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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3860_Библиотеки_им_академика_М_И_Перельмана
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304 A. Kerr
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mal structures. Consequently, blood will preferentially
pass through this path of least resistance rather than go
through the capillary bed of adjacent tissues. The size of
vascular malformations tends to increase with time. Pelvic
vascular malformations may cause a palpable mass, pain,
bleeding, leg swelling, and, rarely, high output cardiac
failure. The two types of vascular malformations are arterial venous malformations (AVM) and arteriovenous fistulas (AVF).
Arterial venous malformations are congenital. They result from incomplete differentiation of embryonic vascular tissue into arteries, capillaries, and veins. An arteriogram of a pelvic AVM usually shows a mass of innumerable
vascular communications perfused by dilated arteries and
drained by dilated early filling veins. Asymptomatic arterial venous malformations should be left alone. Complete
obliteration of a pelvic AVM by embolization or surgical
resection or both is successful about one third of the
40
time.
In most cases after therapy, parts of the arterial
venous malformation that have not been occluded or resected enlarge, causing reappearance of the mass. An arterial venous malformation is not a tumor. Its cells do not
multiply or metastasize, but small, residual parts of the
malformation can dilate enormously, leading to clinical
relapse.
40,41
To date, no consistently successful therapy for
this condition has been established (Fig. 25-5). One report describes successful embolization of 14 of 17 uterine
arterial venous malformations, with five subsequent pregnancies.
42
It seems that many of these cases were postsurgical arteriovenous fistulas and were not arterial venous
malformations.
Arteriovenous fistula
A pelvic arteriovenous fistula is an acquired communication between a previously normal artery and vein (Fig.
25-6). Most are caused by penetrating trauma. Less commonly, an arteriovenous fistula can be caused by blunt
trauma and, rarely, by rupture of an arterial aneurysm
into a vein.
easier to treat than is an AVM, because it consists of only
a single arterial to venous connection. Occluding it cures
the condition. Ideally, the AVF tract should be occluded
by spring coils. Alternatively, the AVF can be treated by
placing the coils in the feeding artery immediately proximal and distal to the AVF. This coil “sandwich” will prevent antegrade and retrograde filling of the AVF. The
sandwich method, of course, will sacrifice at least a short
segment of the feeding artery. Traumatic AVFs are often
associated with a pseudoaneurysm at the fistula site.) If
so, both the pseudoaneurysm and the feeding artery
should be embolized with coils. Particulate agents such as
Gelfoam or polyvinyl alcohol would be likely to pass
through the fistula to become pulmonary emboli. Essen-
43
(An arteriovenous fistula is usually much
A
B
FIGURE 25-5. Congenital buttock arteriovenous malformation in a 47-year-old man. Note the
numerous arteriovenous communications.
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305
A
FIGURE 25-6. AP pelvic arteriogram (A) and oblique subtraction (B) review of selective internal
iliac artery injection. Internal iliac arteriovenous fistula in a 33-year-old man who sustained pelvic
fractures when he was hit by a bus at age 10. He came to the emergency department for treatment
of gastroenteritis. A bruit was heard on auscultation of the abdomen. There is a single communication between the artery and vein. Also note the dilatation of the affected vessels caused by the
long-standing fistula.
tial vessels such as the common and external iliac femoral, or subclavian arteries must remain patent while the
internal iliac arteries and other branch vessels can usually
be sacrificed. When major vessel patency is required open
surgical repair or endovascular graft placement should
be used.
■ Angiographic Technique for Diagnosis
and Treatment of Pelvic Hemorrhage
Optimally, arterial catheterization should be performed
from a femoral approach because it is usually easier and
safer than an axillary arter y puncture. If possible, the
puncture should be made on the side of the patient
opposite the suspected site of bleeding because it is easier
to catheterize the internal iliac artery selectively on the
side opposite the puncture site than to catheterize it on
the same side. For example, if a trauma patient has leftsided pelvic fractures, angiography should be done from
a right femoral artery approach. In several situations pelvic angiography for hemorrhage should be performed
from a left axillary approach. The trauma patient may
have bilateral acetabular or pubic ramus fractures with
extensive adjacent soft tissue hematomas obscuring the
pulse and making manipulation painful. The patient may
be in shock with inflated MAST pants (military antishock
trousers) covering the femoral arteries. Alternatively, the
patient may be a high-risk pregnancy patient in the angiography suite for prophylactic angiographic catheter
placement before cesarean delivery. Radiation to the fetus must be minimized.
