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The liver is one of the most commonly injured solid organs in blunt abdominal trauma. Non-operative management is considered to be the gold standard for the care of most blunt liver injuries. Angioembolization has emerged as an important adjunct that is vital to the success of the non-operative management strategy for blunt hepatic injuries. This procedure, however, is fraught with some possible serious complications. The success, as well as rate of complications of this procedure, is determined by degree and type of injury, hepatic anatomy and physiology, and embolization strategy among other factors. In this review, we discuss these important considerations to help shed further light on the contribution and impact of angioembolization with regards to complex hepatic injuries.

Hemorrhage is one of the most significant complications of percutaneous nephrolithotomy (PCNL) and may lead to clinically significant persistent hematuria requiring digital subtraction angiography (DSA) and transcatheter arterial embolization (TAE). Identifying predictors of TAE may improve perioperative planning and risk stratification. To determine predictors of need for TAE in patients evaluated with DSA for persistent post-PCNL hemorrhage. Single-center retrospective observational study. From 2021 to 2024, a total of 2947 tubeless PCNL procedures were performed at our institution. Consecutive adult patients who developed clinically significant persistent post-PCNL hemorrhage and underwent DSA were assessed. Persistent hematuria was operationally defined as severe visible hematuria persisting for >24 h despite conservative management or recurrent severe hematuria after initial stabilization. DSA referral followed predefined escalation criteria after failure of conservative measures, including hemodynamic instability, Hb drop ⩾3 g/dL within 24 h or progressive decline, transfusion requirement ⩾2 units within 24 h, and/or recurrent clot retention requiring clot evacuation and/or continuous bladder irrigation. TAE was performed only when DSA demonstrated a culprit vascular lesion. The mean age of the study population was 55.1 ± 10.6 years, and 68% were male. Among the 100 patients who underwent DSA for persistent post-PCNL hemorrhage, 36 (36%) required TAE, while 64 (64%) had normal angiographic findings and were managed conservatively. On multivariable logistic regression analysis, diabetes mellitus (odds ratio (OR) 7.42), larger stone size (OR 1.27 per mm), higher stone density (OR 1.007 per Hounsfield unit), greater skin-to-stone distance (OR 1.14 per mm), and longer operative time (OR 1.18 per minute) independently predicted the need for TAE. Pseudoaneurysm was identified in 77.8% of embolized patients and arteriovenous fistula in 22.2%. Selective coil embolization achieved 100% clinical success without the need for repeat embolization, surgical exploration, or nephrectomy. Among patients undergoing DSA for clinically significant persistent post-PCNL hemorrhage, diabetes mellitus, larger stone size, higher stone density, greater skin-to-stone distance, and longer operative time were independently associated with the need for TAE.

To compare outcomes of middle meningeal artery embolization (MMAE) alone versus combined with conventional surgery in the management of chronic subdural hematoma (cSDH). A systematic literature search was performed on PubMed, Google Scholar, Scopus, and CINAHL, followed by a meta-analysis comparing recurrence rates, surgical rescue, mortality, in-hospital complications, and length of hospital stay was conducted. Mean differences and risk ratios were pooled using a random effects model, with subgroup analysis performed using Cochrane RevMan 5.4.1 software. A total of 23 studies including 302,168 patients (62.5 % male, 37.5 % female) were analyzed, with most studies published between 2017 and 2024. Among these patients, 299,195 (99.0 %) were treated with conventional surgery, whereas 3113 underwent MMAE. MMAE patients showed a significantly lower recurrence rate compared to conventional surgery, with a 0.35 times lower risk of recurrence (95 % CI: 0.24–0.51, p<0.01). However, adjunctive MMAE was associated with a longer hospital stay (SMD: 2.61 [95 % CI: 2.46–2.76], p<0.01), though MMAE alone had a shorter stay compared to adjunctive MMAE. Additionally, MMAE demonstrated a lower risk of surgical rescue (0.29 times, p<0.01). While no significant difference was found in-hospital complications (RR: 1.01, 95 % CI 0.90–1.14, p=0.84) and mortality rates (RR: 0.88, 95 % CI 0.69–1.14, p=0.34). MMAE stand-alone or adjunctive with conventional surgery presents a promising alternative to conventional surgery alone for chronic subdural hematomas due to lower recurrence and surgical rescue risk. Further prospective studies are needed to study the efficacy of this new approach. •Studies have reported high complication and recurrence rates among chronic subdural hematoma (cSDH) patients treated with conventional surgeries, highlighting a need for alternative therapies like middle meningeal artery embolization (MMAE).•The current meta-analysis reveals a significantly lower recurrence rate with adjunctive MMAE compared to conventional surgery and a longer hospital stay. No significant difference was found in within hospital complications and mortality rates between the two groups.•MMAE alone and as an adjunct presents as a promising alternative and further prospective studies are needed to gain further insight into these approaches.

