.5 mm for the entire cohort. For the patients who had initially been observed and had subsequently required intervention, the largest change in the ARSA cross-sectional diameter was observed 1 cm distally to the vessel ostium at a rate of 3.05 mm annually (95% confidence interval, 1.54-4.56; P < .001). No statistically significant changes in the annual growth rate of the aortic segments were observed in the entire cohort or for those patients who had undergone intervention (P > .05). CONCLUSIONS: The decision to intervene on an ARSA should be individualized by the presence of symptoms (eg, dysphagia lusoria) or complications (eg, dissection, concomitant aortic aneurysmal disease, enlarging Kommerell diverticulum). Asymptomatic patients with nonaneurysmal ARSA might not require any intervention and can be safely observed. Measurement of the cross-sectional ARSA diameter 1 cm distally to the ostium of the vessel might aid in the surveillance of vessel diameter changes. Additional studies are required to determine the specific size criteria as an indication for operative repair of asymptomatic Kommerell diverticulum.

Compensatory reserve detects subclinical shock with more expeditious prediction for need of life-saving interventions compared to systolic blood pressure and blood lactate.

INTRODUCTION: We conducted a prospective observational study on 205 trauma patients at a level I trauma facility to test the hypothesis that a compensatory reserve measurement (CRM) would identify higher risk for progression to shock and/or need a life-saving interventions (LSIs) earlier than systolic blood pressure (SBP) and blood lactate (LAC). METHODS: A composite outcome metric included blood transfusion, procedural LSI, and mortality. Discrete measures assessed as abnormal (ab) were SBP <90 mmHg, CRM <60%, and LAC >2.0. A graded categorization of shock was defined as: no shock (normal [n] SBP [n-SBP], n-CRM, n-LAC); sub-clinical shock (ab-CRM, n-SBP, n-LAC); occult shock (n-SBP, ab-CRM, ab-LAC); or overt shock (ab-SBP, ab-CRM, ab-LAC). RESULTS: Three patients displayed overt shock, 53 displayed sub-clinical shock, and 149 displayed no shock. After incorporating lactate into the analysis, 86 patients demonstrated no shock, 25 were classified as sub-clinical shock, 91 were classified as occult shock, and 3 were characterized as overt shock. Each shock subcategory revealed a graded increase requiring LSI and transfusion. Initial CRM was associated with progression to shock (odds ratio = 0.97; p < .001) at an earlier time than SBP or LAC. CONCLUSIONS: Initial CRM uncovers a clinically relevant subset of patients who are not detected by SBP and LAC. Our results suggest CRM could be used to more expeditiously identify injured patients likely to deteriorate to shock, with requirements for blood transfusion or procedural LSI.

Thoracic outlet decompression for subclavian venous stenosis after ipsilateral hemodialysis access creation.

OBJECTIVE: Central venous stenosis is one of the most challenging complications in patients requiring hemodialysis. Venous thoracic outlet syndrome is an underappreciated cause of central venous stenosis in patients requiring dialysis that can result in failed percutaneous intervention and loss of a functioning dialysis access. Limited data exist about the safety and outcomes of first rib resection in patients requiring hemodialysis, and the results have been confounded by the various surgical approaches used. The purpose of the present study was to evaluate the safety, operative outcomes, and patency of the existing dialysis access after transaxillary thoracic outlet decompression. METHODS: A retrospective medical record review was performed from January 2008 to December 2019 of patients who had undergone thoracic outlet decompression for subclavian vein stenosis with ipsilateral upper extremity hemodialysis access. The baseline characteristics and comorbidities were reviewed. The operative and postoperative course were evaluated. The survival and patency rates were analyzed using the life-table method and Kaplan-Meier curve. RESULTS: A total of 18 extremities in 18 patients were identified. Their mean age was 59 ± 11 years, and 89% were men. A total of 13 fistulas and 5 grafts were included. All patients had undergone repair via a transaxillary approach. First rib resection, anterior scalenectomy, and circumferential venolysis were performed in all 18 patients. The mean operative time was 99 ± 19 minutes, with an estimated blood loss of 78 ± 66 mL. The median length of stay was 2 days. No patient had died at 30 days. The survival rate at 1 year was 83%. The primary, primary-assisted, and secondary patency at 1 year were 42%, 69%, and 93%, respectively. CONCLUSIONS: Thoracic outlet decompression via the transaxillary approach is a technically feasible and safe operation in patients with ipsilateral upper extremity hemodialysis access. Patients with threatened dialysis access due to subclavian vein stenosis should be carefully evaluated for possible extrinsic compression at the costoclavicular junction. These patients might benefit from transaxillary first rib resection, scalenectomy, and venolysis.

