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252 T. Tivorsak and C. Vu
Contraindications
• Absolute—None
• Relative
◦ Non-salvageable limb—this will require amputation, this may be the best
primary therapy.
◦ Uncorrectable coagulopathy.
◦ Signs of ischemia.
◦ Limited collateralization.
◦ Dialysis grafts/fistulas.
◦ Renal insufficiency.
Anatomy
Injury Can Affect the Major Artery or Small Branch Vessels
Upper extremity arteries—proximal to distal
Artery Major branches
Subclavian Vertebral, internal mammary, thyrocervical trunk, dorsal scapular artery
Axillary Superior thoracic, thoracoacromial, lateral thoracic, subscapular, anterior
Brachial
Radial Radial collateral, middle collateral, and radial recurrent arteries
Ulnar Superior and inferior ulnar collateral arteries, anterior and posterior ulnar
Interosseous
and posterior humeral circumflex
recurrent arteries
The brachial and forearm vessels are the most commonly injured with approximately equal incidence. The subclavian and axillary arteries are the least the
frequently injured vessels thought to represent 2–12% of all upper limb arterial
injury. Paradoxically interventional radiologists may be needed more frequently in
these larger central vessels.
Aberrant Anatomy
• The radial and ulnar arteries frequently arise proximally from the brachial or
axillary arteries.
• Arteriography of the upper extremity should include the axillary artery to identify
major arterial anomalies.
26 Embolization of Extremity Trauma 253
• Anomalous radial or ulnar arteries in the forearm are typically superficial to the
flexor muscles, making them more vulnerable to trauma.
Lower extremity arteries—proximal to distal
Artery Major branches
Common femoral artery
(CFA)
Superficial femoral artery
(SFA)
Profunda femoral artery Lateral femoral circumflex, medial femoral circumflex,
Popliteal artery Genicular arteries, sural branches, ATA, TPT
Anterior tibial artery (ATA) Muscular, dorsalis pedis
Tibioperoneal trunk (TPT) PTA, peroneal artery, muscular branches
Posterior tibial artery (PTA) Muscular branches medial and lateral plantar arches
Peroneal artery Muscular branches, anterior and posterior terminal divisions
PFA and SFA, inferior epigastric, lateral circumflex iliac
artery
Descending genicular, muscular branches
perforating arteries of adductor magnus
Variant Anatomy of Lower Extremity
• Persistent sciatic artery—less than 0.1%. Normal fetal branch of internal iliac
artery that continues into lower extremity as the popliteal artery supplying the
runoff vessels.
• High origin of one or more of the tibial arteries—2–8%. Important to identify to
prevent unexpected arterial injury during surgery.
• Peroneal origin from anterior tibial artery—1%.
• True popliteal artery trifurcation (no tibioperoneal trunk)—4%.
• Hypoplastic tibial arteries—2%. Peroneal artery supplies foot instead.
Identification may prevent false diagnosis of arterial damage in trauma if ankle
pulses are absent or diminished.
Equipment
Catheters
Non-selective
• Multi-sidehole pigtail or straight catheters for flush aortic angiography and iliac
angiography.
Selective Catheters
• Shapes to catheterize aortic arch vessels, cross aortic bifurcation, and access
peripheral vessels: head hunter, Berenstein, Cobra, Sidewinder.
• End-hole catheters for embolization.
254 T. Tivorsak and C. Vu
• Microcatheters for more selective embolization.
• Occlusion balloon or angioplasty balloon to temporize bleeding from major
vessels. An aortic balloon can be lifesaving!
Guide Catheters and Sheaths
• Appropriately sized sheath for primary access.
• Long sheath or guide catheter if necessary for upper limb procedures.
Embolic Agents
For Dispensable Branch Vessels
• Gelfoam.
• Coils/microcoils.
• Coil–Gelfoam sandwich—useful in coagulopathic patients in whom coils are
going to be used. Adding Gelfoam allows for mechanical occlusion.
R
• Glue/Onyx
cally challenging to use. May be useful in AVF. Limited utility in extremities.
• Particles—risk of ischemia depends on size; may be useful with redundant
vascular supply to decrease risk of retrograde bleeding. Limited utility in
extremities.
—risk of ischemia from distal embolization, expensive, and techni-
For Indispensable Vessels
• Stent grafts—not embolic agents but extremity work is where they are often
essential to stop bleeding and preserve distal flow!
Medication
• Analgesia and sedation with fentanyl and midazolam. Hemodynamically unstable patients will require resuscitative support.
