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Author's Accepted Manuscript

Blunt abdominal trauma: Imaging and intervention


Shivanand Gamanagatti MD, Krithika Rangarajan,
Atin Kumar MD, JineeshValakada MD

www.elsevier.com/locate/enganabound

PII: S0363-0188(15)00009-2
DOI: http://dx.doi.org/10.1067/j.cpradiol.2015.02.005
Reference: YMDR341

To appear in: Curr Probl Diagn Radiol

Cite this article as: Shivanand Gamanagatti MD, Krithika Rangarajan, Atin Kumar MD,
JineeshValakada MD, Blunt abdominal trauma: Imaging and intervention, Curr Probl
Diagn Radiol, http://dx.doi.org/10.1067/j.cpradiol.2015.02.005

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Blunt abdominal trauma: Imaging and Intervention

Abstract
Interventional radiology, particularly percutaneous angioembolisation plays an important role in
the management of blunt abdominal trauma involving solid organs and pelvic fractures. The
traumatic injuries of the central nervous system, heart and great vessels often lead to death at the
site of trauma. Though patients with visceral organ injuries can also expire at the site of trauma,
these patients often reach the hospital thus giving us an opportunity to treat them with surgical or
radiological intervention depending upon the clinical condition of the patient.
The management of these trauma patients is now well codified: patients who remain unstable
despite resuscitation should be shifted, either to an operating room for laparotomy if the
ultrasound revealed hemoperitoneum, or to a interventional room for angioembolization in
cases of pelvic fractures. In all other cases, computed tomography (CT) is essential. Currently,
MDCT with contrast is the gold standard imaging modality for the diagnosis of traumatic
abdominal injuries, it helps in assessing the extent of injuries and further management can be
planned.

INTRODUCTION
Trauma is a leading cause of morbidity and mortality and ranked fourth after heart disease,
malignancies and lower respiratory illnesses as per data in the United States(1). Blunt abdominal
trauma accounts for more abdominal injuries than the less frequent penetrating injuries(1).
Spleen followed by liver(2) are the most common visceral organs to be affected in blunt trauma
to the abdomen, followed by genitourinary injury, involved in only 3-10% of cases (1,3). In our
experience, of all the injuries incurred, over 90% are minor injuries and can be managed with
conservative therapy with no significant complications. It is only the more grave injuries, like
grade 4 or more injuries in visceral organs, vascular pedicle injuries, active contrast
extravasations, pseudoaneurysm, pelvicalyceal system (PCS) injury, which require active
intervention in the form of interventional radiology or surgery. After thorough clinical
evaluation, Contrast enhanced computed tomography (CECT) is the modality of choice for
evaluation of solid organ injures today and can determine the various grades of injury and
associated complications (4,5).
Multidetector computed tomography (MDCT) has significantly improved the detection of both
vascular and visceral injuries following blunt abdominal trauma. With the quicker examination
times and improved spatial resolution of current MDCT scanners, sites of parenchymal injury
and/or active extravasation are increasingly detected. Detection of extravasation sites from solid
organs (eg, liver, spleen, and kidney), bowel, mesentery, or vascular structures may necessitate
therapeutic intervention by either surgery or angiography (with coil embolization or intravascular
stent placement). However, not all sites of active extravasation require intervention. A trend
toward conservative management is evolving based not only on the presence of active
extravasation but also on its location, size, demonstration of enlargement over time, and clinical
condition of the patient (6).

In this review we first deal with protocol for radiological evaluation, then discuss basic
principles of diagnostic imaging in trauma, discuss specific imaging features of solid and hollow
organ trauma, then move to general principles and organ-specific principles of radiological
interventions

Radiological evaluation of trauma- Imaging modalities


Overview of recommendations in the setting of trauma is first given; each modality is then
discussed further in the text that follows.

Recommendations (6) (Chart 1)


Hemodynamically unstable patients presenting with blunt abdominal trauma commonly
require assessment with chest radiographs, FAST (Focussed assessment with Sonography in
trauma) scanning and Pelvic X ray. MDCT with IV contrast may not be appropriate for
patients who are hemodynamically unstable following blunt abdominal trauma.
MDCT with IV contrast is the imaging modality of choice for evaluating hemodynamically
stable patients following blunt abdominal trauma.
Patients who are hemodynamically stable following blunt (or penetrating) trauma to the
abdomen or pelvis with pelvic fracture, gross hematuria, or >35,000 red blood cells per high-
power field (RBC’s/hpf) require evaluation of the bladder to rule out bladder perforation or
urethral injury. This is most easily performed by CT cystography following initial assessment
of the abdomen and pelvis with MDCT using IV contrast.
Role of Magnetic Resonance Imaging (MRI) : MRI has no role in acute setting, however it is
indicated in pancreatic injuries to look for MPD integrity. In this setting though, ERCP is
preferable to MRCP since it is both diagnostic and therapeutic

Focused abdominal sonography for trauma (FAST)


FAST refers to a targeted 6-point ultrasound screening of the abdomen to look for
haemoperitoneum, indicating solid organ injury and need for further evaluation.FAST should be
performed by an experienced sonologist to check for intraperitoneal free fluid in Morrison’s
pouch, perisplenic area, paracolic gutters and pelvis to look for hemoperitineum (7,8). In our
centre in India, FAST is performed by a radiologist, unlike in some other countries (like the
United States of America) FAST is generally performed by an Emergency Physician. More
detailed ultrasound (US) to check for organ injury should not be attempted as it takes too long
time in this setting and suffers from poor sensitivity (9) .Extended FAST may be done to look for

pneumothorax and pleural effusion(10).

Computed Tomography (CT)

CT is the primary radiological imaging modality for deciding whether a patient needs urgent
surgery, therapeutic angiography or close observation (5,11).