Timing of repair of blunt thoracic aortic injuries in the thoracic endovascular aortic repair era.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) is the preferred operative treatment of blunt thoracic aortic injuries (BTAIs). Its use is associated with improved outcomes compared with open surgical repair and nonoperative management. However, the optimal time from injury to repair is unknown and remains a subject of debate across different societal practice guidelines. The purpose of this study was to evaluate national trends in the management of BTAI, with a specific focus on the impact of timing of repair on outcomes. METHODS: Using the National Trauma Data Bank, we identified adult patients with BTAI between 2012 and 2017. Patients with prehospital or emergency department cardiac arrest or incomplete data sets were excluded from analysis. Patients were classified according to timing of repair: group 1, <24 hours; and group 2, ≥24 hours. The primary outcome evaluated was in-hospital mortality; secondary outcomes included overall hospital and intensive care unit length of stay. Multivariable logistic regression was performed to identify independent predictors of mortality. RESULTS: The analysis was completed for 2821 patients who underwent TEVAR for BTAI with known operative times. The overall mortality in the patient cohort was 8.4% (238/2821); 75% of patients undergoing TEVAR were repaired within 24 hours. Mortality was more than twofold greater in group 1 compared with group 2 (9.8% [207/2118] vs 4.4% [31/703]; P = .001). This mortality benefit persisted across injury severity groups and was independent of the presence of serious extrathoracic injuries. Logistic regression analysis, adjusting for age ≥65 years, Glasgow Coma Scale score ≤8, systolic blood pressure ≤90 mm Hg at admission, and serious extrathoracic injuries, showed a higher adjusted mortality in group 1 (odds ratio, 2.54; 95% confidence interval, 1.66-3.91; P = .001). CONCLUSIONS: The majority of patients with BTAI undergo endovascular repair within 24 hours of injury. Patients undergoing delayed repair have improved survival compared with those repaired within the first 24 hours of injury in spite of similar injury patterns and severity. In patients with BTAIs without signs of imminent rupture, delaying endovascular repair beyond 24 hours after injury should be considered.

Impact of posthospital syndrome on outcomes of elective endovascular repair of abdominal aortic aneurysm.

