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272 O. van Delden
• Renal embolization will result in loss of function in any parenchyma distal to the
embolization.
Aftercare
Arterial Puncture Site
Closure device: preferably used in all patients as
◦ Coagulopathy is frequently present especially if the patient is hypothermic or has
received multiple transfusion.
◦ Agitated patients are unlikely to lie still for a longer period of time.
◦ The groin will not be observed in patients who proceed to surgery after the
embolization.
Post-embolization
• Continue to monitor the following:
◦ Complications of embolization
◦ Further bleeding
◦ Other injuries: In the context of major trauma, it is easy to overlook important
but non-life-threatening injuries in the heat of the moment.
Follow-Up: No specific follow-up is indicated and the patient should be managed
clinically.
Keypoints
Imaging with contrast-enhanced CT is essential for triage of any patient who
does not require immediate surgery (the importance of blood pressure!).
Patients with major injury require physiological support during imaging
and embolization—this is not the role of the interventional radiologist and
must be delivered by other trained providers.
CT with reformats will identify patients with injury to liver, spleen or
kidneys, who are candidates for embolization.
Contrast extravasation at CT, the so-called “blush” is the best predictor of
arterial hemorrhage as found at angiography. Pseudoaneurysms also mandate
emergency embolization.
The goals of solid organ embolization in the trauma setting are as follows:
• To improve outcome by stopping bleeding without the morbidity and
mortality associated with emergency major surgery.
27 Solid Organ Embolization in Trauma 273
• To avoid surgery all together or to delay surgery to a more elective stage.
Embolization materials of choice for trauma embolization of liver, spleen, and
kidney are coils and gelfoam.
Embolization should be performed as selectively as time permits. In
severely hypotensive patients, saving the patient is more important than saving
the organ!
Chapter 28
Post-traumatic Priapism
Peter Littler, Peter Rowlands, and Richard McWilliams
Clinical Features
• Priapism is defined as a sustained, often painful erection unrelated to sexual
stimulation.
• Priapism is idiopathic in 50% but other etiologies such as trauma, hyperviscosity
syndromes, sickle cell disease, and drugs are recognized causes.
• Priapism can be classified as low flow (common) or high flow (uncommon).
Low-Flow Priapism
• Due to intrinsic or extrinsic venous outflow obstruction.
• Causes tissue ischemia and is painful.
• Treatment is an emergency. Options include aspiration, irrigation, anticoagula-
tion, or shunt formation designed to improve cavernosal outflow.
High Flow or Arterial Priapism
• Usually due to penile or pelvic trauma.
• Due to laceration of a cavernosal artery and arteriocavernosal fistula
formation.
• Painless and causes a partially erect penis, which can increase in rigidity on
sexual stimulation.
• Patients can present days or even weeks following perineal or penile trauma.
• Treatment of high-flow priapism is not an emergency, unlike in low-flow
priapism. However, reduced potency is reported in longstanding cases.
• Treated by embolization.
Transcatheter Embolization and Therapy,
Techniques in Interventional Radiology, DOI 10.1007/978-1-84800-897-7_28,
C
Springer-Verlag London Limited 2010
275
276 P. Littler et al.
Diagnostic Evaluation
History and examination will usually discriminate between low- and high-flow
priapism.
Laboratory
Cavernosal Blood Gas Analysis
• Low pO2/high pCO2in a patient with painful priapism is suggestive of a veno-
occlusive low-flow cause. The aspiration of cavernosal blood is often therapeutic.
• High pO
tive of high-flow arterial priapism. The aspiration of cavernosal blood is not
therapeutic.
in a patient with painless priapism and history of trauma is sugges-
2
Imaging
Color Doppler Imaging of the Penis
• Axial and parasagittal ultrasound of the penis in greyscale and with optimized
color Doppler to detect cavernosal arterial flow and pseudoaneurysms.
• Dilated cavernosal sinuses with increased flow are commonly reported in highflow priapism, and a turbulence may be seen at the site of the arterio-cavernosal
fistula.
