Spontaneous Retroperitoneal Hematoma Treated with Percutaneous Transarterial Embolization in COVID-19 Era: Diagnostic Findings and Procedural Outcome

Round 1

Reviewer 1 Report

Perfect and well-timed job.

I would like to get  the explanation for this sentence in your article: '...the 96-hours follow-up based on clinical and laboratory parameters and, when indicated, CTA evaluation...'. Did you scanned all patient after the embolisation procedure? And how you decided that there are or not indications for the follow up CTA?  Maybe only CT, not CTA was done for all the emobolised patients? 

Author Response

REVIEWER 1

Comments and Suggestions for Authors

Perfect and well-timed job.

• We thank the reviewer for the very encouraging comment on our paper.

I would like to get the explanation for this sentence in your article: '...the 96-hours follow-up based on clinical and laboratory parameters and, when indicated, CTA evaluation...'. Did you scanned all patient after the embolisation procedure? And how you decided that there are or not indications for the follow up CTA?  Maybe only CT, not CTA was done for all the emobolised patients?

• We thank the reviewer. The 96 hours follow-up was based first on clinical and laboratory signs of rebleeding to assess the clinical success rate. There was no systematical re-scan of all patients after the embolization procedure. After TAE, CTA was performed in those patients who presented clinical and/or laboratory signs of bleeding.

Reviewer 2 Report

Dear authors

You present the results of embolisation of retroperitoneal haematomas comparing a COVID and non-COVID population. I think that this study has too many confounding biases to be able to interpret the results (follow-up too short, no notion of all the associated therapies in this complex pathology which concerns patients with heavy management). It is essential to review the information on anticoagulants if you want to draw conclusions.

Below are my detailed remarks:

Intro : 
Remove the part about the epidemic. Put the problem faster

Why figures in the introduction????

Method :
L186 : leves --> levels

Laboratory findings : transfusion or not ? how to normalise ?, better mortality at 1 month

Result:
Need a flowchart (patient ratio)
More details on failures are needed. More detail on blinded embolization (how many arteries, which ones? etc)

Many biases: no notion of anticoagulant treatment, reversion of treatments, we are given the INR but for heparin, it is more interesting to have the TCK, no details on failures: resorable material? no visible bleeding, maybe not the right embolised artery?
No notion of follow-up. These are complex patients and the postoperative period is important.

Too small number of patients for comparison.

Best

Author Response

Please see the attachment.

 

 

 

Author Response File: Author Response.pdf

Reviewer 3 Report

A single centre experience of radiological-clinical findings and  endovascular management - outcome of SRPH comparing 10 covid vs 14 non covid patients is extensively reported. Described diagnostic and therapeutic management of SRPH are according to current standards of clinical practice. Based on their experiences, no significant difference in management and outcome was noted between the 2 groups (apart from the sanitation precautions-measurements).  

Writing style and readability of the manuscript is adequate. Minor typo's, layout and spelling issues.

The value of the manuscript is not very high, as it primarly describes the results of a common clinical practice in a hospital with an IR unit. Also, the imaging features (although adequately illustrated) are already generally well known. However, it is useful in a way that it is noted that Covid 19 + doesn't preclude the normal way of managing these patients, apart from the preventive hygienic management and desinfective measurements.

I have the following comments:

• In my humble opinion the manuscript is too extensive. I think the message can be poured into a bit more concise version
• Were all the patients intubated? Where was this done? If angiosuite, special precautions?
• Covid 19 + patients: make a differentiation between admitted with concurrent (secundary problem) or due (primary diagnosis) to covid 19 infection?
• I think that aortic injections in patients with - CTA is of no additional value, except for navigation purposes. In these situations, selective angiograms from all potentially supplying arteries are more indicated.
• LMWH in all patients? Or according to protocol, without regarding covid status? Please, be more specific.
• It would be interesting to have a more elaborative analysis of the coagulability status of the patients, by including more specific biomarkers for cytokine storm - endothelial dysfunction in covid 19 (eg anti thrombine levels, d-dimer levels). Can we detect the patients with additional risk for developing thrombo-embolic or hemorrhagic complications by laboratory findings (or any means) before and during embolisation procedures?
• It appears that conservative management of hemorrhagic covid 19 patients is less effective than the actual endovascular treatment. It might be interesting to make an analysis of the comparison of SRPH patients before the embolization phase as well.
• I suppose that the residents assisted the IR's rather than doing the procedures by themselves? 

 

Author Response

Comments and Suggestions for Authors

A single centre experience of radiological-clinical findings and endovascular management - outcome of SRPH comparing 10 covid vs 14 non covid patients is extensively reported. Described diagnostic and therapeutic management of SRPH are according to current standards of clinical practice. Based on their experiences, no significant difference in management and outcome was noted between the 2 groups (apart from the sanitation precautions-measurements). 

Writing style and readability of the manuscript is adequate. Minor typo's, layout and spelling issues.

The value of the manuscript is not very high, as it primarly describes the results of a common clinical practice in a hospital with an IR unit. Also, the imaging features (although adequately illustrated) are already generally well known. However, it is useful in a way that it is noted that Covid 19 + doesn't preclude the normal way of managing these patients, apart from the preventive hygienic management and desinfective measurements.

• We thank the reviewer for the encouraging comment on our paper.

I have the following comments:

In my humble opinion the manuscript is too extensive. I think the message can be poured into a bit more concise version

• We thank the reviewer, and we agree with the suggestion. We summarized a little the introduction.

Were all the patients intubated? Where was this done? If angiosuite, special precautions?

• No, not all patients were intubated. However, when intubation was needed, it was often performed in intensive care unit or by the emergency team.

Covid 19 + patients: make a differentiation between admitted with concurrent (secundary problem) or due (primary diagnosis) to covid 19 infection?

• Covid 19 + patients were, to our knowledge, admitted with clinically relevant Covid19-pneumonia. However, unfortunately we do not have information about possible concurrent diseases.

 

I think that aortic injections in patients with - CTA is of no additional value, except for navigation purposes. In these situations, selective angiograms from all potentially supplying arteries are more indicated.

• We thank the reviewer. We started DSA evaluation of bleeding with aortic injection, but selective and, in some cases, super-selective angiograms of potentially bleeding arteries were also performed.

LMWH in all patients? Or according to protocol, without regarding covid status? Please, be more specific.

• We thank the reviewer. Unfortunately, we could not assess if all patients were undergoing anticoagulant or antiplatelet drugs since these data were not available on our digital medical records or on our RIS/PACS system.

It would be interesting to have a more elaborative analysis of the coagulability status of the patients, by including more specific biomarkers for cytokine storm - endothelial dysfunction in covid 19 (eg anti thrombine levels, d-dimer levels). Can we detect the patients with additional risk for developing thrombo-embolic or hemorrhagic complications by laboratory findings (or any means) before and during embolisation procedures?

• We thank the reviewer for the interesting suggestion. Since this is a retrospective study, we could not better (and extensively) indagate the coagulability status of the patients, but we agree with your thoughts, and we hope that further studies will assess this.

It appears that conservative management of hemorrhagic covid 19 patients is less effective than the actual endovascular treatment. It might be interesting to make an analysis of the comparison of SRPH patients before the embolization phase as well.

• We thank the reviewer; we agree with the reflection but this study was focused on the evaluation of the efficacy and safety of transarterial embolization treatment for SRH. Your interesting suggested analysis could be batter performed including all patients with SRH, not only those who underwent TAE treatment.

I suppose that the residents assisted the IR's rather than doing the procedures by themselves?

• Yes, your guess is right.