OBJECTIVE: Posthospital syndrome (PHS) is an acquired, transient period of health vulnerability after a hospital admission for acute illness. It is characterized by physiologic deconditioning secondary to stressors from disruption in circadian rhythm, depletion of nutritional and physiologic reserve as well as the pain and discomfort associated with hospitalization. PHS is reported as an independent risk factor for readmission and adverse postoperative outcomes. The aim of this study is to investigate whether preoperative hospitalization affects outcomes of elective endovascular repair of abdominal aortic aneurysm (EVAR). METHODS: The Healthcare Cost and Utilization Project State Inpatient Database for California (2009-2011) were queried using International Classification of Disease Codes, Ninth Edition, codes of 441.4 (abdominal aneurysm without mention of rupture), 397.1 (EVAR with graft), and 397.8 (EVAR with branching or fenestrated graft). PHS exposure is defined as any inpatient admission 30 or fewer days before elective EVAR. Primary outcomes are all-cause mortality and overall complications. Secondary outcomes include length of stay (LOS), 30-day readmission, and hospital charge. RESULTS: A total of 6155 patients were identified. of which 327 patients (5.6%) had more than one episode of hospital admission 30 days or less before elective EVAR. In-hospital mortality was comparable after PHS exposure (P = .09). However, PHS exposure was associated with increased 30-day readmission (9.5% vs 18.4%; P < .001), LOS (3.0 vs 4.5 days; P < .001), and overall complications (14.8% vs 24.5%; P < .001). Risk adjustment was made based on age, sex, race, baseline comorbidities, and reason for preoperative admission. Multivariate logistic regression analysis demonstrated that PHS exposure was a predictor for longer LOS (odds ratio [OR], 2.5; 95% confidence interval [CI], 2.0-3.2; P < .001), higher incidence of 30-day readmission (OR, 2.0; 95% CI, 1.4-2.6; P < .001), and overall complications (OR, 1.7; 95% CI, 1.3-2.2; P < .001). Additional cost associated with increased 30-day readmission attributable to PHS exposure was estimated at $448,302 per 100 cases. CONCLUSIONS: PHS is an independent risk-adjusted predictor for increased LOS, 30-day readmission, and overall complications after elective EVAR. Recent hospital admission should be assessed carefully before elective EVAR. Medical optimization with an attempt to delay elective surgery by up to 30 days may help to improve surgical outcomes and decrease unnecessary health care expenditures.

Validating clinical threshold values for a dashboard view of the compensatory reserve measurement for hemorrhage detection.

BACKGROUND: Compensatory reserve measurement (CRM) is a novel noninvasive monitoring technology designed to assess physiologic reserve using feature interrogation of arterial pulse waveforms. This study was conducted to validate clinically relevant CRM values with a simplified color-coded dashboard view. METHODS: We performed a prospective observational study of 300 injured patients admitted to a level I trauma center. Compensatory reserve measurement was recorded upon emergency department admission. Data collected to complement the analysis included patient demographics, vital signs, lifesaving interventions, Injury Severity Score (ISS), and outcomes. Threshold values of CRM were analyzed for predictive capability of hemorrhage. RESULTS: A total of 285 patients met the inclusion criteria. Mean age of the population was 47 years, and 67% were male. Hemorrhage was present in 32 (11%), and lifesaving intervention was performed in 40 (14%) patients. Transfusion of packed red blood cells was administered in 33 (11.6%) patients, and 21 (7.4%) were taken to the operating room for surgical or endovascular control of hemorrhage. Statistical analyses were performed to identify optimal threshold values for three zones of CRM to predict hemorrhage. Optimal levels for red, yellow, and green areas of the dashboard view were stratified as follows: red if CRM was less than 30%, yellow if CRM was 30% to 59%, and green if CRM was 60% or greater. Odds of hemorrhage increased by 12-fold (odds ratio, 12.2; 95% confidence interval, 3.8-38.9) with CRM less than 30% (red) and 6.5-fold (odds ratio, 6.5; 95% confidence interval, 2.7-15.9) with CRM of equal to 30% to 59% (yellow) when compared with patients with CRM of 60% or greater. The area under the receiver operating characteristic curve for three-zone CRM was similar to that of continuous CRM (0.77 vs. 0.79) but further increased the ability to predict hemorrhage after adjusting for ISS (area under the receiver operating characteristic curve, 0.87). CONCLUSION: A three-zone CRM could be a potentially useful predictor of hemorrhage in trauma patients with added capabilities of continuous monitoring and a real-time ISS assessment. These data substantiate easily interpretable threshold dashboard values for triage with potential to improve injury outcomes. LEVEL OF EVIDENCE: Diagnostic, level II.

Application of electronic medical record-derived analytics in critical care: Rothman Index predicts mortality and readmissions in surgical intensive care unit patients.

