35

Contemporary Management of Hepatic Trauma:

What IRs Need to Know
Shenise Gilyard, MD1 Kaitlin Shinn, BS2 Nariman Nezami, MD3 Laura K. Findeiss, MD, FSIR1
Sean Dariushnia, MD1 April A. Grant, MD4 C. Matthew Hawkins, MD1 Gail L. Peters, MD1
Bill S. Majdalany, MD1 Janice Newsome, MD, FSIR1 Zachary L. Bercu, MD, RPVI1
Nima Kokabi, MD, FRCPC1

1 Division of Interventional Radiology and Image-Guided Medicine, Address for correspondence Shenise Gilyardm, MD, Division of
Department of Radiology and Imaging Sciences, Emory University Interventional Radiology and Image-Guided Medicine, Department of
School of Medicine, Atlanta, Georgia Radiology and Imaging Sciences, Emory University School of
2 Department of Medical Education, Emory University School of Medicine, 1364 Clifton Road NE, Suite D112, Atlanta, GA
Medicine, Atlanta, Georgia (e-mail: chray@uic.edu).
3 Division of Vascular and Interventional Radiology, Department of
Radiology and Radiological Science, Johns Hopkins School of
Medicine, Baltimore, Maryland
4 Division of Trauma/Surgical Critical Care, Department of Surgery,

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Emory University School of Medicine, Atlanta, Georgia

Semin Intervent Radiol 2020;37:35–43

Abstract Trauma remains one of the leading causes of death in the United States in patients
younger than 45 years. Blunt trauma is most commonly a result of high-speed motor
vehicular collisions or high-level fall. The liver and spleen are the most commonly
injured organs, with the liver being the most commonly injured organ in adults and the
spleen being the most affected in pediatric blunt trauma. Liver injuries incur a high level
Keywords of morbidity and mortality mostly secondary to hemorrhage. Over the past 20 years,
► liver trauma angiographic intervention has become a mainstay of treatment of hepatic trauma. As
► injury there is an increasing need for the interventional radiologists to embolize active
► hepatic hemorrhage in the setting of blunt and penetrating hepatic trauma, this article aims to
► embolization review the current level of evidence and contemporary management of hepatic trauma
► interventional from the perspective of interventional radiologists. Embolization techniques and
radiology associated outcome and complications are also reviewed.

The liver is the most commonly injured organ in adult blunt
abdominal injury.1 The spleen is the most commonly injured
organ in children. According to the most recent National
Trauma Data Bank (NTDB)2 data, abdominal injuries made up
11% of the 100,996 adult admissions for trauma in 2016.
Motor vehicle accidents and falls accounted for the majority
of blunt trauma mechanisms in both adults and children.2
In the pediatric trauma population, 10 to 15% of all
patients with trauma have an associated abdominal injury.3
More than 90% of abdominal injuries in pediatrics are caused
by blunt trauma. Of those patients with abdominal injuries,
splenic trauma is the most common, followed by hepatic
injury.4 In a cohort of pediatric patients from the NTDB,
approximately 30% of pediatric patients with abdominal
trauma had an isolated injury to the liver, whereas 50%
had isolated injuries of the spleen.4
Currently, the options for the management of hepatic trau-
ma in adults and children are open surgery, angioembolization,
and nonoperative management (NOM). Traditionally, NOM
included careful monitoring of the hemodynamically stable
patient and radiological interventions such as embolization.5
Over the past 20 years, NOM has become the standard of care in
the hemodynamically stable patient.6 Although an invasive
intervention, many studies have historically grouped angioem-
bolization under the umbrella of NOM. As the implementation
of angioembolization has evolved over this time period, this

