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Angioembolization in Pediatric Solid Organ Injury: The ATOMAC Protocol
Maria Linnaus, MD1, Nilda M Garcia, MD2, Karla A Lawson, PhD2, Crystal S. Langlais, MPH1, Cynthia Greenwell3, Robert W. Letton, MD4, R. Todd Maxson, MD5, James W Eubanks III, MD6, Adam C. Alder, MD3, David Tuggle, MD2, Todd A Ponsky, MD7, Shawn D St. Peter, MD8, Amina M. Bhatia, MD9, Charles M. Leys, MD10, David M Notrica, MD1. 1Department of Surgery and Trauma, Phoenix Children's Hospital, Arizona, USA, 2Department of Surgery and Trauma, Dell Children's Medical Center Austin, Texas, USA, 3Trauma Services, Dallas Children's Medical Center, Dallas, Texas, USA, 4Department of Surgery, Oklahoma Children's Hospital, Oklahoma City, OK, USA, 5Department of Surgery, Arkansas Children's Hospital, AK, USA, 6Division of Pediatric Surgery, Le Bonheur Children's Hospital, Memphis, TN, USA, 7Division of Pediatric Surgery, Akron Children's Hospital, Ohio, USA, 8Children's Mercy Hospital, Kansas City, MI, USA, 9Emory University School of Medicine, Atlanta, GA, USA, 10University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.

Background: Non-operative management of the stable child with solid organ injury (SOI) is standard of care. Options for unstable children include angioembolization (AE) or surgical intervention. While AE is proven effective in adult patients, limited evidence exists to support its use in pediatric trauma.

Methods: A 10-center prospective study of pediatric patients treated at level 1 pediatric trauma centers between 2013 and 2016 with blunt liver and/or spleen injury was conducted. The ATOMAC guideline for SOI management was used. Data collected included injury demographics, interventions, and techniques used for embolization.

Results: Data on 945 children with blunt liver or spleen injury were included in the full cohort. At presentation, 271 had recent/ongoing bleeding and were considered unstable. Thirty-one patients had angiography and 18 had AE. Of the 18 patients undergoing AE, 8 had hepatic artery embolization, 9 had splenic artery embolization (main artery (35.3%), branch artery (64.7%)), and 1 patient had both liver and splenic AE. Embolization materials used included coil (53.3%), foam (26.7%), and beads (20.0%). Six of the eight liver patients (75%) required intervention despite AE, including ERCP with sphincterectomy and stent placement (n=1), laparotomy and packing (n=2), percutaneous drain placement (n=2), and hepatorrhaphy (n=1). No operative interventions were performed after splenic AE. There were no deaths after embolization.

Conclusions: AE appears to be a safe treatment modality for pediatric SOI and should be considered in the treatment of the pediatric patient. While splenic artery embolization appears definitive, AE for liver injury often required additional intervention.

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