INTRODUCTION: The Rothman Index (RI) is an objective measurement of a patient's overall condition, automatically generated from 26 variables including vital signs, laboratory data, cardiac rhythms, and nursing assessments. The purpose of this study was to assess the validity of RI scores in predicting surgical ICU (SICU) readmission rates and mortality. METHODS: We conducted a single-center retrospective analysis of surgical patients who were transferred from the SICU to the surgical floor from December 2014 to December 2016. Data included demographics, length of stay (LOS), mortality, and RI at multiple pretransfer and post-transfer time points. RESULTS: A total of 1,445 SICU patients were transferred to the surgical floor; 79 patients (5.5%) were readmitted within 48 hours of transfer. Mean age was 52 years, and 67% were male. Compared to controls, patients readmitted to the SICU within 48 hours experienced higher LOS (29 vs. 11 days, p < 0.05) as well as higher mortality (2.5% vs. 0.6%, p < 0.05). Patients requiring readmission also had a lower RI at 72, 48, and 24 hours before transfer as well as at 24 and 48 hours after transfer (p < 0.05 for all). Rothman Index scores were categorized into higher-risk (<40), medium-risk (40-65), and lower-risk groups (>65); RI scores at 24 hours before transfer were inversely proportional to overall mortality (RI < 40 = 2.5%, RI 40-65 = 0.3%, and RI > 65 = 0%; p < 0.05) and SICU readmission rates (RI < 40 = 9%, RI 40-65 = 5.2%, and RI > 65 = 2.8%; p < 0.05). Patients transferred with RI scores greater than 83 did not require SICU readmission within 48 hours. CONCLUSION: Surgical ICU patients requiring readmission within 48 hours of transfer have a significantly higher mortality and longer LOS compared to those who do not. Patients requiring readmission also have significantly lower pretransfer and post-transfer RI scores compared to those who do not. Rothman Index scores may be used as a clinical tool for evaluating patients before transfer from the SICU. Prospective studies are warranted to further validate use of this technology. LEVEL OF EVIDENCE: Retrospective database review, level III.

Impact of time to repair on outcomes in patients with lower extremity arterial injuries.

BACKGROUND: Six hours has long been considered the threshold of ischemia after peripheral artery injury. However, there is a paucity of evidence regarding the impact of operative delays on morbidity and mortality in patients with lower extremity arterial injuries. METHODS: We analyzed the records of 3,441,259 injured patients entered into the National Trauma Data Bank Research Dataset from 2012 to 2015. Patients (≥16 years) with lower extremity arterial injuries were identified by International Classification of Diseases, Ninth Revision injury and procedure codes. Patients with crush injuries, patients with prehospital or emergency department cardiac arrest, those not transferred directly from point of injury, and patients in whom a nonoperative management strategy was attempted were excluded from analysis. RESULTS: We examined the data from 4406 patients with lower extremity arterial injuries; 85% of the patients were male, with a mean age of 35 years. The overall mortality in this cohort was 3.2% (143/4406); the amputation rate was 11.3% (499/4406). Using a multivariate logistic regression model, blunt mechanisms of injury, increased time from injury to operating room arrival, nerve injury, associated lower extremity fractures, increased age, and Injury Severity Score were associated with increased amputation risk. The amputation rate in those undergoing repair within 60 minutes was 6% compared with 11.7% and 13.4% in those undergoing repair after 1 to 3 hours and 3 to 6 hours, respectively. CONCLUSIONS: Optimal limb salvage is achieved when revascularization of lower extremity arterial injury occurs within 1 hour of injury. To improve survival and recovery after extremity arterial injury, efforts should be focused on strategies to expedite reperfusion of the injured limb.

Compensatory Reserve Index: Performance of A Novel Monitoring Technology to Identify the Bleeding Trauma Patient.