Issue Theme Emergency IR; Guest Copyright © 2020 by Thieme Medical DOI https://doi.org/
Editors, Brian Funaki, MD and Charles E. Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0039-3401838.
Ray, Jr., MD, PhD, FSIR New York, NY 10001, USA. ISSN 0739-9529.
Tel: +1(212) 760-0888.
36 Contemporary Management of Hepatic Trauma
article is defining NOM as admission with serial abdominal
examinations and serial hemoglobin measurements without
embolization.7 In a 2011 study, 94% of NOM patients were
successfully managed without open surgery or embolization.7
With the advent of hybrid operating rooms, a new category of
management (angioembolization with surgery) has emerged.
This combined approach has been demonstrated to reduce
mortality in severely injured patients.8,9
Although the landscape in the management of hepatic
trauma continues to evolve, this article aims to review the
most up-to-date available evidence on the management of
adult and pediatric patients, discuss the efficacy of different
treatments (surgery, embolization, NOMt), and outline the
essentials of what interventional radiologists (IRs) need to
know in this arena.
Grades of Liver Injury
Understanding the numerous classification schemes in liver
injury is of paramount importance in understanding the
treatment options for these patients. There are four major
classification systems which stratify various traumatic
injuries by severity: the Abbreviated Injury Score (AIS),10
the American Association for Surgery of Trauma (AAST)
grading system, the Injury Severity Score,11,12 and World
Society of Emergency Surgery (WSES) grading system.9 The
AIS is an anatomically based global severity system that
classifies injury severity by body region.10 Initially designed
for classifying injuries due to motor vehicle and airplane
crashes, it has been widely adopted into a coding system to
classify injuries taking into account survival data.13 The AIS
is internationally adopted into medical coding and these
data have been collected as part of the NTDB. Although the
Fig. 1 Summary of American Association for the Surgery of Trauma (AAST) Grading of Hepatic Trauma.
Seminars in Interventional Radiology Vol. 37 No. 1/2020
Gilyard et al.
AIS and Injury Severity Score are used in research data
collection, the AAST grading system and now the WSES are
mainstays of classification in the current clinical settings.
The AAST is a radiographic scoring system which catego-
rizes injury from grade I to VI based on hematoma, lacera-
tion, and vascular compromise14 (►Fig. 1). The higher the
grade, the greater the CT evidence of hepatic compromise
(►Table 1). While widely adopted, the AAST fails to
take into account the clinical presentation of the patient.
The 2016 WSES guidelines aim to rectify this by stratifying
patients based on AAST score and hemodynamic stability.
Patients are mild, moderate, or severe based on AAST grade.
Any patient will be categorized as severe (WSES grade IV) if
hemodynamically unstable.15
Overview of Management of Hepatic
Trauma in Adults
Current recommendations for managing adult hepatic trauma
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are supported by the World Society of Emergency Surgery
(WSES) 2016 classification of liver injury.15 Most recent guide-
lines stratify liver injury according to the WSES classification
scheme, which utilizes the AAST grading and takes hemody-
namic stability into account. For the hemodynamically stable
patient with AAST grade I–IV, NOM is the most evidence-based
treatment.16 Multiple institutional studies and case reviews
have established NOM as a safe and highly effective manage-
ment option. Most studies show a success rate of 80 to 100% for
NOM of the adult patient with blunt hepatic trauma. NOM is
achievable in an estimated 80% of all hepatic trauma cases.11 To
qualify for NOM, patients must be hemodynamically stable,
have an adequate response to initial resuscitation attempts, and
have no peritoneal signs. These patients should be imaged with
 Contemporary Management of Hepatic Trauma Gilyard et al. 37

Table 1 American Association for the Surgery of Trauma (AAST) grading system for hepatic injury

Injury type Injury description WSES grade15

Ia Hematoma Subcapsular <10% of surface Grade I
Minor if hemodynamically stable—includes
Laceration Capsular tear <1 cm depth
blunt and penetrating lesions
IIa Hematoma Subcapsular 10–50% of surface area,
intraparenchymal hematoma, <10cm in diameter
Laceration 1–3 cm parenchymal depth, <10 cm in length
III Hematoma Subcapsular > 50% of the surface area or expanding, Grade II
ruptured subcapsular or parenchymal hematoma, If hemodynamically stable in blunt or
intraparenchymal hematoma >10 cm penetrating lesion
Laceration >3 cm parenchymal depth
IV Laceration Parenchymal disruption 25–75% of hepatic lobe Severe
Grade III—hemodynamically stable
Vascular Hepatic injury near major hepatic
Grade IVa—AAST grades I–VI
vein or near the hepatic IVC
if hemodynamically unstable
VI Vascular Hepatic avulsion

Abbreviations: IVC, inferior vena cava; WSES, World Society of Emergency Surgery.

