Contemporary Management of Hepatic Trauma: What IRs Need to Know

Abstract

Trauma remains one of the leading causes of death in the United States in patients younger than 45 years. Blunt trauma is most commonly a result of high-speed motor vehicular collisions or high-level fall. The liver and spleen are the most commonly injured organs, with the liver being the most commonly injured organ in adults and the spleen being the most affected in pediatric blunt trauma. Liver injuries incur a high level of morbidity and mortality mostly secondary to hemorrhage. Over the past 20 years, angiographic intervention has become a mainstay of treatment of hepatic trauma. As there is an increasing need for the interventional radiologists to embolize active hemorrhage in the setting of blunt and penetrating hepatic trauma, this article aims to review the current level of evidence and contemporary management of hepatic trauma from the perspective of interventional radiologists. Embolization techniques and associated outcome and complications are also reviewed.

Keywords: embolization; hepatic; injury; interventional radiology; liver trauma.

Fig. 1

Summary of American Association for the Surgery of Trauma (AAST) Grading of Hepatic Trauma.

Fig. 2

Summary of variant hepatic anatomy.

Fig. 3

Open surgery followed by embolization. A 30-year-old patient status post gunshot wound taken directly to operating room for hemodynamic instability. Angiography was done intra-operatively after packing was performed due to continued bleeding and patient instability. Blush of contrast demonstrated a pseudoaneurysm (arrow) in area of hepatic laceration ( a ). Post angiography Clips ( b ). Coil embolization of the middle hepatic artery Pseudoaneurysm ( c–e ). Post embolization angiography demonstrated patency of right hepatic artery branches without opacification of the pseudoaneurysm ( f ).

Fig. 4

Arterioportal fistula. A 28-year-old patient status post stab wound presenting with acute drop in hemoglobin on postoperative day 2 for second exploratory laparotomy for washout. CTA shows a blush of contrast on arterial phase ( arrow ) ( a ). Diagnostic angiography of the celiac, proper hepatic, and left hepatic arteries ( b and c ) shows large left hepatic artery–left portal venous fistula ( arrows —left portal vein filling during arterial phase). Successful embolization of left hepatic artery using coil embolization with nonopacification of portal venous system on postembolization angiography from the base catheter in the celiac axis ( d–f ).

Fig. 5

An evidence-based proposed protocol for management of patients with acute liver injury based on WSES guidelines and institutional experience.

Fig. 6

Contained/intrahepatic biloma in patient with grade V hepatic laceration treated with surgical packing followed by Gelfoam embolization due to uncontrolled bleeding ( a ). The biloma was treated with percutaneous drainage ( b ) and resolved after 6 months not shown here.