Primary angioembolization in liver trauma: major hepatic necrosis as a severe complication of a minimally invasive treatment—a narrative review

Abstract

The liver is the second most commonly solid organ injured in blunt abdominal trauma. Liver injuries are classified according to the American Association for the Surgery of Trauma Injury Scale. The choice of Non-Operative Management is based on generalized clinical patients’ conditions combined with the evidence on CT scan imaging. To date, there are no consensus guidelines on appropriate patient selection criteria for those who would benefit from angiography and angioembolization. Major hepatic necrosis is a clinical condition of extended liver damage and is the most common complication after angioembolization. Large amounts of necrotic liver require therapy, but it is unclear if the better technique is debridements supplemented by percutaneous drainage procedures or definitive resection. A systematic review of the literature was performed with a computerized search in a database such as Medline for published papers on the use of angioembolization in trauma patients with hepatic injuries and on the most common complication, the major hepatic necrosis. The systematic review was conducted according to the recommendations of the 2020 updated Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. A total of 3643 patients were included in the study, suffering liver trauma and 1703 (47%) were treated with Non-Operative Management; angioembolization was performed 10% of cases with a variable rate between 2 and 20%. Patients developed different complications. Hepatic necrosis accounted for 16% ranging from 0 to 42%. 74% of patients underwent operative management with a mortality rate of 11%. High-grade liver injuries pose significant challenges to surgeons who care for trauma patients. Many patients can be successfully managed nonoperatively. In hemodynamically stable patients with arterial blush, without other lesions requiring immediate surgery, selective and super-selective AE of the hepatic artery branches is an effective technique. However, these therapies are not without complications and major hepatic necrosis is the most common complication in high-grade injures. Level III, Systematic review

Adult blunt hepatic injury: A Western Trauma Association critical decisions algorithm

“…One study has found major hepatic necrosis in up to 63% of patients who underwent embolization, which correlated with grade of liver injury. Several other studies have also demonstrated hepatic necrosis rates increasing with higher grades of injury 19–21 …”

“…15,16,18,19 One study has found major hepatic necrosis in up to 63% of patients who underwent embolization, which correlated with grade of Several other studies have also demonstrated hepatic necrosis rates increasing with higher grades of injury. [19][20][21] Biliary complications can occur in up to 22% of patients after angioembolization. However, such complications are not always specific to angioembolization and can occur in up to 30% in patients with hepatic trauma managed without embolization, either operative or nonoperative.…”

Hepatectomy for massive hepatic necrosis after transcatheter arterial embolization hemostasis for hepatic hemorrhage following hepatic trauma: A case report

“…Segalini et al, in their review of TAE hemostasis for liver trauma, reported that MHN occurred in 16% of cases. 1 In this case, hepatic necrosis of the posterior section occurred after TAE hemostasis for hemorrhage associated with blunt hepatic trauma. Traumatic occlusion of the posterior portal vein appeared to be the reason for necrosis after TAE.…”

“…Small areas of hepatic necrosis following TAE for trauma are often experienced. Segalini et al, in their review of TAE hemostasis for liver trauma, reported that MHN occurred in 16% of cases 1 …”

“…Transcatheter arterial embolization (TAE) is increasingly used as the initial treatment of choice for hemorrhage associated with liver trauma 1 . Small areas of liver necrosis following TAE are often noted, although complications such as infection rarely require additional procedures 1 .…”