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a
Advance grade I for multiple injuries up to grade III.

multiphase CT immediately and treated according to imaging
findings.
NOM of stable patients suffering from penetrating trauma
from gunshot wounds is being carefully explored in select
patients.17 In this very select group, NOM is independently
associated with improved mortality and fewer complications.17
Failure of NOM following blunt traumatic injury is infre-
quent, with failures reported secondary to hemorrhage,
peritonitis, or abdominal compartment syndrome.7 Hemor-
rhage is the most common cause of failure of NOM and can be
managed with open surgery alone or combined open surgery
and embolization or embolization alone.
According to WSES’ most recent guideline published in
2016, patients with hepatic trauma who are hemodynamically
stable with no signs of free air; localized bowel thickening;
evisceration; and impalement on contrast-enhanced CT of the
chest, abdomen, and pelvis without evidence of active arterial
extravasation/blush are appropriate candidate for NOM. Those
who demonstrate active arterial extravasation/blush are rec-
ommended to undergo angioembolization. If embolization is
effective and the patient remains hemodynamically stable,
no further invasive intervention is required. If not, open
surgery with or without intraoperative angioembolization is
recommended.
In patients who are hemodynamically unstable to tolerate
NOM, open surgery alone or in combination with embolization
is recommended. Intraoperative embolization is associated
with fewer units of blood transfused, fewer complications, and
decreased mortality.9
Overview of Management of Hepatic
Trauma in Pediatrics
Management of pediatric hepatic trauma, like splenic trau-
ma, has shifted over the last few decades from primarily
surgical to successful NOM in greater than 90% of cases.11
NOM is more successful in pediatric patients than in adults,
likely due to differences in physiology and ability to com-
pensate for blood loss as well as differences in mechanism of
injury.4 To date, there is no consensus on the role of
angioembolization in pediatric trauma patients with hepatic
injury. Indications and frequency of use vary greatly by
center. Case series have demonstrated the safety and efficacy
of embolization in patients with evidence of ongoing hepatic
bleeding and hemodynamic instability.10
As in adult patients, initial management of pediatric trauma
patients should focus on injuries associated with the airway,
breathing, and circulation according to the Advanced Trauma
Life Support guidelines. Following stabilization, management is
based on history and physical exam as well as on imaging
evaluation of intra-abdominal injuries. Initial efforts to stan-
dardize management of pediatric patients with blunt solid
organ injury by the American Pediatric Society Association
(APSA) focused on radiologic grading.18 Length of stay, intensive
care unit admission, and other management were determined
by grade of hepatic or splenic injury on contrast-enhanced CT
scan.3 Subsequently, a consortium of level I pediatric trauma
centers known as the Arizona-Texas-Oklahoma-Memphis-
Arkansas Consortium (ATOMAC) released another set of guide-
lines, de-emphasizing focus on radiologic grade and advocating
for hemodynamic status as the primary criteria for manage-
ment.5 Per this guideline, surgical intervention should be
considered based on failure of fluid resuscitation and recurrent
hypotension.5 To date, none of these guidelines establishes
well-defined indications for angiography and embolization.
Many advise that the use of angiography and embolization
should be based on available hospital resources and expertise as
well as clinical judgement.5,6
Mortality and Morbidity
Mortality secondary to liver trauma is variable by severity
and overall it has decreased from over 50% in 1970 to 10–20%
in recent years.19 Some centers are seeing mortality rates
between 2 and 8%.20 This is largely due to advances in