Intraarterial digital angiography can be done in less
than half the time needed for cut-film angiography.
Many pelvic hemorrhage patients are unable to cooperate fully. Consequently, it is necessary to study these patients by using unsubtracted digital angiography to avoid
the motion artifacts that may occur using subtracted digital arteriography. With unsubtracted digital arteriography, the higher doses of contrast used for cut-film studies
are necessary for good vessel opacification.
A nonselective pelvic flush study is done first using a
5 Fr pigtail catheter. The catheter tip is placed above the
origin of the inferior mesenteric artery.
44
The superior
hemorrhoidal branch of the inferior mesenteric artery
perfuses the rectum. The rectum also is perfused by the
B
306 A. Kerr
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A B
FIGURE 25-7. A: Active hemorrhage. Extravasation of contrast from the right superior gluteal artery demonstrated on the pelvic
flush study. B: Following embolization with spring embolus coils and Gelfoam. Hemorrhage has been controlled. Mild persistent
arterial spasm is present.
middle and inferior hemorrhoidal arteries, which originate from the obturator or internal pudendal branches
of the internal iliac artery to form a collateral pathway
so that bleeding from branches of the internal iliac artery may sometimes be demonstrated by inferior mesenteric artery injection and vice versa.
Next the pigtail catheter is exchanged for a cobra 2
catheter. If a bleeding site was demonstrated on the pelvic flush study, the bleeding vessel is selectively catheterized and embolized (Fig. 25-7). If no bleeding site was
demonstrated on the pelvic flush study, selective right
and left internal iliac artery injections are performed.
First, the contralateral internal iliac artery is catheterized. Then the ipsilateral internal iliac artery is catheterized using the Waltman loop or other techniques (Fig.
25-8). If difficulty is experienced crossing the aortic bifurcation, the cobra 2 catheter should be exchanged for
a hooked-shaped catheter such as a Rösch inferior mesenteric artery catheter or a SOS omni selective catheter
or a Simmons catheter, which will allow easy placement
of a guidewire across the aortic bifurcation. Once the
guidewire tip is well seated within the contralateral iliac
artery, the hooked-shaped catheter can be removed over
the guidewire and then replaced by the cobra 2 catheter
(Fig. 25-9A). If attempts to catheterize the ipsilateral internal iliac artery are unsuccessful using a cobra 2 cathe-
ter and the Waltman loop technique, a hooked-shaped
catheter can be used instead (see Fig. 25-9B). In the
internal iliac artery, 12 mm of contrast should be injected over 2 sec with filming obtained for 20 sec to
identify extravasated contrast after intravascular contrast
has cleared. The catheter tip must be in the proximal
internal iliac artery to opacify the lateral sacral and the
iliolumbar branches.
If a bleeding site or sites have been identified, transcatheter embolization is performed (Fig. 25-10). In most
situations in which pelvic embolization is required, Gelfoam cubes are the agent of choice. Because this agent
dissolves in several weeks, it is excellent for use in the
treatment of traumatic and obstetric bleeding. Scatter
embolization is the fastest way to stop the bleeding. The
Gelfoam block should be cut into parallel strips 1 to 2
mm thick, leaving the bases of the strips attached like
matches in a book. The block should then be turned 90⬚
and a series of cuts made across the strips. This will
produce 1 to 2 mm Gelfoam cubes. (This is more efficient
than cutting each strip separately.) Several dozen cubes
should be backloaded into a 10-mL syringe while the
plunger is removed and then filled with contrast. The
Gelfoam should be injected into the internal iliac artery
under fluoroscopic guidance until flow is very slow, and
embolization should be stopped before Gelfoam refluxes
A
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B
C
D
FIGURE 25-8. Waltman loop formed in the contralateral internal iliac
artery. A: Cobra 2 catheter with distal tip in the contralateral internal iliac
artery origin. B: The guidewire is advanced gently into a distal branch.
