Dr Lucian Roseverne: Interventional radiology: standing member or invite only? From CICM ASM PROGRAM 2019.

1. INTERVENTIONAL
RADIOLOGY IN
TRAUMA
LUCIAN ROSEVERNE FRANZCR EBIR

2. INTRODUCTION
SOLID VISCERAL INJURY AND TRAUMA
▸Trend towards non-operative management of solid organ injury over
the last 25 years.
▸NOM management of significant injuries is enabled by:
▸Precise diagnosis using CT
▸Facilities for close monitoring
▸Recourse to angiography +/- embolisation
▸Demonstrated decrease in mortality and hospital stay
▸Fewer blood transfusions
▸Significant reduction is shock index
Wallis et al, World J Emeg Surg, 2010
Wahl et al, J Trauma, 2002

3. INTRODUCTION
CECT
▸Contrast enhanced CT is the best imaging
study in stable patients with significant
trauma
▸Surgery remains mainstay of treatment in
unstable patients with the exception of
bleeding at certain difficult to access sites
with are preferably managed
endovascularly irrespective of
haemodynamic status
▸Allows accurate diagnosis and grading of
injuries
▸Contrast allows localisation of the site of
bleeding or vascular injury
▸The interventional radiologist brings more
than just catheter skills to the trauma team

4. GENERAL
AMERICAN ASSOCIATION FOR THE SURGERY
OF TRAUMA ORGAN INJURY SCALE
▸Most widely accepted system for grading traumatic injuries.
▸Reflects severity, guides management and aids prognosis
▸Updated for liver, spleen and kidney in 2018.
▸“Management of solid organ injury has continued to evolve to one based primarily
on non-operative management with increased reliance on CT for diagnosis and
classification.”
▸Most significant change - incorporation of active haemorrhage and vascular injury
diagnosed on CT.
▸The presence of a vascular injury is associated with high failure rates of NOM.
▸“…it is possible that the higher injury grade may prompt intervention, such as
angioembolisation, though this revision does not address treatment strategies.”
Kozar et al, J Trauma Acute Care Surg, 2018

5. GENERAL
PSEUDOANEURYSM
(PSA)
▸ This is a contained rupture
▸ It must be excluded from the circulation - usually
requiring a “sandwich”/“back door/front door” approach
▸ Coils should not be placed IN acute traumatic PSAs
▸ Covered stents however this is difficult in trauma

6. ARTERIOVENOUS
FISTULAE (AVF)
▸ Fistula between high pressure artery and
vein.
▸ Higher association with penetrating trauma
(esp in extremities)
▸ Pressurised and unstable acutely may
bleed, chronically may result in
aneurysms, steal phenomenon, high
output cardiac failure
▸ Retrograde bleeding is a concern
▸ Technical considerations due to high flow

7. GENERAL
ANGIOGRAPHY IN TRAUMA
▸Coaxial systems and microcatheters allow super-selection of injured vessels to
achieve haemostasis while preserving as much tissue as possible
▸Trauma cases differ from most angiography cases:
▸Younger patients with normal vessels - smaller and tendency to spasm
▸Requirement for speed
▸High cardiac output requiring increased rate and volume of contrast
▸Altered clotting mechanisms (from hypothermia and volume expansion/PRBC
without plasma)
▸Aim at haemostasis before coagulopathy ensues
▸Coagulopathy directs type of embolic agent and selection of target vessel

8. GENERAL
EMBOLICS
▸Numerous options. Choice guided by:
▸Temporary or permanent
▸Size of vessel
▸Stability and proximity
Temporary Permanent
Gelfoam Particles
Coils
Liquids
Plugs
▸ Water insoluble, non-elastic, pliable
gelatine (purified porcine skin)
▸ Workhorse for trauma:
▸ Inexpensive
▸ Readily available (tailorable)
▸ Temporary (2-3 weeks)

9. GENERAL
COAGULOPATHY
▸ With liquid embolics the mechanism of
occlusion independent of coagulation
cascade
▸ N-butyl cyanoacrylate (histoacryl) and
ethylene vinyl alcohol co-polymer (onyx)
require expertise (and time)
▸ Hydrogel coil - platinum coil covered with
expandable hydrogel polymer
▸ We frequently use conventional coils to
build scaffold for gelfoam occlusion

10. HEPATIC TRAUMA
HEPATIC TRAUMA
▸Second most commonly injured organ in blunt trauma.
▸CECT 92-97% sensitive and 99% specific for liver injury.
▸Allows grading of injury, assessment of haemoperitoneum
and detection of active extravasation/vessel injury.
▸Clinically significant haemorrhage is usually arterial.
▸Significant venous injury mandates surgical repair.