INTRODUCTION: Hemorrhage is one of the most substantial causes of death after traumatic injury. Standard measures, including systolic blood pressure (SBP), are poor surrogate indicators of physiologic compromise until compensatory mechanisms have been overwhelmed. Compensatory Reserve Index (CRI) is a novel monitoring technology with the ability to assess physiologic reserve. We hypothesized CRI would be a better predictor of physiologic compromise secondary to hemorrhage than traditional vital signs. METHODS: A prospective observational study of 89 subjects meeting trauma center activation criteria at a single level I trauma center was conducted from October 2015 to February 2016. Data collected included demographics, SBP, heart rate, and requirement for hemorrhage-associated, life-saving intervention (LSI) (i.e., operation or angiography for hemorrhage, local or tourniquet control of external bleeding, and transfusion >2 units PRBC). Receiver-operator characteristic (ROC) curves were formulated and appropriate thresholds were calculated to compare relative value of the metrics for predictive modeling. RESULTS: For predicting hemorrhage-related LSI, CRI demonstrated a sensitivity of 83% and a negative predictive value (NPV) of 91% as compared with SBP with a sensitivity to detect hemorrhage of 26% (P < 0.05) and an NPV of 78%. ROC curves generated from admission CRI and SBP measures demonstrated values of 0.83 and 0.62, respectively. CRI identified significant hemorrhage requiring potentially life-saving therapy more reliably than SBP (P < 0.05). CONCLUSION: The CRI device demonstrated superior capacity over systolic blood pressure in predicting the need for posttraumatic hemorrhage intervention in the acute resuscitation phase after injury.

Comparison of compensatory reserve and arterial lactate as markers of shock and resuscitation.

BACKGROUND: During traumatic hemorrhage, the ability to identify shock and intervene before decompensation is paramount to survival. Lactate is extremely sensitive to shock, and its clearance has been demonstrated a useful gauge of shock and resuscitation status. Though lactate can be measured in the field, logistical constraints render it impractical in certain environments. The compensatory reserve represents a new clinical measurement reflecting the remaining capacity to compensate for hypoperfusion. We hypothesized the compensatory reserve index (CRI) would be an effective surrogate marker of shock and resuscitation compared to lactate. METHODS: The CRI device was placed on consecutive patients meeting trauma center activation criteria and remained on the patient until discharge, admission, or transport to operating suite. All subjects had a lactate level measured as part of their routine admission metabolic analysis. Time-corresponding CRI and lactate values were matched in regards to initial and subsequent lactate levels. Mean time from lactate sample collection to data availability in the electronic medical record was calculated. Predictive capacity of CRI and lactate in predicting hemorrhage was determined by receiver-operator characteristic curve analysis. Correlation analysis was performed to determine if any association existed between changing CRI and lactate values. RESULTS: Receiver-operator characteristic (ROC) curves were generated and area under the curve was 0.8052 and 0.8246 for CRI and lactate, respectively. There was no significant difference in each parameter's ability to predict hemorrhage (p = 0.8015). The mean duration from lactate sample collection to clinical availability was 44 minutes whereas CRI values were available immediately. Analysis of the concomitant change in serial CRI and lactate levels revealed a Spearman's correlation coefficient of -0.73 (p < 0.01). CONCLUSION: CRI performed with equivalent predictive capacity to lactate with respect to identifying initial perfusion status associated with hemorrhage and subsequent resuscitation. LEVEL OF EVIDENCE: Diagnostic, Level II.

Organ Donation, an Unexpected Benefit of Aggressive Resuscitation of Trauma Patients Presenting Dead on Arrival.