Seminars in Interventional Radiology Vol. 37 No. 1/2020

38 Contemporary Management of Hepatic Trauma Gilyard et al.
catheter-based techniques and selective nonoperative
NOM.20 The leading cause of mortality in patients with
the most severe injuries is hemorrhage.21 Prior to the routine
use of arterial embolization, hemorrhage accounted for 54%
of all hepatic mortality after trauma.21 The increasing use of
embolization has been paralleled by decreasing mortality.20
As embolization has been demonstrated as a safe route of
managing patients, there is an ever-increasing role for inter-
ventional radiologists to facilitate optimal patient care via
angiography. Furthermore, a 2015 study evaluating more
than 6,000 high-grade liver injuries in the United States
showed hepatic angiointervention as an independent deter-
minant of survival from severe blunt hepatic injury.22
Unlike adults, mortality in pediatric patients with abdomi-
nal trauma is relatively low, and the most frequent cause of
death is head injury.23 In pediatric patients with blunt hepatic
injury, splenic injuries are often part of the injury complex.10
These patients are preferentially managed nonoperatively.
A prospective study demonstrated a 3% failure rate due to
hepatic or splenic bleeding. However, the mortality for pediat-
ric patients who failed NOM secondary to bleeding was 24%.10
Current Standard of Care in Stratifying Hepatic
Injuries in Adults
Although AAST grading is useful in imaging, there is no
precise correlation between survival and AAST grade.15
This is largely driven by the fact that AAST grading does
not take hemodynamic stability into account. At present, the
WSES recommends using AAST grading in conjunction with
hemodynamic status in evaluating the optimal treatment.24
Using this diagnostic paradigm, we will evaluate the treat-
ment algorithm in patients based on hemodynamic stability.
A. Hemodynamically Stable Adult Patient
The mainstay of management of the hemodynamically
stable adult patient is NOM.25 In the early 2000s, this
was seen as a paradigm shift from exploratory laparotomy,
which had previously been the standard of care for blunt
hepatic trauma.25 Furthermore, multiple prospective stud-
ies have demonstrated that NOM is highly effective with
failure rates of less than 10%.1 As a result of aforementioned
success rates, the standard of care for blunt hepatic trauma
is NOM.18 NOM includes close monitoring, supportive ther-
apy, and angiographic interventions. The most recent inter-
national surgical guidelines recommend NOM for hepatic
injuries irrespective of grade, mandating a significant role
for the interventional radiologist to manage these
patients.10 Of note, there has been no reported correlation
between AAST grade and failure of NOM.19 Due to the
success in NOM, only 13% of liver trauma patients are
currently managed surgically.26
B. Hemodynamically Unstable Adult Patient
Regardless of AAST grade, guidelines still recommend sur-
gical management immediately.24 There are decreased
mortality rates by treating with angiography in addition
to open laparotomy.27 Most previously studied cases have
used physically separate angiography suites from operating
Seminars in Interventional Radiology Vol. 37 No. 1/2020
rooms, and patients are triaged to either the operating
room or the angiography suite. In one study, 63% of unstable
patients underwent hepatic embolization as a first inter-
vention.28 A more recently and evolving technique involves
using c-arm angiography in the operating room for the
management of unstable patients. In these instances, fem-
oral access is established in the operating room and angi-
ography is attained intraoperatively.29 Several studies find
the combined approach superior to either surgery alone or
surgery with delayed angioembolization, with decreased
total time and decreased mortality rate.30
Standard of Care in Managing Pediatric Patient
Pediatric management for blunt trauma is now based on
ATOMAC criteria.31 NOM in the treatment of hemodynami-
cally stable pediatric patients has been well established in
blunt trauma.18 In these patients, there is a significant role
for CT angiography to evaluate for active bleeding prior to
angiography. Notably, there is a higher success rate of NOM in
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children as compared with adults.18 Pediatric patients can be
successfully managed nonoperatively in approximately 95%
of cases, whereas adult patients can be managed with NOM
in 80% of cases. The driving factors for this discrepancy are
not well established. As for adults, surgery is the recom-
mended treatment in hemodynamically unstable patients.
Effective Management of Patients with Embolization
To maximize the likelihood of a successful hepatic artery
embolization in the setting of trauma, the following clinical
and technical aspects should be addressed:
A. Preoperative Evaluation
Emphasis on patient hemodynamic stability: Hemody-
namic stability should be the first determinant of next
steps. Even in patients with immediate plans for open
surgery, trauma CT can be helpful in operative planning.
The rapid acquisition of images in trauma CT has allowed
for a minimal delay in definitive management.32 Although
historically angiography and embolization were reserved