11. Grade I
Haematoma: sub capsular <10% surface area
Laceration: <1cm parenchymal depth
Grade II
Haematoma:subcapsular, 10-50% surface area; intraparenchymal <10cm
Laceration: 1-3cm parenchymal depth <10cm i length
Grade III
Haematoma:subcapsular, >50% surface area or ruptured subcapsular or
parenchymal haematoma; intraparenchymal >10cm or expanding.
Laceration: >3cm in depth
Vascular injury with active bleeding contained within liver parenchyma
Grade IV
Laceration: Parenchymal disruption involving 25%-75%hepatic lobe or 1-3
Courinard’s segments.
Vascular injury with active bleeding breaching the liver parenchyma into the
peritoneum
Grade V
Laceration: Parenchymal disruption involving >75% of hepatic lobe or >3
Couinaud’s segments within a single lobe.
Vascular: Juxtahepatic venous injuries (retrohepatic vena cava/central major
hepatic veins)
Additional
points
Advance one grade for multiple injuries up to grade III
“vascular injury: (i.e. pseudoaneurysm or AV fistula) - appears as a focal
collection of vascular contrast which decreases inattention on delayed images.
“active bleeding” - focal or diffuse collection of vascular contrast which increases
in size or attenuation on a delayed phase.

12. Grade I
Haematoma: sub capsular <10% surface area
Laceration: <1cm parenchymal depth
Grade II
Haematoma:subcapsular, 10-50% surface area; intraparenchymal <10cm
Laceration: 1-3cm parenchymal depth <10cm in length
Grade III
Haematoma:subcapsular, >50% surface area or ruptured subcapsular or
parenchymal haematoma; intraparenchymal >10cm or expanding.
Laceration: >3cm in depth
Any injury in the presence of a liver vascular injury or active bleeding contained
within liver parenchyma
Grade IV
Laceration: Parenchymal disruption involving 25%-75%hepatic lobe or 1-3
Courinard’s segments.
Active bleeding breaching the liver parenchyma into the peritoneum
Grade V
Laceration: Parenchymal disruption involving >75% of hepatic lobe or >3
Couinaud’s segments within a single lobe.
Vascular: Juxtahepatic venous injuries (retrohepatic vena cava/central major
hepatic veins)
Additional
points
Advance one grade for multiple injuries up to grade III
“vascular injury: (i.e. pseudoaneurysm or AV fistula) - appears as a focal
collection of vascular contrast which decreases inattention on delayed images.
“active bleeding” - focal or diffuse collection of vascular contrast which increases
in size or attenuation on a delayed phase.

14. HEPATIC TRAUMA
EFFECT OF GRADE ON OUTCOME
▸18% of patients with grade I injury will require operative
management compared to 68% grade V
▸Mortality increases with grade 6.5% grade I, 92% grade V
▸Increased likelihood of injury to other organs with increased
grade.

15. HEPATIC TRAUMA
DECREASED MORTALITY
▸Mortality from hepatic trauma has declined over the last 25 years:
▸Improved surgical technique
▸CT reducing unnecessary exploratory surgeries and triaging
emergent angiography and embolisation when active arterial
bleeding present.
▸Delayed arterial injury may be caused by erosion of arteries by bile
leaks. Therefore drainage of suspected bilomas is recommended.
Biliary diversion (endoscopically or percutaneous) may be necessary.

16. HEPATIC TRAUMA
INDICATIONS FOR ANGIOGRAPHY
▸Stable patient with active extravasation or vessel injury on CECT.
▸Continued post operative haemorrhage:
▸Planned - as an adjunct to staged surgical techniques/DCS
▸Unplanned - ongoing arterial haemorrhage post laparotomy.
▸Deep parenchymal bleeding from complex traumatic injuries
▸Often more amenable to embolisation than surgery
▸Even in haemodynamically unstable patients recent studies have demonstrated
advantages of embolisation over surgery.
▸Some facilities have protocols mandating angiography for grade IV/V injuries receiving
NOM
Asensio et al, J Trauma, 2000
Bilbao and Gould, both in Semin Intervent Radiol, 2006

17. HEPATIC TRAUMA
2016 WORLD SOCIETY OF EMERGENCY
SURGERY LIVER GUIDELINES

34. HEPATIC TRAUMA
OUTCOMES OF EMBOLISATION
▸ Endovascular success rate >90%
▸ Significant reductions in mortality are reported with higher grade
injuries
▸ Overall success rate of non-operative management very high
▸ Proven benefit in context of continued haemorrhage post Sx
▸ Complications: Delayed haemorrhage, infarction/necrosis,
abscess, biloma or biliary fistula.
▸ Higher rates of complications with higher grades of injury
Lin et al, Injury, 2010.