C: The catheter is gently advanced as far as it will go. Then the guidewire
is withdrawn to the aortic bifurcation. D: The catheter and guidewire are
advanced as one unit and are turned 180 degrees clockwise, forming a
loop. E: The catheter then is pushed up until the tip is in the abdominal
E
aorta and then is pulled down into the ipsilateral internal iliac artery.
308 A. Kerr
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A B
FIGURE 25-9. A: Rösch inferior mesenteric artery catheter crossing the aortic bifurcation. B: Rösch inferior mesenteric artery
catheter in the ipsilateral internal iliac artery.
into the external iliac artery. After embolization is complete, pelvic flush arteriography should be performed to
document that there is no further bleeding (Fig. 25-11).
If the patient is sufficiently stable, subselective embolization of the bleeding branch vessel or vessels can be
performed instead of scatter embolization. If scatter embolization must be performed from the internal iliac
artery trunk because expediant subselective catherization
of the bleeding branch vessels is not possible, then protective spring coils can be placed into the origins of the
superior and inferior gluteal arteries before scatter embolization. The coils will prevent Gelfoam from entering
these internal iliac artery branches and will decrease the
small risk of buttock ischemia and sciatic nerve injury. At
this institution, “coil blockade” is not done frequently
because patients who need scatter embolization are frequently unstable and placing the coils postpones the time
when hemorrhage can be stopped. Most organs suffer
irreversible injury within hours of acute arterial occlusion. Gelfoam’s safety stems from its size, which is small
enough to stop bleeding by causing occlusion distal to
the larger collateral vessels and yet large enough to stop
proximal to the precapillary network of collateral vessels,
not from the fact that it dissolves in a few weeks. The
bleeding site is therefore not deprived of all perfusion.
Other embolic agents
Gelfoam cubes are excellent for treating causes of bleeding that are temporary, such as traumatic or obstetric
hemorrhage. Pelvic malignancies will persist and regenerate despite embolization, which is why a permanent
agent such as polyvinyl alcohol (PVA) is more appropriate. Although the chemical formula of PVA is that of an
alcohol, it is an inert solid. PVA is supplied by the manufacturer in several particle sizes. The term absolute alcohol
refers to a solution of 99% ethyl alcohol. There is no role
for absolute alcohol in pelvic embolization. It causes sclerosis of all arteries with which it comes in contact down
to the capillary level, resulting in infarction of all tissues
in the distribution of those vessels. Gelfoam powder can
be purchased or made from a block of Gelfoam. Because
of its small diameter, particles of Gelfoam powder occlude at the capillary level and is therefore likely to cause
infarction. Like absolute alcohol, Gelfoam powder never
should be used for treatment of pelvic hemorrhage.
Spring embolus coils are rarely used alone for treatment
of pelvic bleeding. They usually occlude too proximally to
stop bleeding from small collateral vessels. Coils are permanent. Therefore, it is not possible to recatheterize
vessels in which they have been placed. They also create
artifacts on magnetic resonance studies. Occasionally, a
large proximal branch of the internal iliac artery is lacerated. Gelfoam cubes may be swept through the laceration
into the extravascular space
46
and consequently have no
effect on the bleeding. In these situations, spring embolus coils should be used. Optimally, coils are placed both
distal and proximal to the bleeding site if the vessel has
not been completely transsected. Distal embolization will
prevent retrograde bleeding from collaterals beyond the
45
Pelvic and Obstetric Hemorrhage 309
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A
FIGURE 25-10 A 26-year-old man sustained multiple pelvic
fractures when he fell off his motorcycle. He remained
hemodynamically unstable despitre orthopedic external fixation. A: Pelvic flush study shows active bleeding on the right
side. B: Selective right internal pudendal angiography demonstrates the bleeding clearly. C: After selective Gelform emboli-
C
zation the bleeding has stopped.
B
site of laceration. On rare occasions, angiography will
demonstrate bleeding from a large vessel that will require
surgical repair, such as from the common or external iliac
artery. Bleeding of large vessels can be slowed by inflation
of an occlusion balloon catheter proximal to or at the
bleeding site.