CT Technique
CT evaluation of the abdomen and pelvis for blunt trauma does not require the use of oral
contrast (12,13). The use of low or iso-osmolar IV contrast (approximately 110-140 cc at 3-5 cc
per second with a 60-70-second scan delay) is essential to identify visceral, vascular, or bowel
injury. Scanning includes the lower lung fields through the floor of the pelvis (5).
Delayed imaging through the abdomen and pelvis (5 minutes) is generally performed if the
patient has gross hematuria or has microscopic hematuria in the setting of fractures in the
vicinity of the flank, or if the first phase shows a laceration in the kidney reaching upto the
pelvicalyceal system to allow better visualizing of the kidneys, bladder and distal ureters (14).
An immediate delayed phase is also taken after acquisition of the venous phase scan if a
pseudoaneurysm or active contrast leak is seen. In case a 5 minute delayed phase is planned this
differentiation may be achieved on this phase as well.
For a CT cystogram, a Foley’s catheter is placed into the bladder, and 300-500 cc of dilute
contrast is instilled into the bladder via the catheter. At the conclusion of the CT cystogram, the
bladder should be drained through the catheter in the bladder (15,16).
In our centre a Radiologist supervises every contrast enhanced scan, thus decisions about
whether delayed scanning is required are effectively taken. In our experience this practice has
greatly improved the quality of scans performed and effectively limited radiation exposure to the
patient

General findings
Hemoperitoneum:
In acute setting, unclotted free blood usually has a measured attenuation of 30-45 HU on CT
scan and looks like clear fluid on ultrasound. Note that as time progresses the blood organizes
and looks more complex on ultrasound. When seen in a trauma setting, the search should be
made for the source of hemoperitoneum.. Just location of hemoperitoneum may not give clue to
source of organ as blood gravitates to the dependent site. For example, depending on the
patient’s position free fluid may be seen in pelvis or Morrison’s Pouch even though source of
bleed may somewhere else. Some specific signs help localize the site of injury.
Sentinel clot sign: Refers to highest attenuation collection; it gives a clue to the likely closest
site of bleeding (18) (Fig 1).
Active Extravasation or Pseudoaneurysm: Immediate repeat scan following routine scanning
helps to differentiate these two entities. In case of active extravasation, there will be increasing
density of contrast and also spread of contrast in adjacent area, on immediate repeat scan (Fig 2).
Where as in case of pseudoaneurysm, the contrast density will follow the density of adjacent
enhancing vessel and it will remain of same size, on immediate repeat scan (19) (Fig 3).
Although the volume of hemoperitoneum may be estimated roughly by searching for fluid in the
various spaces (17), the rate of bleeding and the presence of active extravasation have a more
direct effect on patient care decisions than the amount of hemoperitoneum. A large
hemoperitoneum does not mandate laparotomy.

Spectrum of Injuries (Table 1) (19) (Fig 4)


Imaging findings in visceral organs fit into specific imaging and clinical patterns. These terms
are not specific to any particular pattern, but only refer to a clinic-radiological term used to
describe patterns of injury in any solid visceral organ.
• Contusions: Vague ill-defined hypodense areas that are less well perfused
• Laceration: Linear shaped hypodense areas
• Fracture :Laceration extending from one surface to other
• Hematomas: Oval or round shaped collections of high attenuation
• Devascularization of organs or parts of organs : Non enhancement of part or entire organ
• Subcapsular hematomas : Well defined collection causing indentation over the organ
• Active contrast extravasation :active leak of contrast which is often seen as an
unexpected blob of contrast agent, which on delayed phase becomes more ill-defined and
retains contast density seen on initial phase
• Pseudoaneurysms: also seen as an abnormal blob of contrast, but on delayed phase
remains well defined and follows the contrast attenuation of the vessels
• Arterio-venous fistula : seen as abnormally tortuous veins with early filling (if multiphase
acquisition is performed)(Fig 2, Fig 3)
• Hemoperitoneum
Liver
The liver is the second (2) most frequently injured solid abdominal organ in blunt and
penetrating trauma. Hepatic injury in blunt trauma has been reported to occur in 1-8%.
However, with advent of MDCT and optimal utilization of abdominal CT, hepatic injuries
can be detected in up to 25 % of those with blunt trauma(24). Mortality rates due to liver
injury following blunt abdominal trauma has been reported to range from 3 to 12% (21).
Majority of the liver injuries (90%) are managed by nonoperative management (22,23).
MDCT helps in exact characterization and defining the extent of the injury (Fig 4-6), as per
AAST (American Association for the Surgery of Trauma) organ injury scale (Table 2) (24-
27).
Table 2 AAST organ injury scale for liver

Grade* Description
Grade I Hematoma: subcapsular, <10 % surface area
Laceration: capsular tear, <1 cm in parenchymal depth
Grade II Hematoma: subcapsular, 10–50 % surface area; intraparenchymal, <10 cm in
diameter.
Laceration: 1–3 cm in parenchymal depth, <10 cm in length
Grade III Hematoma: subcapsular, >50 % surface area or expanding or ruptured
subcapsular parenchymal hematoma; intraparenchymal hematoma >10 cm or
expanding or ruptured
Laceration: >3 cm in parenchymal depth
Grade IV Laceration: parenchymal disruption involving 25–75 %hepatic lobe or 1–3
Couinaud segments
Grade V Laceration: parenchymal disruption involving >75 % of a hepatic lobe or >3
Couinaud segments within a single lobe
Vascular: juxtahepatic venous injuries (i.e., central major hepatic veins or
retrohepatic vena cava)
Grade VI Vascular: hepatic avulsion
*Advance one grade for multiple injuries up to grade III (26)
Specific points:
„ Hepatic lacerations are differentiated from hepatic fissures by their irregular edges and
the typical location of fissures
„ If laceration involves bare liver surface between the coronary ligaments leads to
extraperitoneal hemorrhage and produces a sign called “Halo sign” around the IVC (Fig
5)
„ If laceration extending from one liver surface to other produces hepatic fracture
„ Juxtahepatic venous injury include tear of IVC or hepatic veins
„ Hepatic avulsion: devascularization, no contrast enhancement of liver on contrast-
enhanced CT
„ Injury to biliary tree result from laceration extending into bile duct in such cases
intrahepatic or Intraperitoneal fluid can represent bile (0-20HU). Occasionally, may lead
to formation of biloma (collection of bile) around the liver surface.

