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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3733_Библиотеки_им_академика_М_И_Перельмана.pdf
during an intervention for the extremity, can jeopardize the perfusion of the
limb. Endovascular coils, if placed within a proximal segment of vessel, can
herniate into the parent vessel, thereby resulting in unintended occlusion
distal to the point of herniation. Coils can also embolize through
arteriovenous fistulae. The operator must have familiarity with coil retrieval
if providing arterial embolization services.
Knowledge of variant anatomy is easy to forget in the high-stress setting
of trauma embolization, but failure to recognize variants can lead to profound
ischemia. In the pelvis, the two most important variants are (1) the persistent
sciatic artery and (2) the corona mortis.
The persistent sciatic artery (PSA) is a rare congenital variant branch of
the internal iliac artery that exits the pelvis through the obturator
foramen.
51,52
When this is present, the ipsilateral external iliac and common
femoral arteries are hypoplastic. The PSA may give rise to the popliteal
artery and provide most of the blood flow to the lower extremity or it may
supplement the dominant femoral arterial system. In either case, it should be
recognized angiographically. This can also be detected on physical exam if
normal posterior tibial and dorsalis pedis pulses are present with an absent or
diminished ipsilateral femoral pulse.
The corona mortis (or, more ominously translated, “the crown of death”)
is an anatomic variant consisting of an obturator artery originating from the
external iliac artery or an anastomotic connection between the obturator
artery and either the inferior epigastric artery or external iliac artery.
53,54
(It
takes its name not from its reputation with interventionalists but rather from
the propensity for disastrous injury it used to have during orthopedic
procedures.) This can also refer to a connection between the veins of the
pelvis, which is more common than the arterial variant. Close proximity to
the superior pubic ramus predispose this vessel to acute traumatic injury. This
vessel is a potential source of hemorrhage fed by the external iliac artery as
well as a source for back bleeding subsequent to embolization targeting the
internal iliac branches.
Variant anatomy within the extremity is also important to keep in mind.
Important variants include a high takeoff of the radial or ulnar arteries in the
upper extremity and a takeoff of the anterior or posterior tibial artery in the
lower extremity.
55
Attention to diagnostic images must also include the recognition of
acquired variant anatomy, which is actually far more common. A patient with
peripheral vascular disease may have runoff vessels supplied entirely through
collateral flow from the profunda femoral artery. Although the branches of
the profunda can normally be sacrificed without great consequence, in this
setting, their occlusion would be a disaster.
Upper extremity angiography alone introduces a small risk of stroke.
Embolization of proximal upper extremity branches raises this risk of stroke.
Extreme caution must be taken to know the runoff of any proximal
subclavian arteries being considered for embolization and to avoid particles
and liquids when working near the vertebral arteries or spinal arteries.
TIPS AND TRICKS
Pelvic Trauma
• In pelvic trauma, both internal iliac arteries should be imaged even if
the prior CT indicates unilateral injury.
• A compliant occlusion balloon may be placed in the infrarenal aorta at
the start of the procedure to limit ongoing hemorrhage during portions
of the pelvic embolization procedure.
Extremity Trauma
• Extremity arterial embolization can be safely performed in profunda,
muscular, or genicular branches.
• Trauma to the vessels of the lower leg or forearm, although
uncommon, can be treated with endovascular occlusion so long as
appropriate collateralization at the palmar or plantar arches is
confirmed.
• Superselective embolization is almost always preferred, so long as the
patient status will allow it, to prevent early rebleeding and reduce risk
of ischemia.
• If the microcatheter is in stable position, microcoils can be injected to
expedite the procedure.
• The use of high-flow microcatheters allows for power injections to be
performed.
• Microcoil compatibility with high-flow microcatheter must be
confirmed.
• Detachable coils are particularly helpful as the first coil (to confirm
stability and appropriate packing) and as the last coil (to avoid
herniation into the parent vessel).
• Renal protection may be aided by the use of CO2 during certain
portions of the exam.
• A Gelfoam slurry should be kept coarse, particularly if the target is
relatively less selective.
• Gelfoam torpedoes provide a more proximal particle embolization.
• Consider leaving the arterial access if hypothermia or rapid PRBC
administration has caused a coagulopathy or if repeat angiography in
the next 12–24 h is likely.
• Closure devices can be used in the trauma setting to avoid the time
constraint of manual pressure. The use of a closure device does not
preclude the use of repeat short interval access at the same site.
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T
25
Spine and Bone Trauma
Pierre E. Bize • Yann Lachenal • Alban Denys
ranscatheter arterial embolization (TAE) has proven to be useful in
the treatment of hemodynamically stable polytrauma patients.
1,2
It has
also proven to be useful in selected hemodynamically unstable
patients who responded at least transiently to fluid resuscitation.
3,4
However,
the place of TAE in the treatment algorithm of polytrauma patients remains to
be defined.
5–12
TAE has several advantages in selected trauma patients. It can
control several sources of bleeding from one single vascular puncture,
avoiding unnecessary surgical exposure in those fragile patients, thus
avoiding hypothermia, which is often a problem in this setting. It can be
performed in the angiography suite while other resuscitation maneuvers are
carried on. It can be performed without major risks in patients with impaired
coagulation, which is also quite frequent in polytranfused patients. As
opposed to solid organ or pelvic bone fractures, there is little information on
the role of TAE in the treatment of paraspinal bleeding associated with spine
trauma or with fractures of other bones such as in the limbs.
13–21
DEVICE AND MATERIALS
Bleeding associated with spine or bone fractures is usually of osseous or
venous origin and is self-limited. However, some cases of bleeding from an
arterial injury can be associated with significant blood loss. Arterial bleeding
in the paraspinal space and in the limbs may have originated from muscular
branches and thus can be embolized with gelatin sponge or even glue.
Particulate agents such as Bead Blocks (Biocompatible, Farnham UK) are not
usually recommended because they might cause ischemia and
rhabdomyolysis. Coils are convenient when there is a single well-identified
vessel that can be selectively catheterized, such as the intercostal or the
lumbar arteries. However, when using coils, one should use the “front
door/back door” embolization technique to prevent further bleeding from
retrograde flow. This technique consists of placing the coil beyond and
before the vascular lesion. However, glue and gelatin sponge are perfectly
suitable in this particular situation, with the advantage of being able to
control the bleeding from both the antegrade and retrograde flow more
quickly and at a lower cost.
TECHNIQUE
The target vessel should be identified from the computed tomography (CT)
with contrast as it might be difficult to identify bleeding vessels by digital
subtraction angiography (DSA) in hypotensive patients. Arterial access is
gained usually from one of the common femoral arteries. When bleeding
from a lower limb is present and other vessels need to be embolized, it is best
to choose the contralateral common femoral artery and to catheterize the
bleeding side by crossover. Antegrade puncture of the common femoral
artery on the bleeding side is not convenient as it will render catheterization
of other bleeding vessels uneasy if not impossible. In case of nonpalpable
pulse, ultrasound guidance should be used promptly. The Seldinger technique
is used to gain vascular access, and a 5-Fr or 6-Fr introducer sheath is
inserted in the common femoral artery. The choice of catheter curvature will
depend on the vessel to be embolized. A Cobra C2 (Glidecath, Terumo
Europe, Leuven Belgium) catheter usually allows catheterization of the