Leading cause of death in young people Uncontrolled bleeding causes 30-40% of trauma-related deaths IR intervention can be life-saving
Hemodynamically stable, or Hemodynamically mildly unstable but unstable, notresponding to resuscitation responding to resuscitation Bowel, pancr eas, diaphra CT gm injury Ex lap Renal, hepat Pelvic injury Pelvic ic, splenic with bleeding, retroperit injury extravasation oneal hematoma, hepatic bleeding Observe, ex lap, or angio, depending Angiography on nature of injury
Causes more deaths than any other skeletal trauma 3 sources of pelvic hemorrhage Arterial Venous Cancellous bone Over 70% of unstable patients with pelvic fractures will have arterial bleeding
Pelvic trauma with active extravasation on CT Pelvic bleeding which cannot be controlled at surgery Major pelvic fracture with signs of bleeding in whom nonpelvic bleeding sources have been excluded
Pelvic aortogram (12/36) Selective internal iliac angiography – Cobra-2 or Roberts (6/18) Contralateral oblique: lays out anterior division branches Ipsilateral oblique: good visualization of superior gluteal Consider external iliac angiograms Corona mortis (replaced obturator artery) Inferior epigastric Deep iliac circumflex
Subselective embolization when possible Coils for injury to large arteries, AV fistulae, pseudoaneurysms Gelfoam for most other injuries Fails in about 10% of patients ○ Missed arterial bleeding due to temporary spasm ○ Venous bleeding Nonselective gelfoam slurry embolization of bilateral internal iliac arteries if Hemodynamically unstable Continued bleeding despite apparently successful subselective embolization Multiple bleeding sites bilaterally
30 patients had nonselective gelfoam slurry embolization of bilateral internal iliac arteries for pelvic trauma Clinical control of bleeding in 90% (97% with repeat embolization) No severe in-hospital morbidity related to embolization No evidence of pelvic or soft tissue ischemia on CT or autopsy Complications are uncommon, and are usually related to injury No long-term effects on urogenital function Slightly increased risk of buttock, thigh or perineal paresthesia Occasional skin sloughing or necrosis Nonselective bilateral internal iliac embolization is safe and effective, and should be used when selective embolization fails or is not possibleVelmahos GC, et al (2000) Angiographic embolization of bilateral internal iliac arteries to control life-threatening hemorrhage after blunt traumato the pelvis. Amer Surg 66:858-862.Ramirez J, et al (2004) Male sexual function after bilateral internal iliac artery embolization for pelvic fracture. J Trauma 56:734-741.Travis T, et al (2008) Evaluation of short-term and long-term complications after emergent internal iliac artery embolization in patients withpelvic trauma. J Vasc Interv Radiol 19:840-847.
Focal bleeding detected from internal pudendal artery. Bleeding confirmed with superselective microcatheterization. Superselective gelfoam embolization performed.Case courtesy of Christopher Loh, MD
Incidental note of spinal artery arising from injured right L1 artery. Embolization deferred.Internal iliac angiograms show diffuse bleeding on left. Both internal iliacarteries were occluded with gelfoam (insets)
Most commonly injured organ in abdominal trauma Unstable patients should go to surgery Direct control of bleeding and packing Bleeding may be difficult to control >50% operative mortality in complex injuriesSteichen FM (1975) Hepatic trauma in adults. Surg Clin North Am 55:387-407.
Stable (or mildly unstable but responding to resuscitation) patient with hepatic injury and extravasation on CT Uncontrolled hepatic bleeding at surgery
Levin-1, Cobra, or Simmons catheter Selective angiograms Common hepatic (6/30, extend to venous phase) Celiac and/or superior mesenteric (for variant anatomy) Focal injuries Subselect with microcatheter, embolize with coils, particles or gelfoam Diffuse injury (especially if unstable) Lobar embolization with gelfoam slurry Pseudoaneurysm Coil distal and proximal if possible Do not pack aneurysm sac (may rupture)
Free extravasation with common Anterior division Gelfoam and coil embolization ofhepatic artery injection subselected, multiple sites of anterior division bleeding noted
Technical success 90-100% Usually well-tolerated Patent portal vein decreases risk of infarction Rare complications Rebleeding Infarction Abscess Biliary necrosis Gallbladder necrosisHagiwara A, Yukioka T, Ohta S, et al (1997) Nonsurgical management of patients with blunt hepatic injury: efficacy of transcatheter arterialembolization. AJR Am J Roentgenol 169:1151-1156.
