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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3733_Библиотеки_им_академика_М_И_Перельмана.pdf
lumbar arteries and also allows crossover to the contralateral iliac and
femoral arteries. Vascular anomalies such as irregular vessel walls,
dissection, pseudoaneurysm, or active bleeding should be looked for by
selective catheterization using a 4-Fr or 5-Fr catheter. If no abnormality and
no active bleeding is seen in the suspected vascular territory, a forceful hand
injection can reveal the bleeding from an injured vessel, which was occluded
by spasm, dissection, or clot. In case of superselective catheterization, a
microcatheter allowing the use of 0.018-in coils should be used. In case of
embolization of a lumbar artery with coils, care should be taken to embolize
the lumbar arteries above and below the bleeding level to avoid retrograde
filling of the embolized artery by collateral flow from the upper and lower
levels.
In the paraspinal space, always look for spinal arteries, especially in the
dorsolumbar region. The anterior and posterior spinal arteries supply the
spinal cord. The anterior spinal artery receives blood from a large segmental
vessel originating from one of the last intercostal arteries known as the
Adamkiewicz artery (typically located between the vertebral bodies T8–L2
segment). The posterior spinal artery receives many segmental feeders known
as the radiculospinal arteries, which can be recognized by their “hairpin”
shape on angiography (Fig. 25.1
). When present, embolization should take
place from beyond the origin of the radiculospinal artery. Coils or large
gelatin sponge torpedoes are best used in this situation. If particulate agents
are to be used, they should be greater than 350 µm in size.
22
CLINICAL APPLICATIONS
TAE of arterial bleeding associated with spine or peripheral bone fracture can
be convenient in patients with other bleeding sites that also need to be treated
by embolization or in patients with altered coagulation status. One typical
scenario is a patient with a ruptured spleen associated with rib and lumbar
transverse apophysis fractures. Another scenario would be a patient with a
fractured bone and an impaired coagulation status. TAE could resolve the
hemorrhage quickly while the coagulation status is restored before reparative
surgery.
Bleeding in the Paraspinal Space
In trauma patients, bleeding in the paraspinal space is usually associated with
vertebral fractures. Paraspinal bleeding originates mostly from the broken
bone itself or from the azygos and hemiazygos veins and perispinal venous
plexuses. These bleeding sources are not amenable to embolization, but they
are usually self-limiting.19 However, bleeding in the paraspinal space when
associated with bleeding in other territories can lead to significant blood
loss.
21,23
Care should be taken to look for an arterial bleeding source when
interpreting a CT scan in a polytrauma patient with a significant hematoma in
the paraspinal space. In the absence of other sources of bleeding such as the
renal or the internal iliac arteries and their branches, the most frequently
involved arteries in this setting are the intercostal and lumbar arteries.
21,23,24
If the bleeding vessel can be identified from multislice CT imaging, TAE can
be used to control bleeding in the paraspinal space. TAE is particularly useful
in patients with other bleeding sites. As it is the case for abdominal organ
lesions, a good CT with arterial enhancement and multiplanar reconstruction
will guide the embolization procedure and make it quicker and easier,
avoiding the time-consuming catheterization of all lumbar and pelvic arteries.
Figure 25.2 displays the case of a woman on anticoagulants with a vertebral
fracture and paraspinal hematoma with active bleeding treated by TAE.
Another interesting use of TAE is the treatment of bleeding from penetrating
wounds such as stab wounds or gunshot wounds.
1
,18,25
When surgery is not
absolutely mandatory, such as in case of hollow viscus perforation, TAE can
avoid surgery and quickly control bleeding from the injured vessels. Figure
25.3 displays the case of a patient who sustained a stab wound in the
paraspinal region and was treated by TAE only.
Bleeding Associated with Trauma of the Limbs
Most bleeding associated with bone fracture are from osseous or venous
origin and is self-limited. However, in case of a penetrating injury, fractures,
and joint dislocation, arterial lesions can occur and should be searched for.
Angiography is considered to be excellent in revealing vascular lesions in the
extremities. These lesions consist of occlusion, extravasation,
pseudoaneurysm, and arteriovenous fistula. Intraluminal filling defects such
as thrombi and intimal flaps can also be visualized.
