title: Major hepatic necrosis: a common complication after angioembolization for treatment of high-grade liver injuries.
abstract: BACKGROUND
  The management of high-grade liver injuries often involves a combination of operative and nonoperative strategies. Angioembolization (AE) is frequently used in the management of these injuries. Morbidity in patients with high-grade hepatic injuries remains high despite improvements in mortality with a multimodality approach. Major hepatic necrosis (MHN) is a morbid, but underappreciated complication of AE in this patient population. This study will examine the risk factors and outcomes of patients with high-grade liver injures managed with AE who developed the complication of MHN.
  
  
  METHODS
  Patients admitted to the R Adams Cowley Shock Trauma Center between January 2002 and December 2007 with high-grade blunt or penetrating liver injuries (grades III-VI) were identified from the trauma registry and the medical records were retrospectively reviewed. Demographic and injury specific data, complications, and admission physiologic variables were collected. Patients who had therapeutic AE, either preoperatively or postoperatively, and went on to develop liver-related complications including MHN were reviewed.
  
  
  RESULTS
  There were 538 patients with high-grade liver injuries admitted during a 5-year period. One hundred and sixteen patients (22%) underwent angiography, and 71 (13%) had a therapeutic AE. Sixteen patients (22.5%) had grade III injuries, 44 (62%) had grade IV injuries, and 11 (15.5%) had grade V injuries. Overall mortality in this group was 14% with eight patients (11.3%) dying as a result of their liver injury. Complication rates were 18.8%, 65.9%, and 100% in the patients with grades III, IV, and V injuries, respectively, for an overall complication rate of 60.6%. Thirty patients (42.2%) went on to develop MHN. Patients who developed MHN were compared with those who did not. Baseline characteristics, Injury Severity Score, and hemodynamic parameters at admission were no different between the two groups. Patients with MHN had higher grade injuries, required significantly more blood product transfusions, and had a significantly longer length of stay (all p < 0.001). Patients who developed MHN were more likely to have undergone operative intervention (96.7% vs. 41.5%, p < 0.001), with 87% having a damage control laparotomy. Other liver-related complications occurred more frequently in the patients that developed MHN (60.0% vs. 34.1%, p = 0.03). However, mortality was not different in the two groups.
  
  
  CONCLUSIONS
  High-grade liver injuries pose significant challenges to those who care for trauma patients. Many patients can be successfully managed nonoperatively, but there are still patients that require laparotomy. AE is the logical augmentation of damage control techniques for controlling hemorrhage. However, given the nature and severity of these injuries, these therapies are not without complications. MHN was found to be a common complication in our study. It tended to occur in high-grade injures, was associated with higher complication rates, longer hospital length of stay, and higher transfusion requirements. Management of MHN can be challenging. Factors that still need to be elucidated are the role of perihepatic packing and timing of second look operation.
authors.affiliation: Division of Critical Care, Program in Trauma, R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA. ddabbs@umm.edu
authors.forename: Danielle N
authors.initials: DN
authors.lastname: Dabbs
authors.forename: Deborah M
authors.initials: DM
authors.lastname: Stein
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Scalea
mesh_terms: D000293:Adolescent; D000328:Adult; D000792:Angiography; D004621:Embolization, Therapeutic / Q000009:adverse effects*; D005260:Female; D006465:Hemoperitoneum / Q000401:mortality / Q000473:pathology / Q000628:therapy; D006470:Hemorrhage / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D006801:Humans; D015601:Injury Severity Score; D008099:Liver / Q000098:blood supply / Q000293:injuries* / Q000473:pathology; D008297:Male; D047508:Massive Hepatic Necrosis / Q000209:etiology* / Q000401:mortality / Q000473:pathology; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate; D014057:Tomography, X-Ray Computed; D055815:Young Adult