15 - Outcomes from Prophylactic Intercostal Artery Embolization in Patients with Traumatic Hemothorax Refractory to Surgical Intervention

Intercostal artery embolization (IAE) has been shown to be an effective and safe method for managing intercostal artery injuries resulting from trauma and iatrogenic injury.  In the absence of active hemorrhage appreciable on angiography, embolization is often deferred to minimize the risk for non-target embolization resulting in paralysis.  Empiric embolization of intercostal arteries affiliated with rib trauma, refractory to surgical management, is not well understood.  

Materials and Methods:

Single-center retrospective study reviews cases of IAE in the setting of thoracic trauma where surgical management was unsuccessful in definitively managing hemothorax. Outcomes are compared with patients who received IAE in the setting of trauma and iatrogenic injury where active arterial extravasation is appreciated on imaging.  Comparisons are also made with patients who underwent angiography where empiric embolization was deferred. Factors suggesting an improved clinical result—such as diminished chest tube output, improved hemoglobin, diminished pressor requirement, etc.,—are examined and compared across groups. 

Results:

13 patients underwent empiric intercostal artery angiography with embolization following surgical intervention, including VATS for hematoma evacuation and / or rib fixation. The mean number of intercostal arteries treated per patient was 1.46, at levels underlying displaced rib fractures. 9 patients had embolization deferred in the absence of active arterial extravasation identifiable during angiography.  61 patients underwent IAE for other reasons.  The artery of Adamkiewicz was identified 18% (15/82) of the time, and embolization at this level was never performed.  For instances where empiric embolization was performed, microcoils (n=7) and/or gelfoam (n=10) were used.  Post intervention outcomes of diminished chest tube output and improved hemoglobin were observed and considered significant (p< 0.01) relative to outcomes in patients where embolization was deferred. In all patients, a pre-interventional hgb of < 10 g/dl was affiliated with worse outcomes.

Conclusion: The results from this study suggest that empiric IAE at the level of known intercostal artery compromise, underlying displaced rib fractures, is likely safe and affords patients with better outcomes when compared to instances where embolization is deferred.  Special consideration must be taken to identify the artery of Adamkiewicz when possible, and to perform distal arterial embolization using embolic material less inclined to reflux into non-targeted arteries.