2nd most commonly injured solid organ in abdominal trauma Splenic injury traditionally managed with laparotomy and splenectomy Recent trends have favored non- operative management with or without angiography
Monitoring and resuscitation in splenic injury has failure rate up to 34% Adjunctive embolization increases the success rate of non-operative managementSabe A, et al (2009) The effects of splenic artery embolization on nonoperative management of blunt splenic injury: a 16 year experience. JTrauma 67:565-572.Velmahos G, et al (2003) Nonoperative treatment of blunt injury to solid abdominal organs: a prospective study. Arch Surg 138:844-851.Hagiwara A, et al (2005) Blunt splenic injury: usefulness of transcatheter arterial embolization in patients with a transient response to fluidresuscitation. Radiology 235:57-64.
Free peritoneal extravasation Relative indications: Pseudoaneurysm AV fistula Contained extravasation Hemoperitoneum Hemodynamically unstable patients should have surgical repair or splenectomy
Levin-1, Cobra, or Simmons catheter Selective splenic angiography – 5/25, extend to venous phase Embolization – optimal approach is controversial Superselective embolization ○ Microcatheterize each bleeding branch and embolize with coils, glue or gelfoam ○ Acceptable treatment for focal extravasation, AV fistulae, pseudoaneurysms Proximal splenic artery embolization ○ Catheterize main splenic artery just beyond the dorsal pancreatic artery (prior to pancreatica magna) ○ Embolize with coils or Amplatzer plug ○ May be the preferred treatment for splenic extravasation, especially if diffuse
Proximal embolization Superselective embolization Gelfoam scatter embolizationGoal: Decrease splenic Goal: Directly embolize only Goal: Nonselectivelypressure, allowing bleeding the bleeding vessels embolize entire spleento stop Best for: Best for:Best for: One or two focal bleeding Infarcting spleenDiffuse splenic bleeding vessels Producing abscessesMultiple focal bleeds Relatively stable patientUnstable patient Generally not recommendedSelective embolization Advantages:difficult Repeat embolization easier May preserve more splenicAdvantages: functionFasterLower risk of infarct andabscess
CT shows contained extravasation Control angiogram for sizing. Note pancreatica magna (arrow)Amplatzer deployed just prior to pancreatica magna Delayed phase shows late filling of intrasplenic branches Case courtesy of Geogy Vatakencherry, MD
Left: CT shows contained extravasation. Angiogram confirms extravasation with pseudoaneurysm. Above: Selective embolization of affected vessel with NBCA glueCase courtesy of David Liu, MD
Clinical success rate of splenic embolization (patient avoids splenectomy) is >90% in most studies Two studies suggest better success rates with proximal rather than superselective embolization Complication rate is 6-20% Persistent bleeding or rebleeding (11%) Missed injury (3%) Splenic abscess (4%) Coil migration (2%) Infarctions occur in about 20% More with distal embolization Most are asymptomaticKaseje N, et al. Short-term outcomes of splenectomy avoidance in trauma patients. Am J Surg 196:213-217.Haan JM, Biffl W, Knudson M. Splenic embolization revisited: a multicenter review. J Trauma 2004;56:542-547.Hagiwara A, Fukushima H, Murata A, et al. Blunt splenic injury: usefulness of transcatheter arterial embolization in patients with a transientresponse to fluid resuscitation. Radiology 2005;235:57-64.
Renal injury in 7% of penetrating and 5% of blunt abdominal trauma 1-2% of biopsies and nephrostomies Surgery for renal injury is often difficult, and often results in nephrectomy
Be as conservative as possible Monitor closely for hypotension, hematocrit drop, other signs that require intervention Pedicle injuries and avulsions need surgery Revascularization within 12 hours, if at all
Active extravasation on CT, especially if unstable Persistent or recurrent hematuria Large retroperitoneal hematoma seen at surgery Vascular pedicle injury, if not going to surgery
Abdominal aortogram Detect multiple renal arteries (30% of patients) Detect associated retroperitoneal injury (lumbar arteries) Identify renal vascular pedicle injury Selective renal angiography (Cobra or Simmons) – 6/12 Two projections, one being ipsilateral anterior oblique (best evaluation of parenchyma) Rapid imaging for AVF or pseudoaneurysm evaluation Embolization Microcatheterization with embolization as distal as possible Gelfoam, particles or microcoils Occlusion of renal branch vessels will cause parenchymal infarction proportionate to the size of the vessel
Focal extravasation; poor Superselection with Coil embolizationrenal filling microcatheter
Technical and clinical success rate of renal embolization is 82-100% Complications are uncommon Infection Sepsis Renal infarction (small infarcts usually asymptomatic) Nontarget embolization May have transient hypertensionSofocleous C, et al (2005) Angiographic findings and embolotherapy in renal arterial trauma. Cardiovasc Intervent Radiol 28:39-47.