35. HEPATIC TRAUMA
SPLENIC TRAUMA
▸Most commonly injured organ in blunt trauma
▸Historically treated with splenectomy
▸Role in T-cell proliferation, antibody production and
phagocytosis of senescent red cells
▸Filters 10-15% total blood volume every minute
▸Overwhelming post-splenectomy infection (OPSI)

36. SPLENIC TRAUMA
AAST GRADING OF SPLENIC INJURY
▸In stable patients CT confirms diagnosis and grades injury
▸Absence of contrast extravasation from grading has been an
ongoing issue for radiologists.

37. Grade I
Haematoma: subcapsular <10% surface area
Laceration: capsular tear, <1cm parenchymal depth
Grade II
Haematoma:subcapsular, 10-50% surface area; intraparenchymal <5cm
Laceration: 1-3cm parenchymal depth not involving trabecular vessel
Grade III
Haematoma:subcapsular, >50% surface area or ruptured subcapsular or
parenchymal haematoma; intraparenchymal >5cm or expanding
Laceration: >3cm in depth or involving trabecular vessel
Grade IV
Laceration: Involving segmental or hilar vessels producing major
devascularisation (>25%)
Any injury in the presence of a splenic vascular injury or active bleeding
contained within the splenic capsule
Grade V
Shattered spleen
Any injury in the presence of a splenic vascular injury with active bleeding
extending beyond the spleen into the peritoneum
Additional
points
Advance one grade for multiple injuries up to grade III
“vascular injury: (i.e. pseudoaneurysm or AV fistula) - appears as a focal
collection of vascular contrast which decreases inattention on delayed images.
“active bleeding” - focal or diffuse collection of vascular contrast which increases
in size or attenuation on a delayed phase.

39. SPLENIC TRAUMA
OUTCOMES
▸Overall failure rate of NOM at 11% in multi-institutional study of the
Eastern Association for the Surgery of Trauma (EAST)
▸Failure rate increases with increased grade:
AAST Grade Failure of NOM
I 4.8%
II 9.5%
III 19.6%
IV 33.3%
V 75%
▸Number based on conservative use of angiography

40. SPLENIC TRAUMA
INDICATIONS FOR ANGIOGRAPHY +/-
EMBOLISATION
▸Extravasation or vascular injury on CT
▸Failure of NOM 67% in presence of PSA
▸Grade III-V injury
▸Presence of arteriovenous fistulae on angiography
predicts failure rate of 40% for NOM despite TAE.
▸Other indications may include: Large haemoperitoneum,
declining haematocrit, ongoing tachycardia

41. SPLENIC TRAUMA
2017 GUIDELINE FROM WORLD SOCIETY OF
EMERGENCY SURGERY

42. SPLENIC TRAUMA
TECHNIQUE - PROXIMAL SPLENIC ARTERY
EMBOLISATION
▸ Proximal splenic arterial embolisation - artery is occluded beyond the origin of the dorsal
pancreatic artery and proximal to pancreatica magna.
▸ Embolics - coils or vascular occluders.
▸ Aims at avoiding delayed splenic rupture by reducing perfusion pressure while
preserving collateral blood flow.
▸ Appropriate for patients with diffuse parenchymal injury or large haematoma/intrasplenic
haemorrhage on CT.

43. SPLENIC TRAUMA
TECHNIQUE -
DISTALSELECTIVE
SPLENIC ARTERY
EMBOLISATION▸In context of extrasplenic
haemorrhage or localised site of
injury (e.g. PSA,AVF).
▸Co-axial mirocatheter system used
to get as close to the site as
possible.
▸Performed to achieve maximal
homeostatic control.
▸Occult injuries may go untreated
and result in delayed
haemorrhage.

53. SPLENIC TRAUMA
OUTCOMES OF ANGIOGRAPHY +/-
EMBOLISATION
▸Benefits of performing angiography in all cases of high grade injury:
Conservative Pro-active
Success
NOM
75% 96%
Splenic
preservation
57% 88%
Mortality 12% 6%

54. SPLENIC TRAUMA
COMPLICATIONS
▸Both techniques fail to control bleeding in ~5-10%
▸Splenic infarction (usually asymptomatic)
▸Distal - 30%
▸Proximal - 20%
▸Splenic function is maintained
▸Abscess formation rare (3% of complications) - more likely with distal
▸Significantly higher rate of complications if both distal and PSAE performed
(58.8%) compared to PSAE (18.2%) and distal embolisation (28.7%)