for patients who were hemodynamically stable, as
explained earlier, there is increasing role for intraoperative
angioembolization in unstable patients.
Role of single-phase versus multiphase abdominal and
pelvic CT: While single-phase CT is more than 90% specific at
confirming a parenchymal injury, it can detect only approxi-
mately 30% of cases of active hemorrhage.33 To increase the
sensitivity of detection of active hemorrhage, one method is
using a split bolus technique where two or three boluses of
contrast are given sequentially with a time delay or saline
bolus in between followed by a single-pass CT acquisition.
The resultant images are a combination of the arterial phase
and the portal venous phase.32 This technique is noninferior
to conventional multiphase techniques in diagnosing trau-
matic injuries in the spleen but variable results in liver
trauma.34 Hence, for patients who are hemodynamically
stable, multiphase CT has emerged as a preferred imaging
to asses liver trauma and hemorrhage. The major drawback
to multiphase imaging is the radiation exposure and time
 Contemporary Management of Hepatic Trauma
to acquire the images. Although potentially devastating
consequences of inaction in arterial bleeding, multiphase
CT is preferred in cases of suspected hemorrhage.
Antibiosis: Even in the absence of trauma, liver proce-
dures incur an especially high risk of infection. Skin flora and
enteric flora create a clean-contaminated surgical environ-
ment. With a competent sphincter of Oddi, the most recent
Society of Interventional Radiology (SIR) guidelines recom-
mend a choice of 1.5 to 3 g ampicillin/sulbactam IV, 1 g
cefazolin and 500 mg metronidazole IV, or 1 g ceftriaxone
IV perioperatively for hepatic arterial embolization.20,35 If
the patient is allergic to penicillin, consider vancomycin plus
an aminoglycoside.35
B. Procedure Nuances
Arterial access: Increasingly, centers are adopting a radial
approach for arterial work in general. However, femoral access
is the mainstay of treatment in the emergency setting. Utility of
the radial versus femoral approach in the setting of trauma has
yet to be evaluated in the literature. In acute hepatic trauma,
arterial access is obtained by the common femoral artery. Once
access is established, upsize the sheath to the same size or 1 Fr
beyond the expected base catheter size which is usually 5 Fr.36
Using a 5-Fr catheter, the superior mesenteric artery should be
selected.9 Digital subtraction angiography (DSA) should ex-
clude an accessory or replaced right hepatic artery and exclude
active arterial extravasation or pseudoaneurysm (PSA). The
celiac trunk should then be selected. DSA should be performed
to look for the same abnormalities described earlier. Using a
2.4- to 2.9-Fr microcatheter coaxially, access to proper hepatic
artery is established, and DSA is again performed to evaluate for
extravasation or PSA.
Variant anatomy: Recognizing variation in hepatic arte-
rial anatomy is paramount to success in angioembolization.
Because variant hepatic arterial anatomy is common, famil-
iarity of the variations can reduce unintended nontargeted
embolization. Only approximately 60% of patients have
Fig. 2 Summary of variant hepatic anatomy.
Gilyard et al. 39
standard hepatic arterial anatomy with the celiac axis giving
off the left gastric artery, splenic artery, and common hepatic
artery (►Fig. 2). After the origin of the gastroduodenal
artery, the common hepatic artery becomes the proper
hepatic artery, which bifurcates into the right hepatic artery
and the left hepatic artery.37 Approximately 4 to 10% of
patients have a replaced left hepatic artery, 10% of patients
have a replaced right hepatic artery, 10% have an accessory
left hepatic artery from the left gastric artery, and 2 to 7%
have an accessory right hepatic artery from the superior
mesenteric artery.37,38 Less than 1% of patients have replaced
left and right hepatic arteries.37
C. Potential Angiographic Findings
1. No active extravasation: In the case of a known trau-
matic injury, with CT evidence of perihepatic hemor-
rhage such as a subcapsular hemorrhage, with or without
hemodynamic instability, empiric Gelfoam embolization
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of the branch supplying the area of bleeding should be
considered.
2. Pseudoaneurysm: Traumatic psuedoaneurysm s occur in
up to 15% of patients with liver trauma.39 Delayed
rupture of a pseudoaneurysm can have devastating con-
sequences. Pseudoaneurysms can develop in delayed
fashion. Therefore, postinjury contrast-enhanced CT
should be performed 5 to 10 days after the initial scan.
If a pseudoaneurysm is present, all patients should be
treated with embolization immediately, due to the risk of
rupture. Coil embolization is preferred to Gelfoam given
the permanent nature of coils as compared with Gelfoam
(►Fig. 3).
3. Arteriovenous or arterioportal shunting: Arteriovenous
shunting occurs in a rare subset of the traumatic liver
injury population. Arteriovenous and arterioportal shunt-
ing can be assessed on multiphase CT; however, definitive
diagnosis is most accurate on angiography39 (►Fig. 4).
Seminars in Interventional Radiology Vol. 37 No. 1/2020
40 Contemporary Management of Hepatic Trauma Gilyard et al.