Occur in only 1-4% of renal injuries Consider covered stents for main renal artery or large branch artery injuries Dissection Arteriovenous fistula Use of stenting should be weighed against surgical options
85% of GI bleeding comes from the upper GI tract (above ligament of Treitz) Differential for nonvariceal upper GI bleeding Peptic ulcer disease Mallory-Weiss tear Hemorrhagic gastritis Tumor Arteriovenous malformation Hemobilia Aortoduodenal fistula Endoscopy is 95% successful in identifying the source of upper GI bleeding
Medical management Volume replacement H2 blockers or proton pump inhibitors Correction of coagulopathy Early endoscopy Determine etiology Attempt treatment (place clip if unsuccessful) Angiography if medical management and endoscopy fail to control bleeding (5-10% of patients) Surgery if all other treatment modes fail 30-day mortality higher with surgery (14%) than angiography (3%)Eriksson LG, et al (2008) Transcatheter arterial embolization versus surgery in the treatment of upper gastrointestinal bleeding aftertherapeutic endoscopy failure. J Vasc Interv Radiol 19:1413-1418.
Massive bleeding Hemodynamic Transfusion instability requirement of at least OR Systolic BP <100 mm Hg 4 units in 24 hours Heart rate >100 AND Bleeding has failed to respond to conservative medical therapy Bleeding has failed to respond to endoscopic control
Celiac angiogram (Cobra, Simmons, Levin-1) – 6/30 If negative, then perform subselective angiograms Gastroduodenal artery Left gastric artery Splenic artery Superior mesenteric angiogram Especially if repeat hemorrhage after prior embolization Positive findings (seen in 60%) Extravasation of contrast into bowel lumen Pseudoaneurysm Abnormal blush (if correlated with endoscopic findings)
Acceptable techniques Superselective catheterization with embolization ○ Gelfoam, coils, particles, glue Sandwich technique (especially in GDA) ○ Coil distal and proximal to injury site ○ May add gelfoam or particles if desired Scatter embolization ○ If cannot reach bleeding site ○ Gelfoam, glue or particles (at least 300-500 micron) Evaluate for dual blood supply and back-door supply– embolize both if present Superior pancreaticoduodenal – inferior pancreaticoduodenal Right gastroepiploic – left gastroepiploic Right gastric – left gastric
If no extravasation seen, consider empiric embolization of most likely bleeding territory (GDA or left gastric) Coils +/- particles or gelfoam Guide by endoscopy Clinical success is equal to targeted embolization
Study # Technical Clinical Empiric Ischemia patients success success treatment Aina 2001 75 99% 76% 38% 4% Schenker 163 95% 58% 63% 1% 2001 Poultsides 57 94% 51% 38% 7% 2008 Loffroy 2009 60 95% 72% - 0%Aina R, et al (2001) Arterial embolotherapy for upper gastrointestinal hemorrhage: outcome assessment. J Vasc Interv Radiol 12:195-200.Schenker M, et al (2001) Upper gastrointestinal hemorrhage and transcatheter embolotherapy: clinical and technical factors impacting successand survival. J Vasc Interv Radiol 12:1263-1271.Poultsides G, et al (2008) Angiographic embolization for gastroduodenal hemorrhage: safety, efficacy and predictors of outcome. Arch Surg143:457-461.Loffroy R, et al (2009) Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of earlyrebleeding. Clin Gastroenterol Hepatol [Epub ahead of print]
Perform angiography early Delay in angiography, multiorgan failure and high transfusion requirement are all predictors of clinical failure Clinical failure is common in coagulopathic patients Do not use coils alone in these patients Empiric embolization is effective if no extravasation is seen Ischemia is rare Usually self-limited Higher risk in post-operative patients
15% of gastrointestinal hemorrhage comes from the lower GI tract (beyond the ligament of Treitz) Resolves spontaneously in 80% of cases Differential diagnosis for lower GI bleeding Older: Diverticulosis, angiodysplasia, hemorrhoids, tumor, ischemia Younger: IBD, infection
Nonmassive Intermittent bleeding: bleeding, stable patient Colonoscopy Conservative management Consider tagged RBC scan with 24 hour images Elective colonoscopy Consider angiography +/- provocation Massive Massive bleeding, stable patient bleeding, unstable Tagged RBC scan or MDCT patient ○ Positive: Angiography Prompt angiography ○ Negative: Colonoscopy Or, just go to angio Surgery if angiography fails
Superior mesenteric angiogram (Cobra, Sos, Levin-1) – 6/30 Inferior mesenteric angiogram (Sos, Simmons, Mikaelsson) – 2-3/15 If negative, celiac angiogram About 15% of hematochezia has upper GI source Variant middle colic artery (from dorsal pancreatic) If all are negative, consider internal iliac angiograms Inferior and middle rectal arteries (from internal iliac) If repeated angiograms have been negative, consider provocation Heparin 5000 units, nitroglycerin 200 ug, tPA 4 mg Repeat angio in 5-10 minutes; can repeat dosing if negative Successful in 31%, no hemorrhagic complicationsKim CY, Suhocki PV, Miller MJ, et al (2010) Provocative mesenteric angiography for lower gastrointestinal hemorrhage: results from a single-institution study. J Vasc Interv Radiol 21:477-483.