Spleen
Spleen is the most frequently injured organ in blunt trauma(2) and spectrum of injuries on
MDCT vary from contusion, laceration, hematoma or devascularisation. However, with
advent of MDCT and optimal utilization of abdominal CT, splenic injuries can be detected in
up to 40% of those with blunt trauma (28) (Fig 7).Though, traditionally treated with
splenectomy (29), presently there is a trend towards conservative management.
Table 3: AAST organ injury scale for Spleen (26,27)

Grade Description
Grade I Hematoma: subcapsular, <10 % surface area
Laceration: capsular tear, <1 cm in parenchymal depth
Grade II Hematoma: subcapsular, 10—50 % surface area; intraparenchymal, <5 cm
in diameter Laceration: capsular tear, 1—3 cm in parenchymal depth, not
involving a trabecular vessel
Grade III Hematoma: subcapsular, >50 % surface area or expanding; ruptured
subcapsular or parenchymal hematoma; intraparenchymal hematoma >5 cm
or expanding
Laceration: >3 cm in parenchymal depth or involving trabecular vessels
Grade IV Laceration: involving segmental or hilar vessels producing major
devascularization (>25 % of spleen)
Grade V Hematoma: completely shattered spleen
Laceration: hilar vascular injury that devascularizes
spleen
*Advance one grade for multiple injuries up to grade III (26)

Renal Injuries
The kidneys are located high up in the retroperitoneum, well protected and cushioned by the
peritoneum and abdominal viscera anteriorly and by lower ribs, vertebrae and para-spinal
muscles posteriorly which form a tough protective barrier. The kidney is the most commonly
injured organ of the genitourinary system (32) and renal injuries account for only 1-5% of all
abdominal injuries. Of all the incurred injuries, over 95% are minor injuries and can be
managed with conservative therapy with no significant complications(32).
Multidetector computed tomography is now the imaging modality of choice for evaluation of
renal injures today and can delineate the various grades of injury and associated
complications (Fig 8). It is only the more grave injuries, like renal fracture or shattering,
renal pedicle injury or avulsion and severe pelvicalyceal system (PCS) injury, which require
active intervention or surgery (32,33).
The American Association for the Surgery of Trauma classification has been updated, with
vascular injuries now included, denoting a Grade V injury (Table 4) (34)

Table 4: AAST organ injury scale for kidney

Grade Description
Grade I Hematoma: subcapsular, nonexpanding without parenchymal laceration
Contusion: microscopic or gross hematuria, urologic studies normal

Grade II Hematoma: nonexpanding perirenal hematoma con rmed to renal


retroperitoneum
Laceration: <1 cm parenchymal depth of renal cortex without urinary
extravasation

Grade III Laceration: >1 cm in parenchymal depth of renal cortex without collecting
system rupture or urinary extravagation
Grade IV Laceration: parenchymal laceration extending through renal cortex, medulla,
and collecting system
Vascular: main renal artery or vein injury with contained hemorrhage

Grade V Hematoma: completely shattered kidney Vascular: avulsion of renal hilum


that devascularizes kidney
*Advance one grade for bilateral injuries up to grade III (34)
Adrenal Injuries
Prevalence of adrenal injuries is nearly 2% in trauma patients who undergo MDCT and these
hematomas are usually associated with other organ injuries (Fig 9)(36). Although isolated
adrenal hematomas may occur, the presence of an adrenal hematoma should trigger a careful
search for other injuries. Adrenal injuries are managed conservatively and do not require any
surgical intervention (36).
Pancreatic injuries

Pancreatic injuries have been reported as high as 12 % of blunt trauma and 6 % in those with
penetrating trauma (37). Pancreatic injuries indicate significant impact to the abdomen and
are associated with other intra-abdominal injuries 50-90 % of cases (38). Isolated pancreatic
injuries are very rare but do occur. Early diagnosis of pancreatic injuries is crucial, since
delayed complications such as fistula, abscess, sepsis, and hemorrhage may lead to
significant morbidity and mortality. The clinical diagnosis of pancreatic injury may be
difficult due to the retroperitoneal location of the pancreas, peritonitis from a pancreatic
injury may take hours to days to manifest. In addition, serum amylase level is unreliable
marker for the diagnosis of pancreatic injury (39).

MDCT is the modality of choice for diagnosing pancreatic injury and the reported sensitivity
and specificity is as high as 85% (Fig 10). No separate phase is used for pancreas (it would
be difficult to predict and plan a phase prior to the start of scanning) and in our experience
the normal venous phase scan is sufficient for detecting injuries to pancreas. Two important
findings should be conveyed to the surgeons, (a) Relation of pancreatic laceration to superior
mesenteric artery either to right or left, (b) depth of laceration either less than 50% or more
than 50%. It has been said that laceration of the pancreas involving >50 % of the
anteroposterior diameter of the pancreatic body or tail is often associated with ductal
disruption (40).While MDCT gives indirect pointers of ductal injury by determining depth of
parenchyma involved, MRCP helps to directly visualize and look for main pancreatic ductal
integrity (41,42) (Fig 10d-e). Note that ERCP is both diagnostic and therapeutic and is
generally preferrd in such patients.
AAST grading of pancreatic injuries described in Table 5 (34)

Table 5: AAST organ injury scale for pancreas

Grade Description of Injury


I Minor contusion without duct injury
Superficial laceration without duct injury
II Major contusion without duct injury or tissue loss
Major laceration without duct injury or tissue loss
III Distal transection or parenchymal injury with duct injury
IV Proximal transection or parenchymal injury involving ampulla
V Massive disruption of pancreatic head
*Advance one grade for multiple injuries up to grade III (43)
Fresh pancreatic transections or lacerations involving > 50% depth are managed surgically
depending upon the relation of injury to SMA. If it is to the right of SMA, Whipple’s surgery
is done and if it is to the left of SMA, distal pancreatectomy done. If the presentation is late
and there is formation of pseudocyst and pancreatitis, patients are managed conservatively by
catheter placement to drain the pseudocyst. Once the acute inflammation is settled, elective
surgery is planned accordingly (39,44,45).