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Fig. 3 Open surgery followed by embolization. A 30-year-old patient status post gunshot wound taken directly to operating room for
hemodynamic instability. Angiography was done intra-operatively after packing was performed due to continued bleeding and patient
instability. Blush of contrast demonstrated a pseudoaneurysm (arrow) in area of hepatic laceration (a). Post angiography Clips (b). Coil
embolization of the middle hepatic artery Pseudoaneurysm (c–e). Post embolization angiography demonstrated patency of right hepatic artery
branches without opacification of the pseudoaneurysm (f).

Fig. 4 Arterioportal fistula. A 28-year-old patient status post stab wound presenting with acute drop in hemoglobin on postoperative day 2
for second exploratory laparotomy for washout. CTA shows a blush of contrast on arterial phase (arrow) (a). Diagnostic angiography of the celiac,
proper hepatic, and left hepatic arteries (b and c) shows large left hepatic artery–left portal venous fistula (arrows—left portal vein filling during
arterial phase). Successful embolization of left hepatic artery using coil embolization with nonopacification of portal venous system on
postembolization angiography from the base catheter in the celiac axis (d–f).

These patients are managed with coil embolization of the
feeding artery. Failure to treat this abnormality may lead
to the development of significant portal hypertension.
4. Late or venous bleeding: Treatment is based on hemody-
namic stability. If stable, consider Gelfoam slurry to slow
down the arterial pressure head. If unstable, surgical
treatment is warranted. Trauma patients are hypother-
mic, hypotensive/hypovolemic, and coagulopathic. Once
patients are warmed and volume resuscitated, bleeding
may increase.
D. Embolic Choice
The choice of embolic agent should be guided by the pres-
ence of active arterial extravasation seen on CT or
angiography.
i. Coil embolization: Coil embolization is best for targeted
therapy. In a patient with clear extravasation, coils may
be used for downstream targeted embolization of the
selected vessel. Coil embolization results in permanent
vessel occlusion. To reduce risk of coil displacement, coils