Complications
Potential complications of pelvic embolization include
leg ischemia caused by reflux of embolic material into the
external iliac artery, gluteal muscle ischemia and infarc-
tion, sciatic nerve injury, bladder necrosis, and impotence
in males. These complications are uncommon. Their precise incidence in trauma patients is difficult to determine,
because pelvic trauma can cause the same injuries. The
rare cases when bladder infarction has occurred after embolization of pelvic malignancies were usually in patients
whose tumors had been embolized using Gelfoam powder as the embolic agent.
10,13
310 A. Kerr
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FIGURE 25-11. Selective Gelfoam embolization of an actively
bleeding left internal pudendal artery caused by a gunshot
wound. There is a marked slowing of flow. Filling defects in the
artery represent Gelfoam cubes.
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S.I. Wahl, M. B. Rubin, and C. W. BakalPudendal Arteriography
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26
■■■
Pudendal Arteriography
SAMUEL I. WAHL, MICHAEL B. RUBIN, AND CURTIS W. BAKAL
Neurologic activity through the internal pudendal sensory nerves and the parasympathetic cavernosal motor
nerves is responsible for developing and maintaining an
erection. Arterial dilatation and a rapid increase in blood
flow to the penis result from relaxation of the smooth
muscles in the wall of the cavernosal arteries in response
to parasympathetic stimulation. As distention increases,
the small veins that drain the corpora are compressed
against the tunica albuginea, preventing outflow of blood
and maintaining penile erection.
ability to achieve and maintain an erection. In the patient
with normal neurologic function and normal endocrine
balance, impotence may be due to venous incompetence
or arterial insufficiency. Duplex sonography and pulsewaved Doppler analysis have been widely used to evaluate
penile arterial anatomy; pudendal arteriography remains
the “gold standard” for penile arterial evaluation.
riography has identified diffuse bilateral disease of the
internal pudendal, common penile, and cavernosal arteries in impotent patients with atherosclerosis. Focal
stenosis or occlusion involving the common penile or
cavernosal artery is seen most often in young men who
have a histor y of blunt perineal or pelvic trauma.
Pudendal arteriography also can be useful in the evaluation and treatment of both low-flow (ischemic) and
high-flow (nonischemic) priapism, a condition of persistent erection of the penis, often accompanied by pain and
tenderness.
Traditionally, priapism has been classified as being
either idiopathic or secondary. Hemodynamically and
angiographically, it can be separated into two distinct
types: more common low-flow (ischemic) priapism secondary to venous occlusion and less common high-flow
1–3
Impotence is the in-
4–6
7
Arte-
(nonischemic) priapism caused by unregulated arterial
8
flow.
The exact pathophysiology of high-flow priapism is
unknown, but it is associated almost exclusively with direct penile trauma.
■ Duplex Ultrasonography
Duplex ultrasonography is currently used as a screening
modality to assess both function and anatomy.
frequency linear transducer (7–10 MHz) is used to examine the penis in transverse axis both in a flaccid state and
after intracavernosal injection of a vasoactive agent or
prostaglandin E. Some authors advocate using the change
in the cavernosal arterial diameter before and after injection as an indicator of arterial insufficiency.
authors agree that the most sensitive parameter for identifying a patient with arterial insufficiency is the mean
peak systolic velocity.
ity ranges from 35 to 60 cm per second. Peak systolic
velocities of 25 to 35 cm per second indicate moderate
arterial sufficiency, and velocities less than 25 cm per second correspond to severe arterial insufficiency, usually
requiring surgical revascularization or prosthetic implan-
7
tation.
and relative expense of duplex sonography would appear
to be advantageous compared with transcatheter arteriography, it is highly operator dependent. Arterial variability
of the penis also may affect sonographic interpretation.
teers,
sence or hypoplasia of one dorsal artery may lead to
frequent misinterpretation (Fig. 26-1). Other technical
Although the reported accuracy, noninvasiveness
16–18
For example, in up to 30% of potent volun-
19
congenital anomalies such as either unilateral ab-
9–11
3–5,13,14
5,13
Normal mean peak systolic veloc-
12
A high-
Most
313
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