PTS 2015 PLENARY PAPER

The use of angiography in pediatric blunt abdominal

trauma patients
Stephen J. Fenton, MD, Kristin N. Sandoval, MA,
Austin M. Stevens, RN, and Eric R. Scaife, MD, Salt Lake City, Utah

Angiography is a common treatment used in adults with blunt abdominal trauma and/or severe pelvic fractures. The Committee on
Trauma of the American College of Surgeons has recently advocated for this resource to be urgently available at pediatric trauma
centers; however, its usefulness in the pediatric setting is unclear. The purpose of this study was to determine the incidence of angiography in the treatment of blunt abdominal trauma among injured children.
METHODS:
An analysis was performed using an established public use data set of children (younger than 18 years) treated at 20 participating
trauma centers for blunt torso trauma through the Pediatric Emergency Care Applied Research Network. Patients who underwent
angiography of the abdomen or pelvis were identified and analyzed.
RESULTS:
Of the 12,044 children evaluated for blunt abdominal trauma included within the data set, 973 sustained abdominopelvic injuries.
Of these, only 26 (3%) underwent angiography. The median age was 14 years, 65% were males, with a mortality rate of 19%. Overall, 29 angiographic procedures were performed: 21 abdominal, 8 pelvic, with 3 patients undergoing both abdominal and pelvic.
Eleven patients underwent embolization of a bleeding vessel, all of which were related to the spleen. No hepatic, renal, or pelvic
vessels required embolization. The median time to angiography from emergency department evaluation was 7.3 hours. In addition
to angiography, 50% also required surgical intervention, of which 31% underwent a laparotomy. Thirty-five percent of these patients required blood product transfusion, and 42% were admitted to the intensive care unit.
CONCLUSION:
The emergent use of angiography with embolization is uncommon in pediatric patients with blunt abdominal injuries. The requirement that pediatric trauma centers have access to interventional radiology within 30 minutes may be unnecessary. (J Trauma Acute
Care Surg. 2016;81: 261265. Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.)
LEVEL OF EVIDENCE: Epidemiologic study, level III; therapeutic study, level IV.
KEY WORDS:
Pediatric; angiography; blunt abdominal trauma.
BACKGROUND:

ngiography with embolization is well established as an important adjunct in the nonoperative management of solid organ injuries and pelvic fractures in the adult population.1 Although
several studies demonstrate the safety of angioembolization within
injured children, its usefulness is uncertain, as most children can be
managed nonoperatively for these types of injuries.25 As part of
the verification process as a Level I or II pediatric trauma center,
the Committee on Trauma of the American College of Surgeons
has more recently advocated that interventional radiology (IR)
be available within 30 minutes to perform complex imaging
studies or procedures such as angiography.6 Failure to comply
with such recommendations can result in a criterion deficiency
(CD 1133) for the program with possible loss of verification.
The purpose of this study was to determine the incidence of

Submitted: November 14, 2015, Revised: February 16, 2016, Accepted: February
17, 2016, Published online: April 27, 2016.
From the Division of Pediatric Surgery (S.J.F., A.M.S., E.R.S.), University of Utah
School of Medicine, Salt Lake City, Utah, and University of Utah School of Medicine (K.N.S.), Salt Lake City, Utah.
This study was presented at the 2nd annual meeting of the Pediatric Trauma Society,
November 67, 2015, in Scottsdale, Arizona.
Address for reprints: Stephen J. Fenton, MD, Assistant Professor of Pediatric Surgery,
University of Utah School of Medicine, Primary Children's Hospital, 100 N Mario
Capecchi Dr, Suite 3800, Salt Lake City, UT 84103; email: stephen.fenton@hsc.
utah.edu.
DOI: 10.1097/TA.0000000000001097

angiography in the treatment of blunt abdominal trauma among

injured children.