Microcatheterize bleeding vessel If distal vasa recta can be reached Proceed with superselective embolization Microcoils or particles If distal vasa recta cannot be reached Selective coil embolization at marginal artery level (likely increases ischemic risk) -or- Vasopressin ○ Park catheter in proximal SMA or IMA ○ 0.2 units/minute, repeat angio at 20 minutes ○ Can increase to 0.4 units/minute
65 y/o male with massive bleeding – superselective coil embolization
52 y/o with intermittent rectal bleeding, endoscopies negative
Patient began having right abdominal pain Lactate remained normal CT with mild wall thickening but no pneumatosis Colonoscopy 2 weeks later showed ascending colon ulcer, no bleeding Managed expectantly with gradual resolution
Study # Primary embolic Technical Clinical success Major patients success (immediate/durable) ischemiaBandi 2001 48 PVA particles* 73% 69/44% 0%Gordon 1997 17 Microcoils* 82% 76/76% 0%Kuo 2003 22 Microcoils** 100% 86/86% 0%Funaki 2001 27 Microcoils** 93% 96/81% 7%D’Othee 2006 19 Microcoils** 89% 89/68% 11%* Embolization only performed if distal vasa recta could be reached** Embolization performed at vasa recta or marginal arteryGordon R, et al (1997) Selective arterial embolization for the control of lower gastrointestinal bleeding. Am J Surg 174:24-28.Kuo W, et al (2003) Superselective microcoil embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol 14:1503-9.Bandi R, Shetty PC et al (2001) Superselective arterial embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol12:1399–1405.Funaki B, Kostelic JK et al (2001) Superselective microcoil embolization of colonic hemorrhage. AJR 177:829–836.d’Othée BJ, Surapaneni P et al (2006) Microcoil embolization for acute lower gastrointestinal bleeding. Cardiovasc Intervent Radiol 29:49–58
Frequency of positive angiograms is low Consider tagged RBC scan to improve yield Superselective embolization Embolize at distal vasa recta whenever possible Embolization at marginal artery level is usually safe if necessary Microcoils or particles Less collateral supply than upper GI tract But, ischemia remains relatively uncommon
CT is extremely helpful if patient stability permits No longer the “doughnut of death” If angiography is indicated, don’t wait Consider anesthesia support The liver, upper GI tract and pelvis tolerate extensive embolization well Don’t get overly concerned about radiation time or contrast dose in dying patients “Most complications are acceptable alternatives to exsanguination”
Overall sensitivity of angiography for LGIB is about 50% Positive tagged RBC study increases yield from 22 to 53% Technical success rates of embolization are high Vasa recta only: Technical success 73-82%, major ischemia 0% Vasa recta or marginal artery: technical success 89-100%, major ischemia 0-11% Complications Early rebleeding (within 30 days) in 21% Severe ischemic complication (surgery required) in 2% Minor ischemic complication (pain or asymptomatic stricture) in 10%Kuo W, et al (2003) Superselective microcoil embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol 14:1503-9.Bandi R, Shetty PC et al (2001) Superselective arterial embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol12:1399–1405.Funaki B, Kostelic JK et al (2001) Superselective microcoil embolization of colonic hemorrhage. AJR 177:829–836.d’Othée BJ, Surapaneni P et al (2006) Microcoil embolization for acute lower gastrointestinal bleeding. Cardiovasc Intervent Radiol 29:49–58