Visceral artery pseudoaneurysms are rare but life-threatening complications following upper gastrointestinal (GI) surgery. This case series reviews six patients (male-to-female ratio 3:3) who developed pseudoaneurysms, presenting with diverse clinical manifestations. Four patients (66.6%) experienced bleeding, including hemoperitoneum and upper GI bleeding, with one also reporting nausea and vomiting. Two patients (33.3%) developed anastomotic site leakage, leading to hemoperitoneum in one and bile-induced intra-abdominal infection in the other. The pseudoaneurysms involved the proper hepatic artery (n = 3), common hepatic artery (n = 2), right hepatic artery (n = 1), jejunal artery (n = 1), and splenic artery (n = 1). All patients underwent interventional radiology procedures, with angioembolization performed in each case. Recurrent bleeding required re-embolization in three cases: two from previously treated sites and one from a new pseudoaneurysm. Bleeding occurred between the 5th and 27th postoperative days, and one patient succumbed. Early diagnosis and timely endovascular management are critical for improved outcomes in these patients.

The revised American Association for the Surgery of Trauma (AAST) organ injury scale (OIS) for splenic injury incorporates radiologic features but the implications of this are unknown. We hypothesized that the revised AAST-OIS would better predict outcomes. Patients with a blunt splenic injury admitted to a Level I trauma center were reviewed from 2016 to 2021. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for splenectomy were calculated for high-grade injuries (AAST-OIS grades IV-V) using both schemas. Of the 852 patients analyzed, 48.5% were observed, 24.6% were embolized, and the remaining underwent operative intervention. The median AAST-OIS increased from II to III (p ​< ​0.01). Sensitivity (38.0% vs. 73.7%) and NPV (80.9% vs. 88.2%) for splenectomy increased for high-grade injuries but specificity (93.5% vs 70.1%) and PPV (67.5% vs 46.7%) decreased. The revised AAST-OIS better predicted splenic salvage but is less accurate at predicting need for splenectomy. [Display omitted] •Radiologic criteria are used in the revised AAST splenic organ injury scale.•Implications of this new grading system are unknown.•We compared the previous and revised organ injury scales.•The revised organ injury scale better predicted the success of splenic salvage.•It was less accurate at predicting need for splenectomy.