METHODS
With institutional review board approval (No. 79947), an
analysis was performed of an established public use data set obtained through the Pediatric Emergency Care Applied Research
Network.7 A total of 12,044 children were treated for blunt torso
(thoracic and abdominal) trauma from May 2007 to January
2010 at one of 20 participating hospitals, six of which were freestanding children's hospitals and 14 of which were non
freestanding children's hospitals.
All children (younger than 18 years) during this period who
were evaluated for blunt trauma to the thorax and abdomen were
analyzed and included in this study as previously described.8 Inclusion criteria were the following: (1) decreased level of consciousness associated with blunt torso trauma not isolated to the
head with either paralysis and/or multiple nonadjacent long bone
fractures; (2) blunt torso trauma due to motor vehicle crash, automobile versus pedestrian/bicycle, falls 20 feet or greater in height,
crush to the torso, or physical assault involving the abdomen;
(3) evaluating physician concern for abdominal trauma resulting
in acquisition of abdominal computed tomography (CT) or ultrasound laboratory testing to screen for intra-abdominal injury, and
chest or pelvic radiographic imaging.8 Children were excluded if
the injury occurred more than 24 hours before evaluation,

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Fenton et al.

evidence of penetrating trauma, preexisting neurologic disorders,

known pregnancy, or if they were transferred from another hospital with a prior abdominal study (CT scan or DPL).
The data set was analyzed for all children who underwent
angiography (abdominal or pelvic) by IR. Additionally, children
were further analyzed for confirmed abdominopelvic injuries
that might benefit from angiography by IR. These injuries included abdominal solid organ injury (spleen, liver, or kidney),
intra-abdominal vascular injury, and pelvic fractures. All injuries
were confirmed through radiographic imaging, surgical intervention, or findings at autopsy. Splenic and hepatic injuries were
described according to the organ injury grading scales of the
American Association for the Surgery of Trauma.9 The primary
outcome of this paper was incidence of angiography (abdominal
or pelvic) after blunt trauma. All angiographic procedures were
considered whether or not embolization of a vessel was performed. The secondary outcome was time to IR following injury
or emergency department evaluation.
The data were reviewed to obtain patients' demographics
(age, sex, and ethnicity/race), mortality, hospital length of stay
(LOS), disposition, mechanism of injury, confirmed abdominopelvic injuries, surgical intervention, angiography performed,
details of embolization, and time to angiography. For continuous
variables with non-normal distribution, Wilcoxon rank-sum tests
were used. For categorical variables, the Fisher exact test was
used. Significance was assessed at the 0.05 level, and all tests were
two tailed. All analytics were performed using SAS version 9.4.

RESULTS
Of the 12,044 children treated for blunt trauma to the
torso, 973 had abdominopelvic injuries that might require angiography depending on the severity of the injury and hemodynamic stability of the patient (Fig. 1). As seen in Table 1, 61%
of these children were male, with a median age of 12 years (interquartile range [IQR], 715), median Glasgow Coma Scale
score of 15 (IQR, 1415), and median LOS of 3 days (IQR,
26). A solid organ injury (spleen, liver, or kidney) was found
in 62% of the children, with 37% being an isolated spleen injury
and an additional 33% being an isolated liver injury. A total of
451 (46%) of these children sustained a pelvic fracture, 14%
of which underwent surgical repair of the fracture. Only 16

Figure 1. Patient breakdown. SOI,solid organ injury.

262

TABLE 1. Patients' Demographics

All Patients Abdominopelvic
(n=12,044) Injury (n=973)
Age, Median (IQR), years
11 (515)
Male
39%
Mechanism of Injury
Occupant in motor vehicle collision (MVC)
32%
Fall from an elevation
14%
Fall down stairs
2%
Pedestrian or bicyclist struck by moving
19%
vehicle
Bike collision or fall from bike while riding
6%
Motorcycle/ATV/Motorized scooter collision
5%
Object struck abdomen
7%
Unknown mechanism
2%
Other mechanism
14%
ED disposition
Home
50%
Death in ED
0.01%
Admit, short-stay/observation unit
6%
Admit, general inpatient
29%
Operating room
3%
ICU
11%
Transferred to another hospital
0.3%
Blood transfusion
1%
Hospital LOS, median (IQR), days
1 (02)
Mortality rate
1%