Angiography
Access
• Should be chosen according to the clinical scenario
• Most commonly the common femoral artery
• Consider the contralateral side if there are proximal injuries
• Brachial artery access may sometimes help
◦ If both lower extremities involved
◦ To retrogradely negotiate upper limb vascular injury
26 Embolization of Extremity Trauma 255
Angiography: General Principles
• Higher volumes of contrast and higher injection rates may be required in trauma
patients especially due to high cardiac outputs from hypotension and hypovolemia to obtain adequate arterial opacification. (“High, hot, and hell of a
lot.”—Yorum Ben-Menachum.)
• Angiography should
◦ Delineate injury
◦ Demonstrate inflow and outflow
• Selective branch angiography may be necessary.
• Do not get too close to the site of injury until ready to treat.
• Evaluate collateral vessels and variant anatomy.
• In instances where the anatomy or site of injury is unclear, consider contralateral
limb angiography to evaluate for asymmetry.
• Determine treatment plan based on staging angiography.
Angiographic Appearance
Positive Findings of Vascular Injury
• Extravasation in active hemorrhage
• Transection
• Pseudoaneurysm formation
• Arteriovenous fistula
• Occlusion
• Intimal irregularity
• Intraluminal filling defects
• Dissection (Figs. 26.1, 26.2, and 26.3)
Indirect findings may be a sign of a significant vascular injury but are less specific.
Selective angiography may reveal the true nature of the injury, which includes the
following:
• Spasm, protective spasm
• Luminal narrowing or focal widening,
• Arterial deviation by hematoma,
• Slow flow, e.g., in calf due to high compartment pressures.
Clinical Scenarios
Treatment Plan and Technique
The site of the injury governs the approach and the targets for angiography/
intervention.
256 T. Tivorsak and C. Vu
a
Fig. 26.1 Twenty-two-year-old man status post-gunshot wound to the left lower extremity and
continued bleeding from the traumatic injury. (a) Unsubtracted left lower extremity angiography
demonstrating the severity of the osseous injury. (b) Early, mid, and late arterial phase angiography
of the left lower extremity demonstrating retrograde filling of the posterior tibial artery (arrows),
which is the source of the bleeding (open arrows). Due to the inability to selectively catheterize the
posterior tibial artery in retrograde fashion, the patient was taken to the operating room to control
the hemorrhage
b1
b2
b3
a
Fig. 26.2 Nineteen-year-old
man with self-inflicted
gunshot wound to the chest.
(a) Angiography
demonstrates a
pseudoaneurysm arising from
the left midaxillary artery
(arrow).(b) Late arterial
phase demonstrates
persistence of the contrast in
the pseudoaneurysm
following washout of the
intravascular contrast. Due to
the inability to sacrifice
downstream flow (the entire
brachial artery distribution
would have been sacrificed),
an embolization procedure
was not performed. This
patient underwent a surgical
procedure, since at the time
of the procedure (2000)
stent-grafts were not widely
available
b
26 Embolization of Extremity Trauma 257
a
b
c
Fig. 26.3 Forty-five-year-old man with a stab wound to his upper chest and an expanding
hematoma. (a) Angiography of the left subclavian artery fails to demonstrate any active contrast extravasation. Note that there is an underfilled vessel (black arrows) an “indirect sign” of
arterial injury. (b) Superselective angiography of the suprascapular artery demonstrates active contrast extravasation, outlining the importance of pursuing selective angiography in the setting of
high clinical suspicion of bleeding and a negative proximal angiogram. (c) Angiography postembolization using both gelfoam slurry and microcoils (arrow) demonstrates complete cessation
of contrast extravasation
Consider
• Therapeutic options to gain control as rapidly as possible; this may simply be
balloon occlusion.
• Whether the damaged vessels can be sacrificed, if not therapy must preserve flow
either stent grafting or surgery.
Special Considerations
• Arteriovenous fistulae are often treated differently to other traumatic injuries
(e.g., approach from venous side, use of stent grafts, may be preferable to treat in
a delayed fashion).
• Avoid embolization of actively bleeding major vessels which are the sole supply
to the limb such as axillary artery, brachial artery, SFA, and popliteal artery due
258 T. Tivorsak and C. Vu
subsequent limb-threatening ischemia. Injuries to t hese arteries may be treated
with a stent-graft or a temporary occlusive balloon may be placed prior to surgical
intervention.
• Arteries that may be embolized include those that are surgically inaccessible
(e.g., PFA, branch vessels of major arteries).
Specific Blunt Injuries
Upper Limb
Axillary artery injury—anterior and medial to the proximal humerus.
• RARE in anterior dislocation without fracture.
• Severe anterior dislocation injures associated with damage to thoracoacromial
trunk, subscapular, and circumflex humeral.