Bowel and Mesenteric Injury


Usually result either from direct force to the abdomen may crush the gastrointestinal tract or
by rapid deceleration may produce shearing force between fixed and mobile portions of the
tract, leading to a sudden increase in intraluminal pressure may result in bursting injuries
(46). Common sites of injuries in the small bowel following blunt trauma are proximal
jejunum, near the ligament of Treitz and distal ileum, near the ileocaecal valve. In these
regions, mobile and fixed portions of the gut are continuous and therefore are susceptible to
shearing force (47). Bowel injuries occur in 5% of blunt trauma patients (5). MDCT is the
investigation of choice without the need of oral contrast (5,12,13). Various CT findings of
bowel and mesenteric injuries have been described (5,48), that include (Fig 11);
• Bowel wall defect
• Intraperitoneal and mesenteric air
• Intraperitoneal, extraluminal contrast material
• Extravasation of IV contrast materialfrom mesenteric vessels
• Evidence of bowel infarct
• Vascular beading sign
• Abrupt termination of mesenteric vessels
Less specific signs of bowel and mesenteric -injuries include (these signs require correlation
with clinical exam);
• focal bowel wall thickening,
• mesenteric fat stranding with focal fluid and hematoma,
• intraperitoneal or retroperitoneal fluid.
Other causes of small-bowel wall thickening which could mimic injury include;
Could represent a lack of bowel distention
Edema secondary to systemic volume overload or to hypoperfusion(shock bowel)
(49).
Ureter
Ureteral injuries are most frequently iatrogenic, though they can sometimes result from blunt
trauma. CT helps in predicting the presence of ureteral injury based on the presence of
contrast extravasation medial to the kidney and lack of opacification of distal ureter (14). The
most important investigation in this setting though, remains ureterograms done by the
proximal or distal route. Ureterograms can clearly define type and location of injury and also
any associated fistulae or communicating urinomas.
Urinary Bladder
Blunt trauma accounts for 60-80 %, whereas penetrating trauma accounts for 20-40 % of all
bladder injuries (50). In any suspected bladder injury, cystogram must be performed as
described in the CT protocol. Note that delayed imaging is not sufficient to delineate bladder
injuries. Mechanism of injury to the bladder is due to rapid increase of the intravesical
pressure in distended bladder resulting in a tear along the intraperitoneal portion of the
bladder wall (bladder dome) (50). Bladder rupture should be suspected when a patient
presents with gross hematuria, pelvic fluid, and/or pelvic fractures. CT cystography should
be performed following CT of the abdomen and pelvis in hemodynamically stable trauma
patients (Indications for CT cystography are described vide supra) (6,15,16).On CT
cystography (Fig 12), an extraperitoneal bladder injury demonstrates contrast leakage in the
classic flame shaped or molar tooth configuration as the contrast penetrates into the
paravesical tissues. In the case of intraperitoneal bladder injuries, contrast will outline bowel
loops and diffuse freely into peritoneal spaces (51).
Classification of bladder injury (AAST grading) is described in table 6.
Table 6 AAST organ injury scale for urinary bladder (52)

Grade InjuryType Description


Hematoma Contusion,intramuralhematoma
I
Laceration Partialthickness
II Laceration Extraperitonealbladderwalllaceration<2cm
III Laceration Extraperitoneal(≥2cm)orintraperitoneal(<2cm)walllaceratio
IV Laceration Intraperitoneallaceration≥2cm
Intraperitonealorextraperitoneallacerationextendingintotheb
V Laceration
ladder neckor ureteralorifice(trigone)
Advance one grade for multiple lesions up to grade III (52)

While bladder contusions and most extraperitoneal injuries can be managed conservatively,
intraperitoneal bladder rupture requires immediate surgical management (50).
Hypoperfusion Shock Complex
It is a constellation of CECT Signs pointing to hypovolemic Shock following trauma (Fig
13).Any combination of vascular and visceral signs may be present. When hemodynamic
instability is corrected, only end-organ abnormalities may be observed. Mortality for adults
with the hypovolemic shock complex is about 70% (5,53,54)

Vascular signs Visceral signs

Diminished calibre of IVC: AP Hollow visceral abnormalities


diameter less than 9mm on 3 slices of • Increased bowel wall mucosal enhancement
intrahepatic IVC, at and 2 cm below Gastric dilation
renal veins
Diminished calibre of Aorta: AP Solid visceral abnormalities:
diameter less than 1.3 cm, 2cm above, • Intense adrenal gland enhancement (greater
at and 2 cm below renal arteries. than the IVC)
• Renal cortical enhancement (greater than that
of the aorta)
• Dark spleen
• Only pancreatic parenchymal enhancement

Shock bowel: Shock bowel or diffuse small bowel ischemia is seen in patients with severe
hypotension following hemorrhage. Due to marked sympathetic stimulation resultant
splanchnic vasoconstriction causes drastic reduction in blood supply to the intestinal mucosa
and this blood is diverted to other crucial organs such as the brain and heart. CT
characteristics of shock bowel include diffuse thickening of the small bowel wall, fluid filled
dilated small bowel, and increased contrast enhancement of the small bowel wall mucosa.
Large bowel appears normal, in these cases (49).

