Diagnosis and management of hemorrhagic complications of interventional radiology procedures

Abstract

Image-guided interventions have allowed for minimally invasive treatment of many common diseases, obviating the need for open surgery. While percutaneous interventions usually represent a safer approach than traditional surgical alternatives, complications do arise nonetheless. Inadvertent injury to blood vessels represents one of the most common types of complications, and its affect can range from inconsequential to catastrophic. The interventional radiologist must be prepared to manage hemorrhagic risks from percutaneous interventions. This manuscript discusses this type of iatrogenic injury, as well as preventative measures and treatments for postintervention bleeding.

Keywords: complications; hemorrhage; interventional radiology; percutaneous.

Fig. 1

Hemobilia caused by transportal vein puncture during percutaneous biliary drainage catheter placement. Patient presented 2 weeks following biliary catheter placement with bloody drainage. Pullback cholangiogram demonstrated traversal of branches of right portal vein (arrowheads). The catheter was upsized with resolution of hemobilia.

Fig. 2

Arterial injury after PBD insertion. The patient presented with overnight hemobilia after PBD insertion with dropping serial hematocrit levels. (a) The initial image obtained after insertion of a right-sided PBD. A left-sided PBD was then placed (not pictured). (b) Initial celiac arteriogram demonstrates no evidence of arterial injury. (c) Repeat celiac arteriogram after removal of bilateral PBDs over guidewires demonstrates brisk active extravasation (arrowheads) originating from the proximal right anterior hepatic artery (white arrow). (d) Follow-up arteriogram of the common hepatic artery after coil embolization of the right anterior hepatic artery and main right hepatic artery. Variant middle/left hepatic artery anatomy is present, with separate branches supplying segments 2 and 3 (white arrow) and segment 4 (black arrow). Notice that multiple branches of the right hepatic artery (block arrow) are reconstituted by interlobar collaterals (arrowheads) from the middle hepatic artery (black arrow).

Fig. 3

Angiographic image of a cystic arteriogram demonstrates the arterial vascularity of a normal gallbladder.

Fig. 4

Anterograde nephrostogram obtained immediately after PCN insertion. Notice the filling defects in the collecting system, which are consistent with clot formation from bleeding. This episode was self-limited without significant hematocrit drop on next-day blood draws.

Fig. 5

Arterial injury following PCN insertion. This patient had large quantity, frankly bloody PCN output immediately after PCN insertion. (a) Renal arteriography demonstrates a pseudoaneurysm (arrow). (b) Follow-up renal arteriogram after coil embolization of the injured branch demonstrates nonfilling of the pseudoaneurysm.

Fig. 6

Inferior epigastric artery pseudoaneurysm following gastrostomy tube placement. Axial thick-slab reformatted image from a contrast-enhanced CT scan during the arterial phase demonstrates a pseudoaneurysm arising from the inferior epigastric artery (arrow). The inferior epigastric artery was successfully coil embolized across the site of extravasation (not shown).

Fig. 7

Perisplenic hematoma following percutaneous biopsy. (a) Ultrasound image demonstrates a faint hypoechoic splenic lesion (arrows). The lesion was percutaneously sampled with a 22-gauge Chiba needle (arrowhead). (b) Immediately following biopsy, the patient complained of left upper quadrant pain. An axial image from a noncontrast CT demonstrates a perisplenic hematoma (thin arrows). The patient was taken emergently to angiography and a branch of the splenic artery was successfully particle embolized (not shown).