1
The bleeding in limb trauma can fall in two categories: (1) major vessel
injuries, such as the superficial femoral artery or the brachial artery, with
immediate threat for the involved limb; and (2) bleeding from secondary
muscular branches. The first category is definitely not to be treated by any
kind of endovascular procedure but necessitates immediate surgical vascular
repair. If surgery is not immediately available or feasible, a tourniquet should
be used to control the bleeding. In the second category, muscular bleeding is
usually self-limited by tamponade effect from the muscular fascia and might
not necessitate TAE. TAE might become necessary if there is evidence of
growing hematoma, compartment syndrome, or impaired coagulation status.
However, even in these cases, surgery has the advantage of addressing the
compartment syndrome that often results from accumulation of large
quantities of blood in the fascia by performing fasciotomies. When the fascia
is ruptured, such as in an open trauma, TAE can be an option if direct
surgical control of the bleeding cannot be performed immediately.
Upper Extremity
The brachial artery should not be embolized as it supplies blood to the hand
and the collateral supply at this level is usually not sufficient to preserve
viability of the hand territory. Segments of the ulnar and radial arteries can be
embolized with coils after angiographic confirmation that the palmar arch is
patent. Glue, gelatin sponge, and particulate agents should definitely not be
used in the upper limbs because they will cause irreversible ischemia in the
hands.22 Muscular branches in the upper extremity can be embolized without
risk due to extensive collateralization.
Lower Extremity
The common and superficial femoral arteries should not be embolized as they
supply the lower extremity and their occlusion could result in irreversible
ischemic damage. The deep femoral artery should be preserved whenever
possible as it also contributes in an important way to the perfusion of the
lower extremity. Superselective embolization of muscular branches, leaving
the main trunk patent, is the preferred way to perform TAE in this territory.
In case of cataclysmic bleeding from the deep femoral artery, a transient
embolic agent such as gelatin foam should be used. Below the knee, one
vessel of the trifurcation is considered sufficient to maintain sufficient
perfusion in the foot. Surgical repair of these vessels is considered difficult
and surgical treatment often consists of ligation of the injured vessel. Hence,
embolization is an alternative as long as one vessel is patent. In case of
disruption, the front door/back door technique should be used to prevent
continuous bleeding from retrograde flow.
POTENTIAL COMPLICATIONS
The most common complication after embolization of a muscular arterial
territory is ischemia and rhabdomyolysis, often accompanied by pain and
inflammatory syndrome. Paresis or even paralysis of the treated limb can
occur due to nerve ischemia from TAE.
26
In the paraspinal space, the most dreadful complication is paraplegia
from inadvertent embolization of a spinal artery.19 To avoid the risk of spinal
cord ischemia, spinal branches from the segmental arteries should be sought
for and embolization should be performed as distally as possible.
TIPS AND TRICKS
Paraspinal Space
• Bleeding in the paraspinal
space originates mostly from
broken bone and veins. These
bleeding sources are not
amenable to embolization but
usually self-limited. Embolize
only when there’s a good
reason.
• Anticoagulation therapy
• Multiple bleeding sites
• Bleeding vessel clearly
identified on CT
• Use coaxial microcatheter
technique to navigate through
potentially small and tortuous
arteries
• Special attention should be
paid to the T8–L2 level where
the Adamkiewicz artery may
be. Embolization of this artery
may lead to paraplegia due to
ischemia of the spinal cord.
• Perform superselective and
precise embolization as close
as possible to the target lesion.
• The posterior spinal artery
feeders can have a hairpin
shape on DSA (Fig. 25.3).
• Preferably use coils for precise
embolization, which should
take place from beyond the
origin of the radiculospinal
artery.
Limbs
• Bleeding associated with bone
fracture are from osseous or
venous origin and self-limited.
• In case of a penetrating injury,
fractures, and joint dislocation,
look for arterial lesions.
• Major vessel injuries with
immediate threat for the
involved limb
• Immediate surgical vascular
repair
• If surgery is not an option, a
tourniquet should be used to
control the bleeding.
• Bleeding from secondary
muscular branches is usually
self-limited; embolize when
with the following:
• Growing hematoma
• Altered coagulation status
• Multiple bleeding sites
• Surgery is the best choice in
case of compartment
syndrome.
• Do not occlude the brachial
and common and superficial
femoral arteries.
• Always check collaterals and
assess blood supply to the
extremity of the limb.
CONCLUSION
The use of TAE in trauma patients with bleeding in the paraspinal space or in
the limbs is marginal. However, in certain situations such as in those patients
with multiple bleeding sites or those under anticoagulation treatment, TAE
could be an efficient way to limit blood loss. Special care should be taken in
the paraspinal space to not embolize any spinal artery and in the limbs to not
cause ischemia distally.
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