Teaching points:
1. Currently, MDCT with intravenous contrast is the standard-of-care in
hemodynamically stable patients who have intra-abdominal fluid on FAST.
2. If there is contrast blush in any area, immediate repeat scan should be done to
differentiate active extravasation vs pseudoaneurysm
3. CT cystography should be performed following abdomen/pelvis CT if bladder injury
is suspected, in hemodynamically stable patients with pelvic fracture.
4. CT findings of mesenteric injury include contrast extravasation into the mesentery,
focal mesenteric hematoma or infiltration, bowel wall thickening
5. Carefully look at the scans especially for pneumoperitoneum, active extravasation,
mesenteric hematoma, intraperitoneal bladder rupture, pancreatic injury.
Role of Interventional Radiology (IR) in blunt abdominal trauma

Indications for transarterial embolisation in the setting of blunt abdominal trauma vary from
centre to centre who have accessibility to the service of interventional radiology.
Angioembolisation in the setting of blunt abdominal trauma was first described by Bass EM et
al in 1977 following hepatic injury and was managed by gelfoam embolization (55).
Splenic artery embolisation for splenic injury was first described by Sclafani SJ et al in early
1980 (56), but this procedure was described long back in 1970 by Maddison F for
hypersplenism (56).
Interventional radiologists play important role in the management of trauma patients and
angio-embolisation has become a valuable adjunct in the management of these patients
(57,58).
Interventional radiology helps in three important clinical scenarios (57,58):
Provides hemostasis in areas difficult to access by surgery eg: Bleeding following pelvic
fractures
Prevents need of re-operation in case of rebleeding eg: rebleeding after surgical packing
for hepatic injury
Assists in the non-operative management of solid organ injuries especially high grade
injuries (≥ grade 4).

Prerequisites for initiation of non-operative management (60-62)


1) Hemodynamic stability (with or without minimal fluid resuscitation)
2) Absence of peritoneal signs
3) CT scan delineation and AAST grading of the solid organ injury Grade 1-3 Vs Grade 4-5
4) Absence of associated intra-abdominal or retroperitoneal injuries that are pertinent on
clinical examination or radiological findings which require operative intervention (i.e. hollow
visceral injury excluded)
5) Avoidance of excessive blood transfusion (some authors recommend less than four units of
RBC)
General principles of Angioembolisation
Management plan should be discussed with the trauma surgeon and also with the family.
Obtain the informed consent.
Angiographic suite should be close to the main operation theatre and emergency room; it
saves time in patient transfer.
The IR should be available 24X7
Critical care support: Ongoing resuscitation (airway maintenance, fluid, medications and
blood transfusion) is critical during all aspects of trauma care even during angiographic
intervention.
Prior to the angiography if the patient had CT scan (hemodynamically stable patients),
operator should clearly look at the scan for the presence, location, and description (such as
extent of injury, presence of active contrast extravasation, pseudoaneurysm or any arterio-
venous fistula) and possibly arterial anatomy also. This saves lot of time in searching for the
possible source of bleeding vessel during angiography.
Laboratory studies such as coagulation profile and renal function tests are not prerequisite for
trauma angiography and angioembolisation should not be delayed in waiting for these
laboratory results.
Once the angioembolisation is decided, angiography should be done expeditiously without
wasting time in patient transfer.

Procedural steps

Majority of these patients usually have contrast enhanced CT scan prior to the angiography,
hence therefore care should be exercised in limiting the amount contrast media used while
performing angiography.
Use of low osmolar contrast media is recommended to prevent contrast induced nephropathy
(CIN). In the context of life threatening bleeding and in comparison to high surgical risk
for these patients, the risk of CIN would appear to be acceptable.
Vascular access: Standard femoral arterial access should be obtained using the Seldinger
technique and vascular sheath is placed. In cases of severe blood loss or in case of pelvic
fractures, obtaining vascular access would be very difficult. In such cases, one should take
either ultrasound guidance for puncturing the femoral artery or surgical arteriotomy. In case
of extensive injurieslocation of those injuries, and the presence of orthopedic fixation devices
may preclude femoral access Axillary or brachial arterial access might be required in such
cases.
During diagnostic angiogram, identification of injured vessels as well as of collaterals and
variant anatomy is required. Always perform selective catheterization of potential bleeding
sources before concluding normal angiogram.
On angiography, findings of vascular injury include contrast extravasation, pseudoaneurysm,
arteriovenous fistula, and complete arterial occlusion.
Once the source of bleeding is identified and decision to perform embolisation is made,
careful selection of catheters is required to prevent non-target embolisation and to reach close
to the source of bleeding area.
End-hole catheters should be used to decrease the risk of non-target embolization. Use of
coaxial systems and microcatheters allows super-selection of injured vessels and hence more
selective embolization.
Once should follow superselective embolization technique that allows rapid hemostasis in an
injured vessel while preserving adjacent non-injured tissue as much as possible.
Based on angiographic findings and site of injury, appropriate embolising material is used
(discussed below).

Specific angiographic situations and the technique;

