Successful minimally invasive management using transcatheter arterial embolization in a hemodynamically stable elderly patient with mesenteric vascular injury in a hybrid emergency room system cin Korea: a case report

Abstract

Mesenteric injury occurs rarely in cases associated with blunt abdominal trauma. Despite its low incidence, mesenteric injury can lead to fatal outcomes such as hypovolemic shock due to hemoperitoneum or sepsis due to intestinal ischemia, or perforation-related peritonitis. For mesenteric injuries, especially those involving massive bleeding, intestinal ischemia, and perforation, the standard treatment is surgery. However, in the case of operative management, it should be borne in mind that there is a possibility of complications and mortality during and after surgery. The usefulness of transcatheter arterial embolization (TAE) is well known in solid organs but is controversial for mesenteric injury. We present a 75-year-old man with mesenteric injury due to blunt abdominal trauma. Initial abdominal computed tomography showed no hemoperitoneum, but a mesenteric contusion and pseudoaneurysm with a diameter of 17 mm were observed near the origin of the superior mesenteric artery. Since there were no findings requiring emergency surgery such as free air or intestinal ischemia, it was decided to perform nonoperative management with TAE using microcoils in hybrid emergency room system. TAE was performed successfully, and there were no complications such as bleeding, bowel ischemia, or delayed bowel perforation. He was discharged on the 23rd day after admission with percutaneous catheter drainage for drainage of mesenteric hematoma. The authors believe that treatment with TAE for highly selected elderly patients with mesenteric injuries has the positive aspect of minimally invasive management, considering the burden of general anesthesia and the various avoidable intraoperative and postoperative complications.

Keywords: Case reports; Hybrid emergency room system; Mesenteric injury; Nonoperative management; Transcatheter arterial embolization.

Fig. 1.

A computed tomography scan performed at a previous hospital shows a pseudoaneurysm that occurred proximal to the superior mesenteric artery (SMA). A saccular pseudoaneurysm of about 17 mm in size was seen near the SMA root (arrows), and a hematoma was observed near the mesentery. (A) Axial view. (B) Coronal view.

Fig. 2.

In the follow-up computed tomography scan, the size of the pseudoaneurysm increased to 20 mm (arrows). The amount of mesenteric hematomas was also increased. (A) Axial view. (B) Coronal view.

Fig. 3.

Angiography of the superior mesenteric artery (SMA). (A) Angiography showed a pseudoaneurysm branching directly from the SMA (arrow). (B) Embolization using detachable coils (Interlock, Boston Scientific; Concerto, Medtronic) was performed for a pseudoaneurysm (arrow). Also, feeding artery was embolized by two Interlocks (arrowhead).

Fig. 4.

Computed tomography performed on the 4th day of admission. (A) The coil was well bundled inside the pseudoaneurysm (arrow). (B) A previously unseen localized hematoma (arrow) was newly observed. There was no evidence of active bleeding.

Fig. 5.

Scans performed on the 13th day of hospitalization. (A) Computed tomography scan showed no significant change in hematoma volume. (B) Percutaneous catheter drainage was performed.

Fig. 6.

Computed tomography scan performed 3 months after percutaneous drainage catheter removal showed that all previously observed hematomas had disappeared.