• A focal area of reduced echogenicity with flow within it on Doppler may be seen
representing a pseudoaneurysm.
• Ultrasound with color Doppler may demonstrate which side the AV fistula
is on, although this can be misleading due to collateral supply or variant
anatomy.
• Localization of the fistula guides arterial access, as the contralateral femoral
artery approach is often preferable for angiography and embolization of the
internal iliac artery.
Indications
For Angiography
These include patients with the following:
• Painless priapism
• A history of trauma to the perineum or penis
28 Post-traumatic Priapism 277
• A penile ultrasound suggestive of a high-flow etiology
• High pO
on the blood gas analysis suggestive of arterial blood
2
For Embolization
• Positive angiography
Alternative Therapies
• Surgical ligation of the internal pudendal artery. This may need to be
bilateral.
• Other methods of treatment reported have poor success rates, including perineal
compression, intracavernosal phenylephrine injection and topical ice.
Cautions
• Bleeding diathesis (as for any angiographic procedure)
• Renal impairment (caution due to contrast burden)
Specific Complications
• General complications of angiography and embolization.
• Impotence: the incidence is not known but this risk should be discussed and doc-
umented during the consent process. The risk is probably greater with highly
selective embolization using permanent agents.
Anatomy
Normal Anatomy
The penis is supplied from the following arteries:
• The anterior division of the internal iliac artery.
◦ The penile artery arises from the internal pudendal artery (Fig. 28.1).
◦ It divides to form the bulbourethral artery to the corpus spongiosum and
part of the urethra and the dorsal penile and cavenosal arteries to the corpus
cavernosum.
278 P. Littler et al.
Fig. 28.1 (Courtesy Dr
Chuck Ray) Normal internal
pudendal artery angiography.
Black arrows—perineal
artery; large
arrowhead—penile artery;
proximal white
arrowhead—bulbourethral
artery; distal white
arrowheads—cavernosal
artery; black
arrowheads—dorsal penile
artery
Aberrant Anatomy
• The penile arterial supply can occasionally arise from the contralateral side as a
normal variant.
Equipment
Catheters
• Non-selective catheters: a pigtail or straight catheter if a flush aortic run is
necessary.
• Selective catheters: a cobra or sidewinder. A microcatheter for selective
embolization.
• Guide catheter: a renal double curve or long sheath may be used to gain stable
position from the contralateral iliac.
Embolic Agents
• Autologous clotted blood: from patient
• Gelfoam: plegets or slurry
• Coils: small diameter microcatheter compatible coils
• N-butyl-cyanoacrylate (NBCA)
• Onyx
28 Post-traumatic Priapism 279
Medication
• Pain control: local analgesia at puncture site. May require analgesia post-
procedure.
• Hydration: pre-hydration for patients with renal impairment.
Angiography
Access
• Via a contralateral or ipsilateral common femoral approach, dependent on
anatomy.
• The likely side of the lesion should be assessed by ultrasound Doppler imaging
pre-angiography.
• Access may need to be bilateral.
Angiography
• If necessary, flush aortography to demonstrate and lateralize the fistula.
• Selective catheterization of the internal iliac arteries and angiography with fur-
ther superselective microcatheter runs of the anterior division/ internal pudendal
arteries.
Angiographic Appearance
• Active cavernosal extravasation or pseudoaneurysm may be seen.
• Direct visualization of the arteriovenous fistula or pseudoaneurysm (Fig. 28.2a).
• Persistent staining is abnormal.
• If identified, then you can proceed to embolization (Fig. 28.2b).
• Note a normal cavernosal blush seen at the base of the penis (Fig. 28.3), which
could be confused with a bleeding point/AV fistula. Differentiation can be difficult, but in a patient with a painless erection following trauma with a persistent
asymmetric cavernosal blush then bleeding is the likely cause.
Aftercare
Post-embolization
• Standard care post-arterial puncture.