If there is active contrast extravasation or pseudoaneurysm and the bleeding vessel is non-
vital (terminal branch), it might be sacrificed
If the bleeding vessel is main vessel or pseudoaneurysm is arising from main artery, covered
stent may be used, but the use of covered stent in emergency setting and in visceral arteries is
very limited. In such cases, it is better to occlude both distal and proximal to the
injury/pseudoaneurysm to prevent retrograde flow in embolised vessel. If care is not taken in
performing distal embolization, bleeding may occur in retrograde fashion via collateral blood
flow.
One should never make an attempt to place coils within the acutely traumatic
pseudoaneurysms, this might lead to expansion and/or rupture of the injured vessel.
In the setting of trauma, when vessels are found to be occluded by thrombus on angiography
the underlying vascular injury may be transection, spasm, or dissection. A vessel that initially
appears stable or occluded may be the source of delayed bleeding. One should never try to
dissolve or thrombolyse these occluded vessels that may lead to torrential bleeding on table.
Arteriovenous fistulae (AVF) represent another form of injury identified in visceral trauma
and is common with penetrating trauma than blunt trauma. As in pseudoaneurysm, if the
fistulous site involves a terminal branch the vessel might be sacrificed. If the fistulous
communication is large avascular plug may be used instead of coil to prevent coil migration.
If the fistulous communication involves main artery and vein, covered stent is preferred for
maintaining the distal arterial flow.
Occasionally, nonselective embolisation using gelfoam may be used when there is no
angiographic evidence of vascular injury. This is particularly used for internal iliac arteries
in pelvic trauma, however it is controversial. This is postulated to work by reducing
perfusion pressure and therefore controlling venous bleeds.
Postembolisation angiography should be obtained to confirm the hemostasis prior to removal
of the vascular sheath.

Types of embolising agents (63):

Temporary Agents:

Gelfoam: It is a temporary embolic agent and their time of resorption is about 3 weeks. It can
be used either in the form of pledgets (cut from gelfoam sheet) or in the form of slurry (Non-
ionic iodinated contrast mixed with gelfoam).
Autologous blood clot: They are difficult to use because of poor visibility and also difficult
to form clot if there is hemodilution by fluid replacements or by repeated blood transfusions.

Permanent Agents

Coils (Regular size, micro coils, and Nester coils): Often fibered to increase the
thrombogenic effect, they can be used either alone or in combination with gelfoam. They are
easy to use with good visibility. Widely used in embolisation of solid organ injuries or to
embolise post traumatic pseudoaneurysm.
Particulate agents (PVA particles): Role of these particles in setting of trauma is limited and
they do not any real benefit compared to gelfoam. They have disadvantages such as a
significant additional cost and may cause tissue necrosis.
Liquid agents such as Glue and Onyx: Powerful permanent embolising agents when they
come in contact with body fluids such as blood they polymerize and form cast. They should
be used cautiously and with experienced hands otherwise the non-target embolisation will
cause more harm than benefit.
Occlusive devices such as Amplatzer vascular plug: Its a mesh-shaped metal coil, which can
be deployed with great accuracy, replacing a combination of several coils of smaller
diameter, thus saving time . They are useful in large vessel arteriovenous fistula closure.

Specific Situations

Though angioembolization is usually reserved for hemodynamically stable patients;


However, special situations such as pelvic trauma hemorrhage and re-bleeding after surgical
packing may be exceptions to this rule because there is no suitable alternative.

Hepatic injury:

Majority of hepatic injuries are usually managed conservatively, however in cases of


extensive liver injury with hemodynamic instability, rapid damage control surgery with
packing is a recommended approach (64,65). All the hemodynamically unstable patients with
liver injury, who undergo surgical packing, should undergo angiography and embolisation
immediately after damage control surgeries that will improve the overall clinical outcome.
Patients who are hemodynamically stable but have high grade injuries (grade ≥ 4) should also
undergo angiographic embolisation immediately if there is any clinical or CT evidence of
ongoing bleeding (such as, varying vital parameters, active contrast extravasation, and
pseudoaneurysm). This practice will reduce the laparotomy rate and also the complications,
such as abscess, biloma, and bile leak.
Typical embolisation technique involves selective catheterization and reaching up to the site
of abnormality (contrast extravasation / pseudoaneurysm or arterio-venous fistula) and
embolisation using coils (Fig 14). Most commonly encountered technical difficulty is
reaching up to the site of contrast leakage due to severe vessel spasm. In such cases, use of
microcatheter and delicate catheter manipulation across these spasmodic vessels, will help to
reach the site of abnormality. Occasionally, nonselective embolisation using gelfoam of the
hepatic artery of affected lobe without angiographic evidence of vascular injury especially in
cases of extensive liver injury on CECT, may help in achieving hemostasis, however it is
controversial.
In the setting of trauma, technical success rate of hepatic angioembolisation, ranges from
88% -100%, but in cases following surgical packing due to distorted anatomy and
manipulation, technical success rate drops to 60-70% (64). Complications of hepatic artery
embolisation include abscess formation, non target embolization (66).

Splenic Injury
As discussed previously, Traumatic splenic injuries were traditionally treated by
splenectomy, presently there is a trend towards conservative management. A
hemodynamically stable patient with single system injury who is not on any anticoagulation
or non-compliant patient is ideal patient for conservative approach. Proximal splenic artery
embolisation is a viable option especially in grade ≥4 injuries, contrast active extravasation,
pseudoaneurysms or arterio-venous fistula (30). This splenic angioembolization improves the
success rate of nonoperative management of blunt splenic injuries from 87 to 94% (31).
For splenic artery embolisation, initially celiac axis angiogram is performed followed by
selective splenic artery angiogram. Embolisation technique depends upon the angiographic
findings. If there is intrasplenic hemorrhage, proximal coil embolisation is sufficient to
reduce the inflow and pulp pressure so that intrasplenic hemorrhage is controlled. In addition
collateral circulation is preserved that carries low risk of splenic infarction (Fig 15). In
proximal embolisation technique, coil size should be 20% larger than vessel diameter and is
positioned just distal to the origin of dorsal pancreatic artery. Sometimes, sandwich technique
of using gelfoam slurry over the coil may be helpful to reduce the perfusion pressure.
If there is extraspelnic hemorrhage or pseudoaneurysms or intrasplenic AV fistula distal
embolisation, using microcatheter coaxial system, close to the site of abnormality is
worthwhile to achieve maximum hemostatic control.
Proximal splenic artery embolisation in the setting of trauma has technical success rate of 90-
95% with low rate of splenic infarction, distal embolisation is associated with similar success
rate for hemostasis but higher risk for splenic infarction and increased procedural time (69).

