Visceral trauma: principles of management and role of embolotherapy

Abstract

Interventional radiology for the treatment of traumatic visceral hemorrhage has emerged as an important adjunct to modern trauma care. This article outlines the general surgical concepts of the acute care of trauma patients as a guideline for catheter-based therapy. Specific considerations are presented for embolizing visceral injuries in the liver, spleen, and kidney. Expected outcomes and follow-up are reviewed.

Keywords: Trauma; damage control laparotomy; hepatic embolization; hepatic hemorrhage; renal embolization; splenic embolization.

Figure 1

(A) Initial anteroposterior celiac angiogram on a young trauma patient following high-speed motor vehicle crash. The patient had continuing arterial bleeding despite damage control laparotomy and packing. A vigorous bleed is seen originating from a right hepatic artery branch. (B) Completion celiac angiogram on the patient following subselective catheterization and embolization shows achieved hemostasis.

Figure 2

Right hepatic angiogram in a patient with continuous bleeding following hepatic packing. Active arterial bleeding is noted adjacent to the surgical pack.

Figure 3

(A) Abdominal computed tomography in a trauma patient following 30-foot fall. There is extensive liver laceration and focal pseudoaneurysm. (B) Abdominal aortogram confirms active bleeding and conventional anatomy. (C) Selective right hepatic angiogram was performed before microcatheter selection and embolization.

Figure 4

A 44-year-old man after crush injury and grade 3 liver laceration resulting in hemobilia. (A) Celiac angiogram demonstrates a 2-cm pseudoaneurysm arising from a small early branch of the right hepatic artery. (B) Angiogram with microcatheter in the pseudoaneurysm showing an outflow vessel. The distal vessel could not be catheterized and thus large particles, 900 to 1100 μm, were slowly delivered to block potential backbleeding. The pseudoaneurysm and inflow branch were then coil embolized.

Figure 5

Celiac angiogram demonstrates a traumatic pseudoaneurysm arising from between the left and right hepatic arteries. Selective catheterization is necessary to further diagnose and treat the focal bleed.

Figure 6

Common hepatic angiogram shows two pseudoaneurysms (black arrows) in this trauma patient after high-speed motor vehicle crash. Note variant middle hepatic branch. Treating multiple hepatic targets is difficult because the left and right hepatic arteries require subselective embolization to preserve organ function.

Figure 7

Splenic angiogram shows multiple pseudoaneurysms.

Figure 8

Splenic angiogram shows innumerable small pseudoaneurysms, too numerous to embolize individually. Proximal coil embolization was performed.

Figure 9

Splenic angiogram after proximal coil embolization shows reconstitution of the distal splenic artery via the dorsal pancreatic to the transverse pancreatic to the pancreaticomagna collateral route. This allows healing of the injury without inducing infarction of the spleen.

Figure 10

Penetrating trauma to the left flank and hematuria prompted angiographic evaluation. (A) Aortogram shows normal renal artery anatomy and a small inferior pole bleed. (B) Selective left renal angiogram demonstrates the bleed to arise from an interlobar branch. (C) Final angiogram following coil embolization demonstrates cessation of hemorrhage.

Figure 11

(A) Left renal angiogram in a patient with an accessory lower pole artery. Note lack of parenchymal enhancement of the lower pole when studying the upper pole artery. (B) Microcatheter selective angiogram shows active bleeding originating from an arcuate branch. This was selectively coil embolized from this position.

Figure 12

(A) Left renal angiogram in this young patient with intermittent large-volume hematuria 1 week after penetrating trauma to the left flank. A pseudoaneurysm with early filling of the renal vein (arrows) was discovered. (B) Selective angiogram on the same patient demonstrates the aneurysm. (C) Catheter is seen positioned through the pseudoaneurysm into a portion of the fistula and renal vein. This complex lesion was treated with coil embolization, which resolved the hematuria.

Figure 13

Selective left renal angiogram shows a subtle pseudoaneurysm (arrow).