Observation-first versus angioembolization-first approach in stable patients with blunt liver trauma: A WTA multicenter study
Authors: Nguyen Peter D. , Nahmias Jeffry , Aryan Negaar , Samuels Jason M. , Cripps Michael , Carmichael Heather , McIntyre Robert , Urban Shane , Burlew Clay Cothren , Velopulos Catherine , Ballow Shana , Dirks Rachel C. , Spalding M.C. , LaRiccia Aimee , Farrell Michael S. , Stein Deborah M. , Truitt Michael S. , Grossman Verner Heather M. , Mentzer Caleb J. , Mack T.J. , Ball Chad G. , Mukherjee Kaushik , Mladenov Georgi , Haase Daniel J. , Abdou Hossam , Schroeppel Thomas J. , Rodriquez Jennifer , Bala Miklosh , Keric Natasha , Crigger Morgan , Dhillon Navpreet K. , Ley Eric J. , Egodage Tanya , Williamson John , Cardenas Tatiana CP , Eugene Vadine , Patel Kumash , Costello Kristen , Bonne Stephanie , Elgammal Fatima S. , Dorlac Warren , Pederson Claire , Werner Nicole L. , Haan James M. , Lightwine Kelly , Semon Gregory , Spoor Kristen , Harmon Laura A. , Grigorian Areg 
Published: October 2024

BACKGROUNDPrior studies evaluating observation versus angioembolization (AE) for blunt liver injuries (BLT) with contrast extravasation (CE) on computed tomography imaging have yielded inconsistent conclusions, primarily due to limitations in single-center and/or retrospective study design. Therefore, this multicenter study aims to compare an observation versus AE-first approach for BLT, hypothesizing decreased liver-related complications (LRCs) with observation.METHODSWe conducted a post hoc analysis of a multicenter, prospective observational study (2019–2021) across 23 centers. Adult patients with BLT + CE undergoing observation or AE within 8 hours of arrival were included. The primary outcome was LRCs, defined as perihepatic fluid collection, bile leak/biloma, pseudoaneurysm, hepatic necrosis, and/or hepatic abscess. A multivariable logistic regression analysis was used to evaluate risk factors associated with LRCs.RESULTSFrom 128 patients presenting with BLT + CE on imaging, 71 (55.5%) underwent observation-first and 57 (45.5%) AE-first management. Both groups were comparable in age, vitals, mechanism of injury, and shock index (allp> 0.05), however the AE group had increased frequency of American Association for the Surgery of Trauma Grade IV injuries (51.0% vs. 22.0%,p= 0.002). The AE cohort demonstrated increased rates of in-hospital LRCs (36.8% vs. 12.7%,p= 0.038), emergency department representation (25.0% vs. 10.0%,p= 0.025), and hospital readmission for LRCs (12.3% vs. 1.4%,p= 0.012). However, the two cohorts had similar mortality rates (5.7% vs. 5.3%,p= 0.912). After adjusting for age, ISS, and grade of liver injury, an AE-first approach had a similar associated risk of LRCs compared with observation-first management (odds ratio, 1.949; 95% confidence interval, 0.673–5.643;p= 0.219).CONCLUSIONPatients with blunt liver injury and CE undergoing an observation-first approach were associated with a similar adjusted risk of LRCs and rate of mortality compared with AE-first approach. Overall, this calls for reevaluation of the role of routine AE in blunt liver trauma patients with CE. Future prospective randomized trials are needed to confirm these findings.LEVEL OF EVIDENCETherapeutic/Care Management, Level IV.