Renal Injury
Injuries involving the renal arteries usually occur in conjunction with other solid organ
injuries, and majority of blunt renal injuries are minor, self-limiting and require no treatment.
However major renal injuries will often needs surgical nephrectomy.
Patients with solitary kidney need more aggressive nephron sparing procedures. The
endovascular options will be of helpful only if the patient reaches the hospital in right time (<
6 hours) especially in case of main renal artery occlusions. Type of endovascular treatment
depends on type of vascular injury seen.
If there is major renal artery dissection, laceration or extravasation, stent graft may be used to
preserve the flow to kidney if lesion can be crossed safely and successfully.
When there is main renal artery occlusion, thrombolysis with intra-arterial thrombolytic
agents such as urokinase or tissue plasminogen activator may be used to salvage the kidney
provided the procedure is carried out within 6 hours.
Intraparenchymal hemorrhage or pseudoaneurysm is seen and then superselective
embolisation should be performed via microcatheter system and microcoils (Fig 17).
Embolisation is performed as selectively as possible to preserve the maximum functioning
renal tissue (70,71).
If there is arteriovenous fistula, embolisation just proximal to site of fistulous site using coil
is a best option. For ureteric injury or pelvicalyceal injury with urinoma formation, urinary
diversion by percutaneous nephrostomy of the non-dilated pelvicalyceal system should be
performed to allow the site of ureteric injury to heal.
Pelvic fracture bleeding
Pelvic hemorrhage following pelvic fractures is difficult to control with surgery, and surgical
packing is often performed in centers where interventional radiology facility is not available.
In majority of the patients, bleeding is controlled by external pelvic fixating devices. This is
possible because majority of the pelvic bleeds are due to venous and small arterial bleeds. In
patients with major arterial bleed need more aggressive approach, where angioembolisation
plays vital role. With single arterial puncture, both the internal iliac arteries can be accessed
using specially designed uterine artery catheter. Selective angiograms of each internal iliac
artery should be performed and if a single major arterial branch shows contrast extravasation,
superselective embolisation should be performed using microcatheter system and microcoils.
In patients who are hemodynamically unstable with multiple areas of contrast extravasation,
nonselective proximal embolization of both the anterior, posterior divisions of internal iliac
artery with gelfoam slurry followed by coil embolisation of internal iliac artery can be a
lifesaving procedure (72-74). Occasionally, nonselective embolisation using gelfoam of the
internal iliac arteries without angiographic evidence of vascular injury especially in pelvic
trauma may be helpful in achieving venous bleeds, however it is controversial. Serious
complications have been reported after pelvic embolization including uterine and bladder
necrosis, paresis, buttock ischemia, and impotence. Many technical difficulties are
encountered, especially in hemodynamically unstable patients with hematoma reaching up to
groin areas. These difficulties include, difficult arterial access (may need ultrasound
guidance), and spasmodic distal vessels (use Microcatheter system).

Take home message

Angioembolisation, a minimally invasive procedure plays an important role in the


management of selected cases of traumatic injuries of the solid organs and pelvic fracture
bleeding

Trauma centers should have multidisciplinary trauma teams with established trauma
protocols to decide when embolization and/or surgery is required as a part of critical care
management of trauma patients

Embolization should be performed early to control the source of bleeding before


coagulopathy develops.

Various embolising agents and catheter systems are available, one should have detailed
knowledge of each of the agents with respect to when, how and what to use.
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Chart 1. Imaging guidelines for abdominal trauma

Legends

Figure 1. Sentinel clot sign. Axial contrast enhanced CT images showing highest attenuation
hematoma (asterix) suggestive of sentinel clot sign in relation to liver (A) and spleen (C) giving
clue to site of bleeding from liver laceration (arrow) in B and splenic laceration (arrow) in D.

Figure 2. Active extravasation. Axial (A) and coronal 3D reformatted (B) contrast enhanced CT
images showing well hyperdense hematoma in the region around pancreatic head (asterix) with
focus of blob (arrow) in B which has same attenuation to the artery. In the delayed phase (C) and
(D), the central blob has spread and has irregular margins (arrow) suggestive of active
extravasation.
Figure 3. Hepatic artery pseudo aneurysm. Axial (A) and coronal 3D reformatted (B) contrast
enhanced CT images showing hypodense intraparencymal hematoma (asterix) with well
defined focus of blob (arrows) which has same attenuation that of the abdominal aorta
suggestive of pseudo aneurysm.

Figure 4. Axial contrast enhanced CT images (A –F) showing spectrum of liver injuries. (A)
Liver contusion as focal, poorly defined area of low attenuation (asterix). (B) Liver laceration
seen as low attenuation non enhancing linear branching areas (arrow). (C) Liver lacerations
(arrow) extending till the capsular surface with perihepatic hematoma (asterix). (D)
Intraparenchymal hematoma seen as well defined hypodense area in liver (asterix). (E) Hepatic
subcapsular hematoma (asterix) seen as lenticular hypodense area in the periphery of liver with
compression of the underlying liver parenchyma (arrows.) (F) Multiple lacerations noted on liver
(asterix) with hepatic artery pseudoaneurysm (arrow).

Figure 5.Halo sign: a rim of edema (arrow) surrounding a collapsed intra-hepatic IVC suggestive
of bare area (asterix) liver injury.

Figure 6. Axial contrast enhanced CT images (A –D) showing hepatic vascular complications.
(A) Multiple liver lacerations (asterix) with active contrast extravasation (arrow). (B) Multiple
liver laceration reaching up to right hepatic vein (RHV) with thrombosis of RHV(C) Axial CT
showing complete infarct of the segments 2 and 3 of liver (asterix). (D) Axial contrast enhanced
CT image showing hypodense intraparencymal hematoma with well defined focus of blob
(arrow) which has same attenuation that of the abdominal aorta suggestive of hepatic artery
pseudo aneurysm.

