Department of Surgery, University of Colorado Anschutz, Aurora, CO.
Department of Surgery, University of Colorado Anschutz, Aurora, CO.
J Am Coll Surg. 2020 Jul;231(1):123-131.e3. doi: 10.1016/j.jamcollsurg.2020.05.006. Epub 2020 May 15.
Angioembolization (AE) is recommended for extravasation from liver injury on CT. Data supporting AE are limited to retrospective series that have found low mortality but high morbidity. These studies did not focus on stable patients. We hypothesized that AE is associated with increased complications without improving mortality in stable patients.
We queried the 2016 Trauma Quality Improvement Project database for patients with grade III or higher liver injury (Organ Injury Score ≥ 3), blunt mechanism, with stable vitals (systolic blood pressure ≥ 90 mmHg and heart rate of 50 to 110 beats/min). Exclusion criteria were nonhepatic intra-abdominal or pelvic injury (Organ Injury Score ≥ 3), laparotomy less than 6 hours, and AE implementation more than 24 hours. Patients were matched 1:2 (AE to non-AE) on age, sex, Injury Severity Score, liver Organ Injury Score, arrival systolic blood pressure and heart rate, and transfusion in the first 4 hours using propensity score logistic modeling. Primary outcomes were in-hospital mortality, length of stay, transfusion, hepatic resection, interventional radiology drainage, and endoscopic procedure.
There were 1,939 patients who met criteria, with 116 (6%) undergoing hepatic AE. Median time to embolization was 3.3 hours. After successfully matching on all variables, groups did not differ with respect to mortality (5.4% vs 3.2%; p = 0.5, AE vs non-AE, respectively) or transfusion at 4 to 24 hours (4.4% vs 7.5%; p = 0.4). A larger percentage of the AE group underwent interventional radiology drainage (13.3% vs 2.2%; p < 0.001), with more ICU days (4 vs 3 days; p = 0.005) and longer length of stay (10 vs 6 days; p < 0.001).
Hepatic AE was associated with increased morbidity without improving mortality, suggesting the benefits of AE do not outweigh the risks in stable liver injury. Observing these patients is likely a more prudent approach.
CT 检查显示肝损伤外渗时建议采用血管栓塞术（AE）。支持 AE 的数据仅限于回顾性系列研究，这些研究发现 AE 的死亡率较低，但发病率较高。这些研究并未关注稳定型患者。我们假设 AE 会增加并发症，而不会改善稳定型患者的死亡率。
我们在 2016 年创伤质量改进项目数据库中查询了具有 III 级或更高级别的肝损伤（器官损伤评分≥3）、钝性机制、生命体征稳定（收缩压≥90mmHg 和心率 50 至 110 次/分钟）的患者。排除标准为非肝腹内或骨盆损伤（器官损伤评分≥3）、剖腹术时间少于 6 小时以及 AE 实施时间超过 24 小时。使用倾向评分逻辑建模对年龄、性别、损伤严重程度评分、肝器官损伤评分、到达时收缩压和心率以及前 4 小时内输血进行 1:2（AE 与非-AE）匹配。主要结局为住院死亡率、住院时间、输血、肝切除术、介入放射学引流和内镜手术。
符合条件的患者有 1939 名，其中 116 名（6%）接受了肝动脉栓塞术。栓塞中位时间为 3.3 小时。在成功匹配所有变量后，两组死亡率（分别为 5.4%和 3.2%；p=0.5，AE 与非-AE）或 4 至 24 小时内输血（分别为 4.4%和 7.5%；p=0.4）无差异。AE 组接受介入放射学引流的比例更大（13.3%与 2.2%；p<0.001），ICU 天数（4 天与 3 天；p=0.005）和住院时间（10 天与 6 天；p<0.001）更长。
肝动脉栓塞术与发病率增加有关，而死亡率没有改善，这表明在稳定的肝损伤中，AE 的益处并不超过风险。观察这些患者可能是一种更谨慎的方法。
