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microcatheter embolization. J Trauma. 2005;58(2):384–387.
19. Morita S, Tsuji T, Fukushima T, et al. Arterial embolization of an
extrapleural hematoma from a dislocated fracture of the lumbar spine: a
case report. Scand J Trauma Resusc Emerg Med. 2009;17:27.
20. Hamid RS, ul HT, Chishti I, et al. Post traumatic avulsion of lumbar
artery: a rare cause of retroperitoneal haemorrhage treated by glue
embolization. J Pak Med Assoc. 2010;60(6):487–489.
21. Holting T, Buhr HJ, Richter GM, et al. Diagnosis and treatment of
retroperitoneal hematoma in multiple trauma patients. Arch Orthop
Trauma Surg. 1992;111(6):323–326.
22. Burdick TR, Hoffer EK, Kooy T, et al. Which arteries are expendable?
The practice and pitfalls of embolization throughout the body. Semin
Intervent Radiol. 2008;25(3):191–203.
23. Grieco JG, Perry JF Jr. Retroperitoneal hematoma following trauma: its
clinical importance. J Trauma. 1980;20(9):733–736.
24. Goins WA, Rodriguez A, Lewis J, et al. Retroperitoneal hematoma after
blunt trauma. Surg Gynecol Obstet. 1992;174(4):281–290.
25. Velmahos GC, Demetriades D, Chahwan S, et al. Angiographic
embolization for arrest of bleeding after penetrating trauma to the
abdomen. Am J Surg. 1999;178(5):367–373.
26. Hare WS, Holland CJ. Paresis following internal iliac artery
embolization. Radiology. 1983;146(1):47–51.
26
Iatrogenic Lesions
Yann Lachenal • Alban Denys • Pierre E. Bize
BACKGROUND
With the increasing number of minimally invasive diagnostic and therapeutic
procedures, iatrogenic complications have become more frequent.
1–6
These
complications can have no clinical impact and remain silent but can also have
dramatic outcomes. Transarterial embolization (TAE) is in first line for
treatment of vascular lesions such as active hemorrhage, pseudoaneurysm
(PA), arteriovenous fistula (AVF), and arteriocavitary fistula. It is then of the
highest importance for the interventional radiologist to know them, recognize
them and be able to manage them.
2,5–12
Iatrogenic Vascular Access Lesions
The common femoral artery is the most frequent arterial access of vascular
procedures, with an overall complication rate around 6%.13 Other vascular
access locations are less used and have a complication rate estimated from
2% to 36% for brachial access,
14–16
7.7% to 15.7% for popliteal access,
17–19
and less than 3% for transradial access.13 The most frequent vascular
complications are hematoma, AVF, PA, distal embolization, dissection, and
thrombosis.2 There are different ways to manage common femoral artery
access–related injuries, but the discussion will focus on iatrogenic lesions that
require embolization.
Iatrogenic Renal Lesions
Iatrogenic traumas are the main cause of transplanted and native kidney
vascular injuries.
20
–23
Hemorrhagic complications are frequent, with
perirenal hematoma larger than 2 cm seen in 12.5% and macroscopic
hematuria seen in 3.8% of patients after percutaneous biopsy.
24,25
Because of
their prevalence, percutaneous biopsies are the leading cause of iatrogenic
vascular injury in kidney, despite reported rate of transfusion and
embolization in recent studies of 0.9% and 0.2% to 0.6%, respectively.
25,26
Major hemorrhagic complications requiring transfusions and/or embolization
are seen in 12.5% of transjugular kidney biopsy,
27,28
1% to 4% of
percutaneous nephrostomy,29 12% to 14% of percutaneous lithotripsy,29 6%
of partial nephrectomy,30 5% of radiofrequency ablation,31 and 0.7% to 2.6%
of cryoablation.
32,33
Iatrogenic Liver Lesions
Iatrogenic traumas are currently the main etiology of hemorrhagic
complications seen in the liver. This situation finds its origin in the increasing
number of percutaneous procedures over the last few decades.
1,6
Major
hemorrhagic complications have been described after percutaneous (biopsy,
percutaneous transhepatic cholangiography [PTC], percutaneous transhepatic
biliary drainage [PTBD], radiofrequency ablation [RFA]), endovascular
(transjugular hepatic biopsy, transjugular intrahepatic portosystemic shunts
[TIPS]), endoscopic (retrograde cholangiography, endoscopic retrograde
cholangiopancreatography [ERCP]), and laparoscopic (cholecystectomy)
interventions as well as open surgery (pancreatobiliary surgery, liver
transplantation) with an incidence of 0.3% to 6%.
1,8,34–43
Arterioportal fistula (APF) is the most frequent arterial injury type.
Iatrogenic injuries are mostly intrahepatic.
43,44
The rate of APF is 4.2% in the
first week following liver biopsy.45 Most seem to close spontaneously,
whereas only a minority progresses.