Seminars in Interventional Radiology Vol. 37 No. 1/2020

 Contemporary Management of Hepatic Trauma
should be 20% larger than the target vessel. Undersized
coils can result in nontarget embolization. The use of
detachable versus pushable coils depends on operators’
experience and level of comfort with different types of
coils available in their respective institutions.
ii. Glue embolization: N-butyl-2-cyanoacrylate (NBCA) “glue”
is fluoroscopically visible when mixed with ethiodized oil or
tantalum powder, and used as a flow-directed embolic
therapy.40 This substance polymerizes rapidly when con-
tacting blood or any ionic substance and forms a cast of the
vessel.41 In the instance of a known target, glue embolization
can be employed with near-permanent hemostasis inde-
pendent of coagulation status. Given the flow-dependent
and permanent nature, this is not recommended in cases in
which no arterial abnormality is identified. Furthermore,
due to the rapid casting, the catheter must be withdrawn
quickly to prevent adherence to the vessel wall.41
iii. Ethylene vinyl alcohol copolymer (ONYX): This liquid
embolic is similar to the NBCA glue and it produces a
permanent embolic effect. Unlike NBCA, ONYX is intrin-
sically radiopaque.42 In published literature, onyx has
been used in the embolization of vascular malformations
and pseudoaneurysms. Onyx is quite expensive and
rarely warranted in the treatment of hepatic trauma.
iv. Gelfoam: Gelfoam is a gelatin sponge, which initiates the
clotting cascade and provides scaffolding for clot forma-
tion. The Gelfoam is in theory temporary, with vessel
occlusion lasting 3 to 6 weeks.41 A Gelfoam slurry may be
formed by mixing Gelfoam strips soaked in contrast and
saline. A slurry is preferred for nontargeted embolization
in smaller vessels, but can be used in targeted emboliza-
tion of the smaller vessels. In larger vessels, dry pledgets
are tightly rolled and loaded into a catheter and subse-
Fig. 5 An evidence-based proposed protocol for management of patients with acute liver injury based on WSES guidelines and institutional experience.
Gilyard et al. 41
quently injected into the targeted vessel. Gelfoam embo-
lization is preferred in cases of hemodynamic instability
due to the ability to deliver rapid hemostasis.36 In such
cases, the temporary nature of Gelfoam is advantageous
in nontargeted embolization. Additionally, Gelfoam may
be used in combination with coils in cases where an
injury is visualized but the catheter cannot be positioned
beyond a PSA or arterioportal fistula. Gelfoam is used for
distal occlusion to prevent reperfusion/collateral filling
and the coil is placed proximal to the lesion.
Proposed Evidence-Based Management
Algorithm for Treatment of Patients with
Acute Liver Trauma
►Fig. 5 depicts the proposed treatment algorithm for managing
adult patients with hepatic trauma based on WSES recommen-
dations and our institutional experience. All patients should be
assessed for hemodynamic stability. Hemodynamically stable
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patients can be assessed with multiphase CT. If there is CT
evidence of active extravasation or traumatic pseudoaneurysm,
the patient should be further managed with angioembolization.
If there is no evidence of active hemorrhage, patient should be
managed with NOM. If the patient is hemodynamically unstable
and not fluid/blood product responsive, they should be taken to
the operating room (preferentially with c-arm capability) im-
mediately. If the patient is fluid responsive/stabilizes with
minimal intervention, a split bolus CT should be considered if
clinically appropriate. This assessment enables the interven-
tionalist and the surgeon to have a clearer idea of the extent of
the trauma and presence of active arterial bleeding. Subse-
quently, this patient should be taken directly to the operating
room with or without angiography.
Seminars in Interventional Radiology Vol. 37 No. 1/2020
42 Contemporary Management of Hepatic Trauma Gilyard et al.
Fig. 6 Contained/intrahepatic biloma in patient with grade V hepatic laceration treated with surgical packing followed by Gelfoam embolization
due to uncontrolled bleeding (a). The biloma was treated with percutaneous drainage (b) and resolved after 6 months not shown here.
Postprocedural Considerations
Role of Imaging Follow-up after embolization
There is no need for aggressive imaging follow-up if the
patient is not symptomatic. However, if new symptoms arise,
one of the following complications may be the cause. Thus, a
multiphase CT is indicated for postprocedural evaluation in
the setting of new symptoms.
Expected outcomes
In most cases, angiographic embolization is definitive for
establishing hemodynamic control. Although angiographic
interventions incur fewer risks than surgical management,
there are several postprocedural complications IRs must be
aware. According to one study, the most common complica-
tions from large-segment angiography and embolization is
bile leak and hepatic necrosis as separate complications.43
Additional complications include sepsis, hepatic abscess,
sterile biloma, and gall bladder infarction.44
1. Bile leak: This is among the most common complications in
hepatic arterial intervention.43 With embolization, there
can be focal necrosis of the bile ducts, which can leak as a
result. Leak can cause a biloma. Furthermore, posttraumatic
cholecystectomy, when there is a concurrent cystic duct
injury, incurs a high risk of bile leak. Current guidelines on
the management of bile leak recommend treating any
biloma if present with percutaneous drainage and subse-
quent selective coil embolization of the cystic duct.45
2. Intrahepatic/Contained biloma: When a bile leak is con-
tained within the liver parenchyma, it can form a biloma
(►Fig. 6). This fluid can provide a nidus for infection with
potentially devastating consequences. It is therefore rec-
ommended to percutaneously drain the intrahepatic
biloma and control the source of the biliary collection.
3. Hepatic necrosis: An estimated 15% of angioembolization
cases result in some degree of hepatic necrosis.44 Further-
more, patients with liver failure at baseline are at an
increased risk. Although the liver derives the majority of
its blood supply from the portal circulation, the combina-
tion of trauma and embolization confers an increased risk
of hepatic necrosis. Major hepatic necrosis involving a
segment usually requires surgical debridement.46
4. Hepatic abscess: Abscess can be a sequela of trauma alone,
intervention, or a tertiary complication of hepatic necrosis.
Seminars in Interventional Radiology Vol. 37 No. 1/2020
Risk factors for abscess development include poor portal
flow, elevated transaminases, and a high-grade injury.47
The etiology is almost universally contamination from the
bile ducts or the vasculature.48 Management requires a
multidisciplinary approach between interventional radiol-
ogy and trauma surgery to ensure appropriate antibiosis
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and adequate source control. CT-guided percutaneous
drainage is the treatment of choice.
Conclusions
As interventional radiology catheter-based techniques have
improved, the role of embolization in managing patients
with hepatic trauma has increased. Given the improvement
in mortality, embolization will be a mainstay in the treat-
ment of hepatic injury for the foreseeable future.
Conflict of Interest
None declared.
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