PurposeTo analyze outcomes of posterior urethroplasty following pelvic fracture urethral injuries (PFUI) and to determine risk factors for surgical complexity and success.MethodsPatients who underwent posterior urethroplasty following PFUI were identified in the Trauma and Urologic Reconstructive Network of Surgeons (TURNS) database. Demographics, injury patterns, management strategies, and prior interventions were evaluated. Risk factors for surgical failure and the impact of ancillary urethral lengthening maneuvers (corporal splitting, pubectomy and supracrural rerouting) were evaluated.ResultsOf the 436 posterior urethroplasties identified, 122 were following PFUI. 83 (68%) patients were acutely managed with suprapubic tubes, while 39 (32%) underwent early endoscopic realignment. 16 (13%) patients underwent pelvic artery embolization in the acute setting. 116 cases (95%) were completed via a perineal approach, while 6 (5%) were performed via an abdominoperineal approach. The need for one or more ancillary maneuvers to gain urethral length occurred in 4 (36%) patients. Of these, 44 (36%) received corporal splitting, 16 (13%) partial or complete pubectomy, and 2 (2%) supracrural rerouting. Younger patients, those with longer distraction defects, and those with a history of angioembolization were more likely to require ancillary maneuvers. 111 patients (91%) did not require repeat intervention during follow-up. Angioembolization (p = 0.03) and longer distraction defects (p = 0.01) were associated with failure.ConclusionsPosterior urethroplasty provides excellent success rates for patients following PFUI. Pelvic angioembolization and increased defect length are associated with increased surgical complexity and risk of failure. Surgeons should be prepared to implement ancillary maneuvers when indicated to achieve a tension-free anastomosis.

Fragility pelvic fractures (FPF) are increasingly common among elderly patients and, despite being caused by low-energy mechanisms, can result in major arterial bleeding (MAB). However, few studies have examined the prevalence and predictors of MAB in this population. This study aimed to evaluate prevalence and potential risk factors associated with MAB in elderly patients with FPF. This retrospective cohort study used data from the Japan Trauma Data Bank. The study included patients (age ≧ 65 years) with FPF between 2010 and 2021, defining FPF as pelvic fractures caused by a ground-level fall. Demographic, comorbidities, and antithrombotic use were analyzed. MAB was operationally defined by the performance of therapeutic angioembolization (TAE). Multivariable logistic regression was performed to identify predictors of MAB and in-hospital mortality. A total of 1,354 patients met inclusion criteria; 80 patients (5.9%) underwent TAE. Compared with the non-MAB group, the MAB group had significantly higher rates of liver disease, cerebral vascular disease, use of antithrombotic agents, systolic blood pressure (SBP) < 90 mmHg, and lower Glasgow Coma Scale scores. A multivariable logistic regression analysis revealed that age (OR 1.04, 95% CI 1.01–1.07), male sex (OR 2.42, 95% CI 1.49–3.93), cerebral vascular disease (OR 2.11, 95% CI 1.21–3.67), liver disease (OR 6.23, 95% CI 2.36–16.40), and SBP < 90 mmHg (OR 5.43, 95% CI 2.96–9.97) were independently associated with MAB. MAB itself was independently associated with higher in-hospital mortality (OR 4.3, 95% CI 2.1–8.9). Notably, 28% of in-hospital deaths occurred within 48 h and 50% within 7 days of admission. Despite their low-energy origin, FPFs can lead to life-threatening hemorrhage requiring invasive hemostatic intervention. A subset of elderly patients—particularly those with comorbidities or hypotension upon admission—are at elevated risk of MAB and poor outcomes. Early recognition and targeted intervention strategies are essential to improve survival in this growing and vulnerable population.

While angioembolization is occasionally required for craniofacial fracture patients who experience massive maxillofacial hemorrhage, complications such as headache, temporal-facial pain, soft tissue necrosis, and embolic material migration leading to stroke or blindness can arise. Few studies have explored delayed or progressive intracerebral hemorrhage (ICH) following angioembolization for craniofacial fractures. A retrospective review of craniofacial fracture patients from January 1, 2015, to December 31, 2022 at our institution was conducted. We applied univariate and multivariable logistic regression (MLR) analyses to assess whether angioembolization served as an independent factor for delayed or progressive ICH. Propensity score matching (PSM) was used to balance the groups of patients who underwent angioembolization with those who did not. Outcome measurements included delayed or progressive ICH occurring within 72 hours, the need for additional neurosurgical interventions, and the length of stay (LOS) in the intensive care unit (ICU) and hospital. Of the 2,519 craniofacial fracture patients studied over an 8-year period, 21 (0.8%) underwent angioembolization for maxillofacial hemorrhage. MLR analysis revealed that angioembolization was an independent factor for delayed or progressive ICH (odds ratio=5.71, p = 0.028). After 1:2 PSM, patients who underwent angioembolization had greater rates of delayed or progressive ICH (28.6% vs. 7.1%, p = 0.023), an extended hospital LOS (17.0 vs. 15.0 days, p = 0.009) and a longer ICU LOS (10.0 vs. 4.0 days, p = 0.004). A greater probability of delayed or progressive ICH was observed in craniofacial fracture patients who underwent angioembolization for maxillofacial hemostasis.

