Trauma is a cause of lesions in intra-abdominal solid organs and pelvic structures, affecting most patients in young adulthood, being responsible for high morbidity and mortality rates (Azami-Aghdash et al. 2018; Gad et al. 2012). In agreement with other studies, these lesions are the main etiologies of acute active bleeding in abdominal and pelvic structures. Trauma has a great economic impact, being responsible for 12% of health care costs worldwide (American College of Surgeons - Trauma Commite 2012).
Abdominopelvic trauma can be divided into penetrating and contused, the latter being the most common (Karamercan et al. 2008). In our study, the most frequently injured solid abdominal organ includes liver, followed by spleen, and kidney, consistently with other articles (Matthes et al. 2003; Smith et al. 2005) .
Approaches for the treatment of traumatic lesions of abdominal and pelvic structures are based on radiological findings, according to the American Association for the surgery of trauma classification, and the patient’s clinical condition (The ATLS Subcommittee, American College of Surgeons’ Committee on Trauma, and the International ATLS working group, Chicago I 2013).
With the evolution of the technique, materials, experience of interventional radiologists, with better results and lower rates of complications, and its minimally invasive aspect, the treatment of APB by embolization has had a significant role in the emergency scenario.
Among the hepatic vascular lesions, about 85% are caused by trauma (Monsignore et al. 2012); more than 80% of the hepatic lesions related to trauma can be treated with non-surgical interventions, such as clinical/radiological control (Petrowsky et al. 2012; Leppaniemi et al. 2011; Cherian et al. 2016). Embolization represents a significant number in non-surgical therapy, especially in patients with grade IV and V liver trauma, with high rates of success, with 97% of technical success at the end of the procedure (Ierardi et al. 2016; van der Wilden et al. 2013; Stassen et al. 2012; Monnin et al. 2008).
The management of splenic lesions presents divergences in the different trauma centers around the world, which indicates a difficulty in the management of this type of lesion, being widely considered the non-surgical treatment. In most of the reviewed studies, the splenic lesion with embolization was treated using as embolic material metal spirals and PVA particles (Wallis et al. 2010; Ierardi et al. 2016; Raikhlin et al. 2008; Wahl et al. 2004; Hagiwara et al. 2004), in contrast to the present study, which had the NBCA glue as the embolic material of choice. The technical success rates of the main studies are high, with 89 to 95% (Ierardi et al. 2016; Wahl et al. 2004; Hagiwara et al. 2004; Wei et al. 2008; Sabe et al. 2009) of clinical success reported in the literature.
Embolization of active renal bleeding evidenced on CT is considered an adjunct treatment to the non-operative treatment of these lesions. Renal super selective embolization has great value in preserving the functionality of the remaining parenchyma, due to the poor collateral network observed in this organ (Ptohis et al. 2017). The success rates in the transarterial embolization literature are around 96%, while the complication rates are around 8% (Ierardi et al. 2016). The most reported material in the literature for embolization in the treatment of renal trauma are metal spirals (Matthes et al. 2003), while in this study the NBCA was the embolic material of choice.
Pelvic trauma account for a large proportion of cases of trauma. Most of the treatment protocols reported in the literature in relation to pelvic trauma are based on the “Control of orthopedic damage” (Zealley and Chakraverty 2010; Hoff et al. 2002), which recommends a rapid intervention focused on bleeding control and life-saving measures, due to the high degree of bleeding and mortality of this type of trauma. External fixation and direct surgical hemostasis are the measures initially performed in pelvic trauma, but embolization has had an increasing role in emergency hemostasis in this territory (Zealley and Chakraverty 2010). Embolization success rates are high, ranging from 85 to 100% in the literature, and similar rates are observed in this article. The main embolic agents described in the literature for this type of trauma are NBCA, PVA particles and micromoles, alone or in association, in contrast to this study in which all cases were treated with NBCA.
Adrenal lesion secondary to thoracoabdominal trauma is a very rare disease and is difficult to suspect clinically. The literature on the subject is rare, covered only by case reports (Fowler et al. 2013). Imaging exams performed at the admission of polytraumatized patients, such as CT, are helpful in the diagnosis. Treatment of this type of lesion varies with severity, and may be conservative, open surgery, or TE. This kind of treatment of adrenal trauma is rare, as well as its epidemiology; however, it can also be of high value, sparing the patient from open surgery when there is high physiological stress secondary to the trauma. The literature is not sufficiently substantiated to evaluate superiority in relation to the materials used (Fowler et al. 2013). We observed only one case of active bleeding of the adrenal gland after traumatic abdominal trauma and the NBCA was used as the embolizing agent of choice.
When all the abdominal and pelvic territories eligible for embolization of traumatic bleeding are considered, the literature outlines a wide range of embolic agents, including metal spirals, hemostatic gelatin (Gelfoam®), PVA particles and, more rarely, NBCA and non-adhesive liquid embolic agents like Onyx®. The selection of embolic material has as main criterion the experience and preference of the interventional radiologist (Papakostidis et al. 2012; Lopera 2010; Wallis et al. 2010; Monnin et al. 2008).
The NBCA is an embolic agent rarely seen in the literature for the treatment of bleeding of various etiologies. In the current study, embolization performed for the treatment of trauma-related active bleeding lesions were performed with NBCA glue exclusively.
As a liquid embolic material, the NBCA has the benefit of completely occluding a vessel and/or hemorrhagic injury, which is extremely selective, rapidly prepared and used, solving the active bleeding quickly, when used by professionals trained in its manipulation.
Even though there is the possibility of non-target embolization, the NBCA is still considered of highly safety and effectiveness in the treatment of traumatic hemorrhagic lesions. As this embolizing agent does not depend on the patient’s coagulation status, it can be safely be used in cases of severe coagulopathy, which is often observed in patients in the emergency room. Some interventional radiologists avoid the use of adhesive liquid embolic agents because they consider their manipulation and injection very difficult, probably due to lack of experience with the material. The main technical limitation of the use of NBCA is its manipulation. Its characteristics of polymerization, dilution with Lipiodol, injection speed, reflux control, anatomical familiarity are important aspects related to its use, and the physician should know them well to perform safe and successful procedures (Monsignore et al. 2012).
The main complications related to the use of the NBCA are the occlusion of non-target territory, either by mistaken interpretation of the anatomy, migration of embolic material, reflux of embolic material and opening of arterio-arterial anastomoses during injection, or by migration of embolic material into the venous system, which may cause pulmonary embolism or restriction of venous return (Niimi et al. 2003). The limitations of our study were the small number of patients, its retrospective nature and and the absence of a control group, although it was consistent with other reports in the literature.