12 (715)
61%
33%
10%
1%
27%
6%
6%
5%
1%
12%
3%
0.1%
3%
49%
7%
37%
1%
11%
3 (26)
3%

ATV, all-terrain vehicle; ED, emergency department; ICU = intensive care unit.

children (2%) were found to have an injury to an intraabdominal vascular structure, although no further identification
of the structure involved was described. Overall, operative intervention was performed on 27% of the children with the most
common, 65%, being a neurosurgical procedure and 27% requiring abdominal exploration. The injury severity score was
not provided in the data set; however, 11% received a blood
transfusion, and the overall mortality rate was 3%.
Only 23 (2%) of these 973 children underwent angiography by IR. Most (58%) were male with a median age of 16 years
(IQR, 1217). Only three were reported to be younger than
14 years. The median weight was 60 kg (IQR, 4871) with a median Glasgow Coma Scale of 15 (IQR, 7.515). The median
hospital LOS was 6 days (IQR, 410.5) with 39% of these children receiving a blood transfusion and a mortality rate of 22%.
Twenty-five total angiograms were performed, 18 of which were
abdominal and 7 were pelvic, with 2 patients receiving both. Of
the abdominal angiograms performed, 61% identified a bleeding
vessel that was embolized, all of which were a splenic artery. The
median grade of splenic injury of these children that underwent
embolization was 3 (IQR, 34). No vessels within the pelvis were
embolized. Of the 11 patients with recorded times, the median
time to angiography following injury was 7.9 hours (IQR, 510),
with the median time to angiography after the child was evaluated
in the emergency department being 7.2 hours (IQR, 38).
More than half, 57%, required surgical intervention in addition to angiography, with four patients requiring laparotomy.
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All laparotomies were performed after angiography: one, abdominal; two, pelvic; and 1 with both abdominal and pelvic. None of
these children were found to have bleeding vessels that required
embolization. One child also underwent thoracotomy for an unidentified thoracic injury. Ten children required an orthopedic
procedure, three of which were to repair a pelvic fracture. Two
of these children had undergone previous pelvic angiography,
again without any embolization performed.
Three additional children within the entire cohort (12,044)
were also found to have undergone angiography without confirmed abdominopelvic injuries. Their ages were 16 to 17 years,
with a weight between 70 and 120 kg. All survived, with a hospital LOS between two and three days. All underwent abdominal
angiography, with one also receiving a pelvic angiogram. No
vessels were embolized. Additionally, they received no blood
transfusions, nor did they require surgical intervention.
Therefore, of the 12,044 children evaluated for blunt abdominal trauma, a total of 26 children underwent angiographic
procedures following blunt abdominal trauma for an incidence
of 0.2%. All patients who received an angiogram are outlined
in Table 2. Overall, 29 angiographic procedures were performed:
abdominal, 21; pelvic, 8; with three patients undergoing both.
Eleven patients had bleeding vessels that were embolized, all
of which were described as being related to the spleen. No pelvic, hepatic, or other abdominal vessels were embolized. No description of renal artery stenting occurred. When compared to
the entire cohort, the patients who underwent angiography were
older (median age, 16 vs. 11; p < 0.0001), more likely to be admitted to the intensive care unit (42% vs. 11%; p < 0.001), with
an increased rate of blood transfusion (35% vs. 1%; p < 0.0001), a
longer median hospital LOS (5 days vs. 1 day; p < 0.0001), and

TABLE 2. Children Who Underwent Angiography

No. of patients
Age, median (IQR), years
GCS, median (IQR)
Hospital LOS, median
(IQR), days
ICU admission
Blood transfusion
Mortality
Abdominal surgery
Nonabdominal surgery
Pelvic fracture repair
Abdominal angiography
Pelvic angiography
Abdominal and
pelvic angiography
Embolization*
Time from injury to IR,
median (IQR)
Time from ED to IR,
median (IQR)

Abdominopelvic
Patients

Additional
Patients

All Patients

23
16 (1217)
15 (7.515)
6 (410.5)

3
17 (16.517)
15 (1415)
3 (2.53)

26
16 (12.517)
15 (815)
5 (310)

48%
39%
22%
17%
57%
13%
70%
21%
9%

0%
0%
0%
0%
0%
0%
67%
0%
33%

42%
35%
19%
15%
50%
12%
69%
19%
12%

61%
7.9 (5.39.8)

0%
42%
15 (13.216.8) 8.8 (5.510.8)

7.2 (3.48.3)

7.4 (4.212.8)

*All vessels that underwent embolization were described as splenic.