Figure 7. Axial contrast enhanced CT images (A –F) showing spectrum of splenic injuries. (A)
Splenic laceration seen as linear hypoattenuating lesion (arrow) in the spleen extending till the
capsular surface. (B) Multiple splenic contusions seen as focal poorly marginated areas of low
attenuation (asterix). (C) Active extravasation seen as irregular, contrast blush from the splenic
parenchyma (arrow) with perisplenic hematoma. (D) Subcapsular splenic hematoma seen
crescentic hypoattenuating lesion in the periphery of spleen with indentation on the splenic
surface (arrow). (E) Diffuse non-enhancement of spleen suggestive of complete
devascularisation (asterix). There are also associated hepatic lacerations in left lobe. (F)Splenic
artery pseudoaneurysm (arrow) showing as contrast filled outpouching having same attenuation
of the abdominal aorta in the region of splenic hilum.

Figure 8. Axial contrast enhanced CT images (A –G) showing spectrum of renal injuries.(A)
Renal contusion seen as focal ill-defined hypoattenuating area (arrow) in the left kidney.(B)
Renal laceration seen as linear hypodense lesion communicating with pelvicalycecal
system(PCS)( arrow ) with hyperdense contents in the PCS (asterix). (C) Subsegmental infarct
seen as sharply demarcated wedge shaped area of decreased attenuation (arrow) in the interpolar
region of left kidney. (D) Renal hilar injury showing extravasation contrast from renal artery
near the hilum (arrow) with non enhancement of right kidney. (E) Thick maximum intensity
projection of delayed phase showing urinary extravasation (asterix) of contrast from the upper
ureter s/o ureteric injury. (F) Axial contrast CT showing diffuse hypoattenuating right kidney
(asterix) with thrombus in the right main renal artery (arrow) suggestive of complete
devascularisation injury.

Figure 9. Coronal 3D reformatted CT image showing well-defined hypodense lesion in the right
adrenal gland (arrow) with free fluid in Morrison’s pouch (asterix ) suggestive of adrenal
hematoma.

Figure 10. Axial contrast enhanced CT images (A –G) showing spectrum of pancreatic injuries.
(A) Axial contrast enhanced CT showing pancreatic transaction involving distal pancreas (arrow)
(Type 3 pancreatic injury). (B) Coronal 3D reformatted CT image showing pancreatic head
contusion (asterix) with active extravasation of contrast (arrow) from gastroduodenal artery. (C)
Axial T2W MR image showing laceration (arrow) in neck region involving entire thickness of
pancreatic parenchyma (D) Axial T2W MR image showing pancreatic laceration (arrow) with
peripancreatic fluid collection in the lesser sac (asterix).

Figure 11. Axial contrast enhanced CT images (A-F) showing spectrum of bowel and mesenteric
injuries. (A) Axial contrast enhanced CT image showing focal thickening of transverse colon
(arrow) with free fluid in abdomen. There is associated pneumoperitoneum (arrow) suggestive of
colonic perforation. (B) coronal 3D reformatted CT image showing non enhancing small bowel
loops in right lower quadrant (arrow) suggestive devascularised bowel loops. Mesenteric injuries
(C-E): Axial contrast enhanced CT images showing streakiness in the mesentery (arrow) in C,
beading of mesenteric vessels (arrow) in D and mesenteric hematoma seen as stellate area of
hyperdensity in the root of mesentery (asterix) in E. (F) Axial contrast enhanced CT showing
active extravasation from superior mesenteric artery (arrow) suggestive of mesenteric vascular
injury.

Figure 12. Axial contrast enhanced CT images (A-F) showing spectrum of bladder injuries.(A)
Axial CT cystogram showing contrast lining the bowel loops (asterix) with rent noted in the
dome of bladder ( arrow) in B suggestive of intraperitoneal bladder rupture.(C) CT cystogram
showing contrast extravasation into the perivesical space (asterix ) suggestive of simple
extraperitoneal bladder injury. (D) Axial CT cystogram demonstrates complex extraperitoneal
bladder rupture with contrast extravasation in the perineum (asterix).

Figure 13. Hypoperfusion complex in a patient with road traffic accident (A) Axial contrast
enhanced CT image showing diffusely enhancing bowel loops ( compared to psoas muscle) with
hyperenhacing renal cortex ( equal to that of aorta ). There is reduced calibre of IVC (arrow) in B
and aorta with enhancing adrenal (notched arrow) in B and pancreas (asterix) in C. The spleen
shows hypoenhacement (asterix) in B.

Figure 14. Role of angioembolisation in hepatic vascular injury. (A) Axial CT scan showing
multiple laceration and contusion with active contrast extravasation (arrow) involving right lobe
of liver. (b) Digital Substraction angiogram images showing the active extravasation of contrast
(arrows in B, C) from right hepatic artery. The right branch of hepatic artery was selectively
embolised by coil (arrow) and the post embolisation angiogram (D) shows no active
extravasation.
Figure 15. Role of angioembolisation in splenic injury. Axial CT images (A, B) showing
multiple splenic lacerations (asterix) involving >75% of splenic parenchyma with perisplenic
hematoma (grade 4 splenic injury). (C) Digital subtraction angiogram of splenic artery showing
no pseudo aneurysm or active extravasation. (D)Prophylactic splenic artery embolisation was
done using coil (arrow).

Figure 16. Role of angioembolisation in renal injury. A. Axial contrast enhanced CT showing
well-defined contrast filled out pouching (arrow) suggestive of pseudoaneurysm with
surrounding perinephric hematoma in relation to right kidney. 3D reformatted (Volume
rendered) CT image (B) showing the pseudoaneurysm arising from right segmental renal artery
(arrow). Digital subtraction angiogram (C) showing pseudoaneurysm arising from right lower
polar artery (arrow). Post embolisation angiogram showing coil (arrow) in the right segmental
renal artery with complete blockage of pseudoaneurysm.
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