Role of Interventional Radiology in the Management of Venous Trauma

Abstract

Traumatic injury to the large, central venous vasculature, although rare, is associated with high morbidity and mortality rates. Conventional open surgical treatment by repair or ligation can be technically challenging in anatomically difficult areas to expose. Furthermore, open surgical approach can release tension on the venous injury and result in uncontrollable bleeding. Endovascular techniques such as stenting and embolization can be used effectively for the treatment of traumatic venous injury. This article will discuss the morbidity and mortality associated with traumatic venous injuries, venous anatomy, endovascular treatment options, and management of traumatic venous injury.

Keywords: hemorrhage; interventional radiology; stenting; venous trauma.

Fig. 1

A combined endovascular and open surgical approach was implemented to retrieve a dominant 2-cm ballistic fragment lodged near the inferior cavoatrial junction in a 39-year-old female with a gunshot wound to the upper abdomen. ( a ) Two 35-mm snares were positioned superiorly and inferior to the ballistic fragment within the inferior vena cava (IVC). The inferior snare was used to retract the ballistic fragment toward the right femoral vein access site. The superior snare was used as a temporary measure to prevent ballistic embolization to the heart. ( b ) The ballistic fragment was retracted inferiorly into the infrarenal IVC. An IVC filter was then deployed as a permanent measure to prevent ballistic embolization. Attempts to remove the ballistic fragment via ( c ) rigid forceps and ( d ) Fogarty embolectomy balloon were unsuccessful. ( e ) The ballistic fragment was removed by surgical cutdown with primary vein closure. Postoperatively, the patient developed extensive right lower extremity deep vein thrombosis (DVT) secondary to trauma imposed by the retracted ballistic fragment against the vein wall. Management included fasciotomy, skin grafting, and iliofemoral DVT thrombectomy.

Fig. 2

Endovascular recanalization of the inferior vena cava (IVC), thrombosed in the setting of trauma with contraindication to thrombolytic therapy. The patient sustained a gunshot wound to the right upper quadrant, requiring surgical repair of retrohepatic IVC injury and liver laceration as well as coil embolization of an actively bleeding lumbar artery. ( a ) Coronal contrast-enhanced and ( b ) IVC venogram demonstrated extensive thrombus of the IVC and hepatic veins. ( c ) Maceration via a rotational thrombectomy system was implemented for clot removal. ( d ) Post-thrombectomy venogram demonstrated patency of the treated segment of the IVC (inferior IVC, left; superior IVC, right), although ( e ) IVC stenosis was noted superiorly, secondary to repair. ( f ) Uncovered stents were deployed across the stenosed segment. ( g ) Post-stenting venogram confirmed patency of the entire IVC (inferior IVC, left; superior IVC, right).

Fig. 3

A 68-year-old female presented as a trauma after she was pinned against a garage door by motor vehicle with a 10-minute extrication time. ( a ) Pelvic X-ray demonstrates extensive comminuted and displaced pelvic ring including fractures of the right superior and inferior pubic rami (asterisks), right-sided acetabular wall (thin arrow), right sacral ala (block arrow), left ilium, and left superior and inferior pubic rami (arrow heads). ( b ) Pelvic venogram demonstrates transection of the right internal iliac vein (arrow) and left internal and external iliac veins (arrowhead) with active extravasation. ( c ) Balloon tamponade of the area of venous injury was performed for temporary hemostasis as a covered stent is being prepped for deployment across the injury. ( d ) Successful deployment of a covered stent within the common and external iliac artery, across the ostium of the transected right internal iliac vein. No evidence of contrast extravasation. ( e ) A covered stent was placed in the common and proximal external iliac artery, across the ostium of the transected left internal iliac vein. Left: After the stent placement, note was made of focal extravasation arising from the distal external iliac artery (blue arrow). Right: An additional covered stent was deployed across the area of injury resulting in cessation of extravasation.