GCS,Glasgow Coma Score.

7.3 (3.48.4)

TABLE 3. Comparison of Children Who Underwent

Angiography

Age, median age (IQR), years

GCS, median (IQR)
Hospital LOS, median (IQR), days
ICU admission
Blood transfusion
Mortality
Abdominal surgery
Non-abdominal surgery
Pelvic fracture repair

All Patients
(n=12,044)

IR Patients
(n=26)

p Value

11 (515)
15 (1515)
1 (02)
11%
1%
1%
11%
10%
54%

16 (1317)
15 (815)
5 (310)
42%
35%
19%
15%
50%
12%

<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.001
<0.0001
<0.001

higher mortality rate (19% vs. 1%; p < 0.0001). This comparison is shown in Table 3.

DISCUSSION
The nonoperative management of significant abdominal
and pelvic injuries is the standard of care in the pediatric patient
who has had a blunt traumatic injury. More than 95% of isolated
solid organ injuries are successfully managed without surgery.10,11 The American Pediatric Surgical Association uses
the rate of splenectomy as a benchmark to compare pediatric
trauma centers and tertiary care children's hospitals, with splenectomy rates expected to be less than 5%.12,13 Angiography
with embolization has been used as an adjunct to support nonoperative management although its role in children is less defined.
Trauma literature details the efficacy of angioembolism in
treating blunt abdominopelvic injuries in the adult population,1
but pediatric literature is much more limited.2,4,5,1416 Skattum
et al.4 demonstrated an improvement of nonoperative management with splenic preservation from 90% to 98% with use of
splenic angioembolization. However, 10 patients were preemptively embolized as per an institutional protocol for high-grade
injuries with extravasation without attempting nonoperative management. Gross et al.15 embolized 15 children as initial management for contrast blush on CT scan over a 10-year period.
Although the transfusion rate was higher in the children undergoing angioembolization when compared to the nonoperative
group (40% vs. 17%), it did improve their splenic salvage rate
to 93%. Kiankhooy et al.2 successfully treated seven children
with angioembolization: hepatic, three; and splenic, four. Interestingly, the average time from evaluation to embolization in this
study was 11 hours. Vo et al.5 demonstrated that hemorrhage
due to pelvic fractures could successfully be managed with
embolization.
Although these studies describe the use of angioembolization in nonoperative management, other studies question
whether it is necessary even when CT imaging demonstrates extravasation of contrast. Van der Vlies et al.17 reviewed 9 studies
with a total of 117 patients comparing nonoperative management
with and without embolization when a contrast blush was present
on CT scan. Failure rates in both groups were similar. Bensal
et al.18 discussed 47 of 270 children with blunt splenic injury
who demonstrated contrast blush on CT imaging. None of these

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Fenton et al.