BACKGROUND: We sought to determine whether aggressive resuscitation in trauma patients presenting without vital signs, or "dead on arrival," was futile. We also sought to determine whether organ donation was an unexpected benefit of aggressive resuscitation. STUDY DESIGN: We conducted a review of adults presenting to our Level I trauma center with no signs of life (pulse = 0 beats/min; systolic blood pressure = 0 mmHg; and no evidence of neurologic activity, Glasgow Coma Scale score = 3). Primary end point was survival to hospital discharge or major organ donation (ie heart, lung, kidney, liver, or pancreas were harvested). We compared our survival rates with those of the National Trauma Data Bank in 2012. Patient demographics, emergency department vital signs, and outcomes were analyzed. RESULTS: Three hundred and forty patients presented with no signs of life to our emergency department after injury (median Injury Severity Score = 40). There were 7 survivors to discharge, but only 5 (1.5%) were functionally independent (4 were victims of penetrating trauma). Of the 333 nonsurvivors, 12 patients (3.6%) donated major organs (16 kidneys, 2 hearts, 4 livers, and 2 lungs). An analysis of the National Trauma Data Bank yielded a comparable survival rate for those presenting dead on arrival, with an overall survival rate of 1.8% (100 of 5,384); 2.3% for blunt trauma and 1.4% for penetrating trauma. CONCLUSIONS: Trauma patients presenting dead on arrival rarely (1.5%) achieve functional independence. However, organ donation appears to be an under-recognized outcomes benefit (3.6%) of the resuscitation of injury victims arriving without vital signs.

Psychosocial Support of the Inflammatory Bowel Disease Patient.

Inflammatory bowel disease (IBD) is a chronic, debilitating disease whose effects spread far beyond the gut. IBD does not generally result in excess mortality; health care providers should thus focus their efforts on improving health-related quality of life and minimizing associated morbidity. A bidirectional relationship exists between IBD and psychiatric conditions; chronic inflammation can produce neuromodulatory effects with resultant mood disorders, and the course of IBD is worse in patients with anxiety and depression. Screening for the early signs of depression or anxiety and initiating appropriate treatment can lead to improved functioning and positively impact disease course.

"Blush at first sight": significance of computed tomographic and angiographic discrepancy in patients with blunt abdominal trauma.

BACKGROUND: "Blush," defined as a focal area of contrast pooling within a hematoma, is frequently encountered in patients with severe blunt torso trauma. Contemporary clinical practice guidelines recommend the use of angiography with embolization in all hemodynamically stable patients with evidence of active extravasation. Patients presenting with blush visualized on computed tomography (CT), but not demonstrated on subsequent angiography, present a challenging clinical dilemma. The purpose of this study was to study the natural course of patients with this blush disparity between CT and angiography. METHODS: The study was conducted as a retrospective analysis of patients who underwent angiography after initial CT scans revealed blush after blunt abdominal trauma at a level I trauma center (January 2005 to December 2014). RESULTS: A total of 143 patients with blunt splenic injuries were found to have CT blush and underwent catheter angiography. Of the 143 patients with blush on CT, 24 (17%) showed no evidence of blush on angiography. Patients with CT-angiographic discrepancy were more than twice as likely to rebleed compared with those with angiographic evidence of blush (25% vs 10%, P < .05). This is due to the fact that although all patients with blush on angiography underwent embolization, only 7/22 of those with no evidence of blush were embolized. Sixty-eight patients with blunt liver injuries demonstrated blush on CT and underwent catheter angiography. Of the 68 patients with blush on CT, 22 patients (33%) showed no evidence of blush on angiography. None of these 22 patients underwent angioembolization. The rebleeding rate in this cohort was 32% (7/22). Again, this was more than twice the rate observed in patients who did have angiographic evidence of blush and were embolized (11%, 5/46). CONCLUSIONS: CT imaging has enhanced our ability to detect contrast extravasation after injury, and evidence of blush on CT suggests the presence of active hemorrhage. This analysis suggests that in clinical situations in which CT blush is noted secondary to blunt trauma to the spleen or liver, a negative angiogram still carries a significant risk of recurrent hemorrhage; consideration for empiric embolization at the time of the initial procedure even in the absence of blush on angiographic evaluation is thus warranted. Prospective studies are needed to validate these findings and to assess the utility of this clinical paradigm.