280 P. Littler et al.
(a) (b)
Fig. 28.2 Selective angiography of (a) the left internal iliac artery showing cavernosal arteri-
ovenous fistula. (b) Successful occlusion of the arteriovenous fistula following selective coil
embolization
Fig. 28.3 Normal cavernosal
blush (arrow) at the base of
the penis seen at conventional
aortic angiography in a
patient investigated for
peripheral vascular disease
Follow-Up
• Repeat Doppler ultrasound of the penis, if no clinical improvement.
• Most high-flow priapism resolves in the first 24 h post-embolization.
28 Post-traumatic Priapism 281
Keypoints
• A painless partial erection following perineal or penile trauma is highly
suggestive of high-flow priapism.
• Doppler ultrasound is sensitive for the detection of high-flow arteriocavernosal fistulae and pseudoaneurysm, can aid in lateralization of the
lesion, and is useful in follow-up.
• Superselective angiography of the internal pudendal arteries and embolization of the causative vessel is the mainstay of treatment.
Safety
• Be aware of a normal cavernosal blush on angiography simulating bleeding. In the context of painless post-traumatic priapism, asymmetric persistent cavernosal blush on angiography is likely to represent bleeding and
should prompt embolization.
• Document the risk of erectile dysfunction following therapy.
Suggested Reading
Bertolotto M, Quaia E, Mucelli F P et al. Colour doppler imaging of posttraumatic priapism before
and after selective embolization. Radiographics 2003; 23: 495–503
Kang B.C, Lee D.Y, Byunt J.Y et al. Post-traumatic arterial priapism: colour doppler examination
and superselective arterial embolization. Clin Rad (1998) 53, 830–834
Schrumpf J.D, Sommer G, Jacobs R.P, Bleeding simulated by the distal internal pudendal artery
stain. Am J Roengenol (1978) 131, 657–659
Shankar K.R, Babar S, Rowlands et al. Posttraumatic high-flow priapism: treatment with selective
embolisation. Pediatr Surg Int (2000) 16: 454–456
Yilmaz T, Parildar M, Oran I et al. High-flow priapism due to cavernosal artery fistula with
pseudoaneurysm treated by N-butyl-cyanoacrylate embolization. Eur J Radiol Extra (2003)
46, 56–59
Chapter 29
Embolization for Pancreatic Bleeding
Tony Nicholson
Clinical Features
• Embolization for hemorrhage secondary to pancreatic pathology is usually
carried out as an emergency or very urgent procedure.
• Pancreatic bleeding typically occurs in the context of pancreatitis and pancreatic
surgery.
Hemorrhage in Pancreatitis
• 10% of patients with acute pancreatitis develop arterial or portal venous vascular
complications; these are commonest if there is pseudocyst development.
• Leakage of pancreatic enzymes leads to the development of aneurysms and
pseudoaneurysms of the pancreatic vasculature.
• The mortality rate for pancreatic hemorrhage is over 90% if only treated
conservatively. The mortality for surgery has been quoted to be as high as 56%.
• Recurrent bleeding occurs in up to 10% of patients surviving surgery.
• Early upper abdominal pain without active bleeding (“herald pain”) may precede
a bleed.
• Occasionally patients with pancreatitis can develop occult pseudoaneurysms,
which manifest as a decreasing hemoglobin on serial full blood counts and/or
a pulsatile upper abdominal mass.
Hemorrhage Following Pancreatic Surgery
• Pancreatic hemorrhage can also be iatrogenic secondary to pancreatic surgery for
cancer or pancreatitis. The most common location for such hemorrhage is the
gastroduodenal artery, but any artery in the pancreatic arcade can be affected.
• Post-pancreatico-duodenectomy hemorrhage occurs in approximately 10%, with
2% occurring from the pancreatic cut surface and 8% from the gastroduodenal
artery stump due to infection or poor suture technique.
Transcatheter Embolization and Therapy,
Techniques in Interventional Radiology, DOI 10.1007/978-1-84800-897-7_29,
C
Springer-Verlag London Limited 2010
283