Background Pelvic ring fracture is often combined with other injuries and such patients are considered at high risk of mortality and complications. There is controversy regarding the gold standard protocol for the initial treatment of pelvic fracture. The aim of this study was to assess which risk factors could affect the outcome and to analyze survival using our multidisciplinary institutional protocol for traumatic pelvic ring fracture. Material and methods This retrospective study reviewed patients who sustained an unstable pelvic ring fracture with Injury Severity Score (ISS) ≥ 5. All patients were admitted to the emergency department and registered in the Trauma Registry System of a level I trauma center from January 1, 2008, to December 31, 2017. The annular mortality rate after the application of our institutional protocol was analyzed. Patients with different systems of injury and treatments were compared, and regression analysis was performed to adjust for factors that could affect the rate of mortality and complications. Results During the 10-year study period, there were 825 unstable pelvic ring injuries, with a mean ISS higher than that of other non-pelvic trauma cases. The annual mortality rate declined from 7.8 to 2.4% and the mean length of stay was 18.1 days. A multivariable analysis showed that unstable initial vital signs, such as systolic blood pressure < 90 mmHg (odds ratio [OR] 2.53; confidence interval [CI] 1.11–5.73), Glasgow Coma Scale < 9 (OR 3.87; CI 1.57–9.58), 24 > ISS > 15 (OR 4.84; CI 0.85–27.65), pulse rate < 50 (OR 11.54; CI 1.21–109.6), and diabetes mellitus (OR 3.18; CI 1.10–9.21) were associated with higher mortality. No other specific system in the high Abbreviated Injury Scale increased the rates of mortality or complications. Conclusion Poor initial vital signs and Glasgow Coma Scale score, higher ISS score, and comorbidity of diabetes mellitus affect the mortality rate of patients with unstable pelvic ring fractures. No single system of injury was found to increase mortality in these patients. The mortality rate was reduced through institutional efforts toward the application of guidelines for the initial management of pelvic fracture.

Whether AE or PPP would be associated with survival among hemodynamically unstable pelvic fracture remains controversial. This is a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program database from 2016 to 2018. Patients >16 years with a severe pelvic fracture (abbreviated injury scale 3–5) who underwent AE or PPP were recruited. The primary outcome was in-hospital survival. Data were evaluated using a propensity-score matching (PSM) analysis. A total of 1123 patients met our inclusion criteria. Of these, AE and PPP were performed in 964 (85.8%) and 159 (14.2%) patients, respectively. Concomitant hemorrhage control laparotomy was performed in 25.6% and 82.4% of AE and PPP patients, respectively. In 220 PSM patients, the mortality rate between AE and PPP groups was not significantly different (30.9% vs. 38.2%, P = 0.321). Though patients’ characteristics differed between AE and PPP groups, comparable propensity-matched patients with severe pelvic fractures showed no significant difference in in-hospital survival. PPP was more likely to be selected for severe pelvic fractures necessitating laparotomy. [Display omitted] •Propensity-matched patients with severe pelvic fractures showed no significant difference in in-hospital survival between angioembolization and preperitoneal packing (PPP)•PPP was more likely to be selected for severe pelvic fractures necessitating laparotomy•Hemorrhagic control strategy for severe pelvic fracture should be individualized based on each patients' physiologies and anatomical features, and available resources