55. RENAL TRAUMA
RENAL TRAUMA
▸ CECT imaging modality of choice
▸ Urinary extravasation resolves
spontaneously in ~80% - may
require percutaneous intervention
▸ Retroperitoneal and protected by
ribs, thick fascial layer and
perirenal fat
▸ Penetrating trauma more frequent
than blunt trauma.
▸ Discontinuity of Gerota’s fascia
and an expanding haematoma on
CT means that the potential for
tamponade is lost

56. Grade I
Haematoma: subcapsular haematom and/or parenchymal contusion without
laceration.
Grade II
Haematoma: Perirebal haematoma confined to Gerota’s fascia
Laceration: <1cm depth without urinary extravasation
Grade III
Laceration: >1cm in depth without collecting system rupture or urinary
extravasation
Any injury in the presence of a kidney vascular injury or active bleeding
contained within Gerota’s fascia
Grade IV
Laceration: extending into th ecollecting system with urinary extravasation; renal
pelvis laceration and/or complete ureteropelvic disruption
Segmental renal vein or artery injury
Active bleeding beyond Gerota’s fascia (retroperitoneal/peritoneal)
Segmental or complete infarction due to vessel thrombosis without active
bleeding
Grade V
Main renal aretery/vein laceration or avulsion at hilum
Devascularized kidney with active bleeding.
Shattered kidney with loss of identifiable parenchymal renal anatomy
Additional
points
Advance one grade for multiple injuries up to grade III
“vascular injury: (i.e. pseudoaneurysm or AV fistula) - appears as a focal
collection of vascular contrast which decreases inattention on delayed images.
“active bleeding” - focal or diffuse collection of vascular contrast which increases
in size or attenuation on a delayed phase.

57. RENAL TRAUMA
MANAGEMENT
▸Grades I-II have historically been treated with NOM
▸Grade III - Nephrectomy rate low (3-9%) - studies have shown a significant
difference since the utilisation of embolisation
▸Grade IV - Trend toward NOM. In 149 pts with grade IV/V injuries managed with a
non-operative protocol success was 83% (89%/52%) - 18% were embolised
▸Grade V - Successful NOM demonstrated in 9 patients managed with embolisation
▸In a study 97 (83%) of 117 with grades III-V received NOM, 9 of these went on to
require intervention - 8 were embolisations, one required nephrectomy
▸Delayed haemorrhage occurs in 13-25% grade III-IV injuries on NOM however most
cases are successfully treated endovascularly
▸American Urological Association guidelines for trauma 2014 - grade IV-V blunt renal
trauma who are haemodynamically stable can be managed non-operatively with
active surveillance and recourse to angiography

58. RENAL TRAUMA
OUTCOMES
▸Renal arteries are end arteries
▸Overall success rate of 95% (89% for 1st attempt and 82% 2nd)
▸Nephron sparing – average less than 30% parenchymal loss in a study from 1989
▸Complications: Re-bleed, infarct, abscess, ?hypertension

64. PELVIC TRAUMA
PELVIC FRACTURES
▸ Associated with significant haemorrhage
▸ 85% is from bones or venous
▸ Only 10mmHg pressure required to
tamponade venous bleeding
▸ Therefore initial management is pelvic
stabilisation/reduction with a binder.
▸ Opposes bony fragments to stabilise
clot formation
▸ Reduces pelvic volume - 3cm diastasis
doubles pelvic volume to 8L
▸ Arterial injury is high pressure and unlikely
to respond to binder

65. PELVIC TRAUMA
INDICATIONS
▸Angiography is preferred over surgery
irrespective of the haemodynamic status
▸FAST –ve/non-pelvic bleeding excluded
▸Disadvantages of surgery:
▸Source multiple small peripheral branches
which are difficult to identify
▸Ligation of internal iliac artery is ineffective
▸Surgery may destabilise clot
▸Packing requires return to OR
While not mandated there
is usually time to acquire
a CT.

66. PELVIC TRAUMA
SELECTIVE VS NON-SELECTIVE
▸ Selective – 1-2 sites of extravasation which
can be reached quickly.
▸ Non-selective - bilateral embolisation of
internal iliac arteries using gelfoam slurry
▸ Flow directed and fast++
▸ Clinical control of bleeding 90% (97% on
rpt) in n=30.
▸ No severe morbidity in this study
▸ Used when selective not possible
Velmahos, Am Surg, 2000

67. PELVIC TRAUMA
OUTCOMES
Time to embo Mortality
>4hours 88.9%
>3hours 75%
<3hours 36.4%
<60mins 16%
Evers et al, Arch Surg, 1989
Agnolini et al, J Trauma, 1997
Tanizaki et al, Injury, 2014

78. THANK
YOU

79. +
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