Hepatic trauma

Abstract

Management of trauma-related liver injury has undergone a paradigm shift over the past four decades. In hemodynamically stable patients, the standard of care in the majority of level-one trauma centers has shifted to nonoperative management with high success rates, especially with low-grade liver injuries (i.e., grade I and II liver injuries). Advances in critical care medicine, cross-sectional imaging, and transarterial embolization techniques have led to the improvement of patient outcomes and decreased mortality rates in patients with arterial injuries. Currently, no consensus guidelines on appropriate patient selection criteria have been published by the Society of Interventional Radiology (SIR) or the American Association for the surgery of Trauma (AAST). Based off the current literature, nonoperative management with hepatic angiography and transarterial embolization (TAE) should be the treatment of choice in hemodynamically stable patients with clinical suspicion of arterial injury. TAE has been shown to improve success rates of nonoperative management and is well tolerated by most patients with low complication rates. Hepatic necrosis is the most common and concerning reported complication but can be reduced with selective approach and choice of embolic agent. The majority of literature supporting the use of TAE for trauma-related liver injury consists of retrospective case series and additional larger scale studies are needed to determine the efficacy of TAE in this setting. However, it is clear from the current literature that hepatic TAE is an effective and safer option to operative management in treating arterial hemorrhage in the setting of traumatic hepatic injury.

Keywords: Transarterial embolization (TAE); emergency interventions; hepatic trauma.

Figure 1

Digital subtraction angiography in a patient status post rollover all-terrain vehicle accident. Selective common hepatic (left) and superselective right hepatic (right) angiography demonstrate multifocal areas of arterial extravasation from the liver (asterisks). Note the displacement of the liver capsule from the chest and abdominal wall, indicating the presence of a large perihepatic hematoma (arrows). Images courtesy of Dr. Keith Quencer.

Figure 2

TAE for non-penetrating trauma. (A) Contrast enhanced CT done in an 8 month old victim of non-accidental trauma showed arterial extravasation/pseudoaneurysm formation in the left lobe of the liver (asterisk). (B) Common hepatic angiogram failed to show the extravasation/pseudoaneurysm. (C) Selective left hepatic artery injection via cannulation of an accessory left hepatic artery arising from the left gastric artery showed the site of extravasation(asterisk). This was treated with gelatin sponge slurry embolization to good angiographic effect (not shown). Care was withdrawn due to significant intracranial injuries and the patient unfortunately passed shortly thereafter. Images courtesy of Dr. Keith Quencer. TAE, transarterial embolization.