children underwent angioembolization, and all were successfully

managed nonoperatively. They found no differences in the need
for blood transfusion, LOS, or need for splenectomy when compared to children without contrast blush. Additionally, in a review
of children managed for blunt splenic trauma, Zamora et al.19
found that performing angioembolization in high-grade injuries
(IVV) did not significantly increase their rate of nonoperative
management.
Although we do not refute the value that angioembolization may provide in the nonoperative management of blunt
traumatic injuries in children, this study demonstrates that the
use of angiography, regardless of whether embolization is performed, is extremely low in a large cohort of children evaluated
for blunt abdominal and pelvic trauma across many different institutions. This rate remained low, even in the children found to
have abdominopelvic injuries that might require intervention.
Furthermore, our data also indicate that these procedures were
not performed urgently with a significant amount of time passing before the patient was taken to IR after evaluation. This delay
is consistent with what has been reported in other previous
studies.24 This raises the question of the need for urgent access
(within 30 minutes) to IR at verified pediatric trauma centers.
Even when needed for repair of traumatic aortic injuries (thoracic
endovascular aortic repair),2022 axillosubclavian injuries,23 or injuries to peripheral vasculature,24 in trauma literature, time to
endovascular intervention of these injuries has been longer than
30 minutes.2024 Additionally, adult experience with endovascular
treatment of blunt traumatic aortic injuries demonstrate that these
injuries can often be managed several days after the initial injury
in a hemodynamically stable patient.25 Fortunately, these types of
injuries are rare within the pediatric population.
While conservative management of splenic injuries in
young children is well accepted, some surgeons may question
whether adolescents and teenagers behave more like adults with
these types of injuries. The standard failure rate of nonoperative
management of solid organ injuries at a pediatric Level I trauma
center is approximately 5%.26 The group at Boston Children's
Hospital used clinical pathways, which included angiography,
to achieve universal splenic salvage over a 20-year period.27
Polites et al.12 showed that when children are separated into
younger patients and teenagers that indeed younger patients
had a lower rate of splenectomy. Their review of the National
Trauma Data Bank revealed a splenectomy rate of 3.9% for patients 14 years or younger and 11% for patients ages 15 to 17.
These studies demonstrate that for pediatric trauma centers,
the overall rate of splenectomy is low, although it may increase
as children move through adolescence.
In adult patients, there are a number of single-institution
studies that advocate for the use of angioembolization in splenic
trauma although the use of angiography has not been standardized.2830 Capecci et al.,31 in a large multicenter study, that
included patients older than 13 years, concluded that trauma
centers with aggressive angiography had a lower rate of splenectomy than centers that were less likely to perform angiography.
The centers that routinely used angiography had a splenectomy
rate of 19% compared to 24% for the low-use centers. The splenectomy rates in centers that pursue angiography in adults are
higher than the typical splenectomy rates seen at pediatric hospitals, even when you focus on teenagers. It remains unclear as to
264

whether aggressive angiography in children 18 years or younger

is superior to the nonoperative management of observation alone.
In this study, 33% of all children evaluated for blunt abdominal trauma were older than 13 years of which 214 (5%)
had a confirmed solid organ injury. Thirteen underwent angiography (12 abdominal only, 1 abdomen and pelvis), with 10 receiving splenic artery embolization. In this study, 5% (10 of
214) of children older than13 years with confirmed solid organ
injury following blunt abdominal trauma underwent angioembolization with the splenic artery being the only artery embolized. More interestingly, the average time to angiographic
intervention from emergency department triage was 6.9 hours.
Therefore, even in the small percentage of patients that underwent angiography, they did not receive it in an emergent fashion.
Our findings are consistent with those previously described in
that the older patients had a higher rate of angiography. However, it remains unknown whether embolization in this setting
provided significant clinical benefit even in those children up
to 18 years of age.
This study is limited, as it may only reflect the practice of
the participating hospitals. In addition, although data were prospectively collected, the intent to treat these injuries cannot be
completely determined, as no laboratory values or vital signs
were included. Additionally, although we are able to determine
the incidence of angiography, we are unable to account for its efficacy in patient management.
We conclude that the emergent use of angiography with embolization is extremely uncommon in pediatric patients with blunt
abdominopelvic injuries. Additionally, there is a significant time
lag between evaluation in the emergency department and the need
for angiography. Therefore, the requirement that pediatric trauma
centers have access to IR within 30 minutes may be unnecessary.
AUTHORSHIP
S.J.F. and E.R.S. designed this study. K.N.S. conducted the literature
search. A.M.S. performed data collection. S.J.F., A.M.S., and E.R.S. contributed to data analysis and interpretation. S.J.F. and K.N.S. wrote the
manuscript. S.J.F. and E.R.S. participated in critical revision.
ACKNOWLEDGMENT
The authors thank Brian T. Bucher, MD, for his assistance and verification
of the statistical analysis of this study.
DISCLOSURE
The authors declare no conflicts of interest.

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