45–47
Clinically, only 17% of APF are
symptomatic,44 with findings related to hemobilia and portal hypertension,
such as gastrointestinal bleeding, ascites, abdominal pain, and diarrhea.
48,49
Diagnosis and management are decided after Doppler ultrasound (US)
examination (see the section “Clinical Applications”).
Arteriohepatic vein fistulas (AHFs) are rare and not well studied. Their
finding is often incidental on computed tomography (CT) in patients who had
a liver biopsy in the past. AHFs may lead to high-output cardiac failure by
increasing cardiac load, but they usually stay clinically silent as vascular
shunt is insignificant.
43,45
PA of hepatic artery is usually of iatrogenic origin. Percutaneous
procedures are the leading cause of intrahepatic lesions, whereas endoscopic
procedures, laparoscopy, hepatobiliary surgery, and liver transplantations are
the cause of extrahepatic lesions.
43,50
The right hepatic artery is the most
common artery involved.
50
Iatrogenic Splenic Lesions
Most splenic injuries are caused by trauma or pancreatitis. Iatrogenic lesions
contribute only to a minority of cases and are caused by splenic biopsy and
abdominal surgery.51 Incidence of major complications after splenic biopsy is
2.2%, most of which are hemorrhagic.52 The rate of splenic injuries during
abdominal surgery is 0.5%.53 These lesions are usually recognized and
treated surgically immediately. Therefore, the incidence of splenic injuries
not recognized during surgery that would require TAE is not known.54 The
spectrum of arterial injuries is the same as for blunt trauma: active bleeding,
PA, and AVF. Clinical presentation is variable and extends from absence of
symptoms to hemodynamic collapse. AVF can additionally show symptoms
of portal hypertension such as abdominal pain, gastroesophageal varices, and
intestinal bleeding.
55
Iatrogenic Pulmonary Lesions
Hemorrhagic complications are seen in up to 23% of lung biopsies,56 but
massive hemorrhages are encountered in less than 0.5% of patients after
biopsy
35,57
and less than 1% after RFA.
58,59
Hemoptysis is the main clinical
manifestation.Mortality after biopsy is low (0.07%)57 and is due rather to
asphyxia than to exsanguination when caused by lung hemorrhage.
Hemorrhagic lung complications are often self-limiting and usually do not
require endovascular treatment. Lesions to the pulmonary artery with
formation of a PA after Swan-Ganz catheter placement and RFA have been
described and treated successfully with embolization, but these lesions
remain rare.
58–60
DEVICE/MATERIAL DESCRIPTION
The choice of embolic agent that will be used depend mostly on the type of
lesion that will be treated and on operator preference. Gelatin sponge is
effective and inexpensive. Vascular occlusion is transitory and lasts a few
days with progressive recanalization of occluded artery. This property is its
main drawback, because if healing of the arterial injury is not complete,
bleeding can reappear. N-butyl cyanoacylate (NBCA) is effective and
permanent. Occlusion is immediate. Because of its liquid nature, it flows
through vessels with blood and occludes vessels more distally than coils. In
liver and other organs, this property is useful if catheter access is limited.
Drawbacks are the long learning curve to use glue and the risk of nontarget
embolization. Coils are very effective and provide a permanent occlusion.
However, they can’t be positioned as far as liquid agents. Covered stents are
used to treat arterial parietal injuries without occluding the feeding artery.
Often, materials are mixed to increase embolization efficacy. Situations in
which these various embolic agents should be used will be discussed in more
detail in the “Clinical Applications” section.
TECHNIQUE
Iatrogenic Vascular Access Lesions
PAs are not usually treated by TAE but rather by US-guided compression,
direct thrombin injection (see “Tips and Tricks”), stent graft insertion, or
surgical repair. AVFs are not usually treated by embolization but by USguided compression, direct thrombin injection, or stent graft placement over
the neck of the fistula. In this case, stent diameter should be oversized 1 mm
larger in normal artery and 2 mm in calcified artery.2 Retroperitoneal
hemorrhage can usually be treated with a stent graft when it is caused by a
leak from a major vessel such as the common femoral or the external iliac
artery. The stent graft diameter should be oversized as stated earlier. When
the bleeding occurs from a secondary branch (as the circumflex iliac artery)
usually perforated by an inappropriate guidewire manipulation, this
secondary branch can usually be embolized with coils, Gelfoam (Ethicon,
Johnson & Johnson, Somerville, New Jersey) or a mix of them.