• EXTREMELY RARE in closed humeral neck fractures.
• Severe medial displacement increases risk.
Brachial artery injury—occurs in
• Up to 5–13% of patients with elbow dislocations (open and closed).
• Up to 38% of patients with completely displaced supracondylar fractures (pedi-
atrics, usually in severe posterior lateral displacement).
• RARE in condylar, transcondylar, intercondylar fractures.
Radial and ulnar artery injuries
• Seldom require intervention.
• Most patients have adequate collateral circulation through the palmar arch
system.
Lower Limb
• Knee dislocation
◦ Popliteal artery injury (14–50%).
◦ Anterior dislocation tends to stretch the popliteal artery, resulting in intimal
disruption or vasospasm.
◦ Posterior dislocations may be associated with transection of the popliteal
artery and with more severe vascular injury.
◦ Ischemia often resolves when the dislocation is reduced.
• Arterial injuries for other fractures are not as common
Femoral artery injury in 2% femoral shaft fractures.
Popliteal artery injury in 3% of fractures about the knee.
26 Embolization of Extremity Trauma 259
Tibial artery injury in 12% of tibial shaft fractures.
Screws and drills used in internal fixation can sometimes result in arterial
injury.
Aftercare
Arterial Puncture Site
Routine care.
Post-embolization
Ensure that the patient is closely observed for ischemia and compartment syndrome.
Follow-Up
◦ Is not normally necessary following definitive embolization.
◦ Repeat imaging if there is any sign of further vascular compromise or bleeding.
Keypoints
• Extremity arterial injury is relatively uncommon.
• Clinical consequences include bleeding, ischemia, and compartment syn-
drome.
• Consider whether the vessel can be sacrificed.
◦ If so embolization may be the treatment of choice.
◦ If flow must be preserved, then consider balloon tamponade, stent
grafting or surgery.
• Use of embolization is limited by ability to sacrifice downstream flow.
• Trauma patients with high cardiac outputs may need higher volumes of
contrast and higher injection rates.
• Gelfoam, coils, and coil–gelfoam sandwich are commonly used.
• Emergent exploration with surgery may be required instead of emboliza-
tion in patients with signs of ischemia and/or hemodynamic instability.
Safety
• Embolization in the upper limb is associated with the risk
◦ of hand ischemia
◦ cerebral embolization via the vertebral artery
260 T. Tivorsak and C. Vu
Suggested Reading
Aksoy et al. Percutaneous transcatheter embolization in arterial injuries of the lower limbs. Acta
Radiol 2005;46:471–475.
Bauer JR, Ray CE Jr. Transcatheter arterial embolization in the trauma patient: a review. Semin
Intervent Radiol 2004;21(1):11–22
Fields, et al. Brachial and forearm vessel injuries. Surg Clin North Am 2002; 82(1):105–14.
Kadir S. Atlas of Normal and Variant Angiographic Anatomy. 1991, Philadelphia: WB Saunders.
Mavili et al. Endovascular treatment of lower limb penetrating arterial traumas. Cardiovasc
Intervent Radiol 2007; 30:1124–1129.
Chapter 27
Solid Organ Embolization in Trauma
Otto van Delden
Clinical Features
• Blunt abdominal trauma from motor vehicle accidents or a fall from height is a
common cause of hemorrhage from liver, spleen or kidney.
• Abdominal injury and significant injury to pelvis and/or chest frequently occur
together necessitating accurate pre-procedure assessment of all potential bleeding
sites.
• Hemodynamic instability or transient response to fluid resuscitation indicates
ongoing bleeding and is often associated with arterial hemorrhage.
• Non-operative management is currently the therapy of choice for blunt injuries
to liver, spleen, and kidneys in hemodynamically stable patients in most trauma
centers. Avoidance of emergency surgery directly after the trauma (the so-called
“second hit”) leads to a better outcome for the patient.
• Non-operative management of high-grade injuries to the liver is associated with
a significant number of late sequelae, such as infected hematomas and bilomas
regardless of whether embolization has been performed or not. Most of these can
be treated percutaneously.
Diagnostic Evaluation
Clinical
The Importance of Blood Pressure in the Context of Trauma
• Incorrectable hemodynamic instability should lead to immediate emergency
laparotomy!
◦ An exception to this is when arterial hemorrhage is due to pelvic fracture. In
this case embolization should be the first step before proceeding to the OR for
pelvic fixation.
Transcatheter Embolization and Therapy,
Techniques in Interventional Radiology, DOI 10.1007/978-1-84800-897-7_27,
C
Springer-Verlag London Limited 2010
261