Summer 2019 — Highly skilled and specialized interventional radiologists from Synergy Radiology Associates serve more trauma centers in Houston than any other radiology group, performing life-saving procedures for hundreds of trauma patients each year. In 2018 alone, Synergy interventional radiologists performed more than 150 emergent procedures, including both trauma and non-trauma, just during the evening and overnight hours. In this issue of the Synergy Report, we talk with two Synergy interventional radiologists involved in trauma IR procedures: Phillip Parmet, M.D., and Michael Richter, M.D.

Interventional radiology (IR) uses image guided, minimally invasive techniques to treat conditions that had previously been performed with more invasive surgery – often with less pain, less risk and quicker recovery time. The biggest differences between “routine” IR and trauma IR are the time factor and the setting. Dr. Parmet explained that Trauma IR services are for patients who have sustained major internal injuries and at risk of death from massive bleeding.

“It’s about us going in quickly, finding the site of injury, and stopping the bleed,” said Dr. Parmet. “From a tiny puncture in the groin, we can navigate our tools inside the body to the injured vessels and deploy hemostatic agents from within the artery to block it off or slow it down sufficiently for the body’s natural clotting process to stop the bleeding on its own.”

“Compared to many other clinical scenarios, trauma adds an acuity factor,” noted Dr. Richter. “While most IR procedures are carefully planned out in advance, with trauma and internal bleeding, time is of the essence.”

The Synergy trauma IR team has three interventionalists on call at any given time, 24/7, available within 30 minutes of any trauma team activation.

“Serving two level II trauma centers and one trauma center pursuing level II designation, we have the largest trauma practice of any private group in the Houston area,” said Dr. Parmet.

Trauma centers served by Synergy radiologists are Memorial Hermann The Woodlands Medical Center, Memorial Hermann Southwest Hospital and HCA Houston Healthcare Clear Lake.

“To cover this geographic area, we divided the greater Houston region into three divisions: North, Central/West and South, and each one of those divisions has 3 to 4 hospitals within it, so it’s a pretty large operation,” observed Dr. Richter. “Our IR team works very hard and may be called out on a moment’s notice at all hours of the night. But it’s nice to step back once in a while to look at the areas we cover and the patients we serve and celebrate the IR team’s life-saving contributions.”

In a life-threatening emergency, interventional radiologists provide trauma treatment through a technique called embolization, which blocks blood flow and stops rapid blood loss. They can also repair severely damaged arteries and veins with stents.

Trauma is divided into blunt trauma and penetrating injury, with blunt trauma being mostly motor vehicle crashes and falls, while penetrating trauma is usually stabbings and shootings. Embolization in trauma IR is the most common treatment. The most common trauma injuries seen by IRs are lacerations to the liver and spleen, which may be actively bleeding or may be at risk for further damage from invasive surgery based on the type of injury.

High-level trauma arriving at the hospital ED is assessed by the trauma surgeon. Based upon imaging and the injury, an IR team member may be called in to address the internal injuries without the patient having to go to the operating room. However, IR may also be called in after a surgical procedure.

“With a liver bleeding from multiple sites, for example, the surgical team may take the patient to the OR to place packing material around the liver for damage control to reduce the bleeding,” observed Dr. Parmet. “This buys time for an unstable patient to be transfused and specific bleeding sites more selectively addressed by the interventional radiologist .”

“If we can selectively treat a bleeding splenic laceration, we can spare much of the normal splenic tissue as opposed to operative management with a complete splenectomy,” added Dr. Parmet. “Preserving most of the spleen allows patients to retain the organ’s key functions, including blood filtering, supporting the immune system and fighting infection.”

Stent grafting for damaged arteries and veins can also be performed in the trauma setting.

“If a vessel is severely damaged but important enough to where you can’t sacrifice it, then sometimes you can put in a stent graft or a covered stent, which has material bonded in it to seal off the arterial injury,” said Dr. Richter.

At Synergy, trauma IR is a component of the group’s vascular and interventional services. Drs. Richter and Parmet both describe a major move toward nonoperative management (NOM) of trauma. This increasingly popular and successful approach is revolutionizing treatment options available for an increasing number of situations.

“There is a paradigm shift in how trauma and emergencies are being treated,” said Dr. Richter. “As our capabilities and expertise expand, the expectation is that minimally invasive approaches are used wherever possible. Interventional radiology is now an integral component of the multidisciplinary approach to trauma.”

“Interventional radiology is on the cutting edge in providing these minimally invasive therapies in the trauma setting and beyond,” said Dr. Parmet. “For critically injured trauma patients, if we’re able to address emergent issues in a less invasive way, hopefully we can help decrease the morbidity associated with alternative major surgical procedures whenever possible. We work hard with our trauma surgery colleagues to help achieve the best possible outcomes for these critically ill patients.”

Dr. Richter provided a recent example of the expanding role of IR in trauma. “I recently went in to embolize a patient’s bleeding artery in the chest from a gunshot wound. That’s something that until recently would have been an open surgical procedure,” described Dr. Richter. “But the expectations are shifting, and if there’s a bleeding artery that can be repaired with nonoperative management, we’re the ones to call. And our essential role will continue to expand in the future.”

In addition to their increasing presence in the acute care setting for trauma patients, Drs. Richter and Parmet both also point to the increased utilization of interventional radiology and the IR support team in the full spectrum of patient care, with minimally invasive techniques and technologies continually being refined to allow for even better care and patient outcomes in the future. For more information, visit the Synergy Vascular & Interventional Services page or the Society of Interventional Radiology Patient Center.

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