Iatrogenic Renal Lesions
Catheterization of the renal artery is performed with a Cobra, Renal Double
Curve (RDC), H-Stick, or Simmons 5-Fr support catheters (Cordis, Johnson
& Johnson Medical, Waterloo, Belgium). Catheter choice depends on the
orientation of the renal artery. Glide catheters should be avoided as they do
not provide strong support. Images can show active retroperitoneal or
calyceal hemorrhage, arterial transection, PA, AVF, or deformation of renal
parenchyma by subcapsular or perirenal hematoma. Iatrogenic lesions are
usually unifocal, so superselective catheterization with 3-Fr or less coaxial
microcatheter is the rule. PA should ideally be embolized with microcoils
filling the PA and extending proximally in the afferent artery. When selective
catheterization is not feasible, embolization of afferent artery is enough. The
classical technique of PA embolization using sandwich technique is not
necessary as kidney vascularization is terminal with few collaterals. NBCA
can be used to fill PA and extend in the feeding artery. It should be used if
lesions are multiple or too distal in location to be reachable with a
microcatheter.10 Gelfoam alone should be avoided as it resorbs over a few
days, but it can be mixed with coils to improve efficacy of embolization.
AVF embolization is most often performed with microcoils (Fig. 26.1
). Care
must be taken in the choice of type and size of coils as there is a risk of coil
migration and nontarget embolization. They must be oversized 1.5 times the
diameter of the target vessel. For high-flow fistulas, the first coil should be
detachable and have enough length for a good control of its stability before
its release and to build a frame. Afterward, pushable coils of smaller size are
used to fill the frame. NBCA can be used, with usual caution. Gelfoam or
particles should be avoided. Vascular plugs are sometimes used, but their
delivery may be impossible in tortuous vessels. In case of arteriocalyceal
fistula with active hemorrhage, embolization of feeding artery with
microcoils or NBCA is usually efficient.
Iatrogenic Liver Lesions
Single curve, Cobra, Sidewinder, or Simmons 5-Fr support catheters (Cordis,
Johnson & Johnson Medical, Waterloo, Belgium) are used to access celiac
trunk. Catheterization should be delicate to avoid dissection. After a digital
subtraction angiographic (DSA) serie by support catheter with patient in
apnea, navigation to the target lesion is performed with a 3-Fr or less
coaxially inserted microcatheter. DSA may show PA, APF, arteriobiliary
fistula, artery transection, and active bleeding.
Hepatic PA embolization approach depends on location of vascular
injury.
If the PA is extrahepatic (common hepatic artery, proper hepatic artery
and its right and left branches), exclusion can be performed with a covered
stent 4 to 6 mm diameter depending on artery size (Coronary Graftmaster
covered stent [Abbott Vascular, Diegem, Belgium] or Advanta V12 covered
stent [Atrium, Rastatt, Germany]) or by filling the lesion with coils or NBCA
to preserve permeability of the injured artery. This approach is mandatory in
transplanted livers as they are very sensitive to ischemia. However, sacrifice
of the left or right branch of the hepatic artery can be considered in native
liver, because intrahepatic collaterals from one side to the other open
immediately after vascular occlusion and oxygenation by portal vein is
usually sufficient if this vein is patent and that portal venous flow is not
hepatofugal.
If the vascular injury is intrahepatic, treatment depends on selectivity of
microcatheterization. If possible, microcoils or NBCA should extend across
the PA’s neck in distal and proximal artery to avoid backflow vascularization
of the PA by collaterals. Catheterization of the PA itself should be avoided
because of the risk of rupture by microcatheter tip. To facilitate stasis and
thrombosis, Gelfoam can be used between coils (“sandwich technique”) or to
fill the PA feeding vessel. As the PA does not have walls, a basic principle is
to avoid treating the PA sac like a true aneurysm would be treated. Attention
should be paid to embolize the feeder(s) vessel(s) if possible. If only the PA
sac is embolized (the exception is embolization of common femoral artery
with direct thrombin percutaneous injection), there is a tendency to
recanalization and reexpansion of the PA sac around the embolic agent as the
feeder vessel can transmit pressure to the soft tissues surrounding the PA. If
microcatheter positioning close to the lesion is not possible, Gelfoam or
NBCA should be used in association or not with coils. Finally, direct
percutaneous puncture of the PA with injection of thrombin or coils has been
described for unreachable lesions.
43,61
Embolization of APF should be performed with microcatheter closely
positioned to the fistulous site. Embolization is usually made with coils, but
other embolic agents have been used (detachable balloon, NBCA, Onyx
[EV3 Europe SAS/International, Paris, France], microspheres [Bead-Block,
Biocompatibles, Farnham, UK] and Gelfoam).62 The fistulous tract is
sometimes very short and it becomes unavoidable to embolize the feeding
artery, so great caution should be taken before embolization of a lesion in an
operated or transplanted liver because of the risk of ischemia. Decrease of
flow through fistula rather than complete occlusion is sometimes enough to
prevent the progression of APF.43 Deployment of coils must be done
carefully because of risk of migration.
The approach to arteriobiliary fistula or artery transection with active
bleeding is the same as for PA (Fig. 26.2).
Iatrogenic Spleen Lesions