Current practices and outcomes of endovascular embolization for traumatic intercostal artery bleeding

Introduction: Endovascular embolization has been introduced for control of intercostal artery(ICA) hemorrhage. We aim to define current practices and outcomes of ICA embolization(ICA-EMB) versus surgical hemostasis(ICA-SURG).

Material & Methods: The American College of Surgeons 2017-2021 Trauma Quality Improvement Program database was queried for patients with ICA bleeding requiring intervention. Failure was defined as repeat ICA-EMB or ICA-SURG within 48 hours, and inappropriate indication for ICA-EMB was injury from other thoracic source later requiring ICA-SURG. Propensity score matching(PSM) controlled confounding.

Results: Of 622 eligible patients, 165(26.5%) underwent initial ICA-EMB. ICA-EMB patients were more likely to be older, have comorbidities, suffer blunt trauma and severe TBI. ICA-EMB use increased over time(2017:17.6% to 2021:34.5%,p=0.002), but varied between facilities, with large hospitals being more frequent users(Figure). ICA-EMB was inappropriately indicated in 7(4.2%) patients who required thoracotomy for repair of lung, diaphragm and/or pleura(1 died). In 7(4.2%) patients, ICA-EMB failed(5 required ICA-SURG, 0 died; 2 underwent second EMB,1 died). ICA-EMB failure occurred more in patients with penetrating injuries and hypotension. On unadjusted analysis, ICA-EMB was associated with higher mortality(20.0% vs 10.9%,p=0.003) and time to intervention(232 vs 93min,p<0.001) but not with higher failure rates than ICA-SURG(4.2% vs 2.4%,p=0.28). After PSM, ICA-EMB did not significantly differ in failure rates(6.7% vs 8.3%,p=1.00), time to intervention(224 vs 165min,p=0.51), nor mortality(20.0% vs 16.7%,p=1.00).

Conclusions: Embolization is an increasingly popular intervention for ICA bleeding, especially for older patients with comorbidities. It has similar failure rates to surgery when appropriately indicated. Further investigation is needed to better define appropriate indications.

Figure: Percent treated initially by embolization by facility.

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