Interventional RadiologicTreatment of blunt abdominal trauma

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Interventional RadiologicTreatment of blunt
abdominal trauma

• Dr. Piet Vanhoenacker

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Perspective

• State-of-the-art digital subtraction angiography
• Helical CT
• Microcatheters, steerable and hydrophilic
  guidewires, and coaxial guiding catheters and
  sheaths
• Novel embolization materials and delivery systems
  
• Stents and covered stents (stent-grafts)

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Diagnosis

• It all starts with CT

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diagnosis

• Grading of solid organ injuries
• High-attenuation focus (may represent
  extravasation of contrast or active bleeding on
  noncontrast scans, ie, the sentinel clot sign,
  implying ongoing hemorrhage)
• Detection of vascular abnormalities, such as
  pseudoaneurysm, intimal dissection, arteriovenous
  fistula, and vascular occlusion
• Prediction of which hemodynamically stable
  patients may benefit from nonoperative management

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Blunt abdominal and pelvic traumaDiagnostic
algorithm

• CT with IV contrast
• Discriminate between surgical and  non-surgical 

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Surgical

• Pancreas
• Bowel

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Non surgical

• Spleen
• Kidney
• Liver
• Pelvic hemorrhage due to osseous trauma

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Non surgical

• Kidney,liver,spleen
• AAST score . Communication with radiologist and
  other specialties

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Interventional treatment when ?

• When rapid occlusion is desired
• When surgical access is difficult
• When the patient is a poor operative risk
• When selective transcatheter embolization may
  limit the amount of normal tissue or parenchyma
  necrotized

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Techniques for embolization

• Glue
• PVA
• Gelfoam
• coils

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Liver(AAST)

• Grade I - Capsular avulsion periportal blood
  tracking superficial laceration less than 1-cm
  deep subcapsular hematoma less than 1-cm
  thickness
• Grade II - Laceration 1- to 3-cm deep
  subcapsular/central hematoma 1- to 3-cm diameter
• Grade III - Laceration greater than 3-cm deep
  subcapsular/central hematoma greater than 3-cm
  diameter
• Grade IV - Massive central or subcapsular
  hematoma greater than 10 cm lobar tissue
  maceration or devascularization
• Grade V - Bilobar tissue maceration or
  devascularization

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AAST grade 1
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AAST 2
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Spleen (AAST)

• Grade I - Small subcapsular hematoma, less than
  10 of surface area
• Grade II - Moderate subcapsular hematoma on
  10-50 of surface area intraparenchymal hematoma
  less than 5-cm diameter capsular laceration less
  than 1-cm deep
• Grade III - Large or expanding subcapsular
  hematoma on greater than 50 of surface area
  intraparenchymal hematoma greater than 5-cm
  diameter capsular laceration 1- to 3-cm deep
• Grade IV - Laceration greater than 3-cm deep
  laceration involving segmental or hilar vessels
  producing major devascularization (gt25)
• Grade V - Shattered spleen hilar injury that
  devascularizes the spleen

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Spleen AAST grade 3
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Spleen AAST 4
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Kidney (AAST)

• Grade I - Contusion or contained and nonexpanding
  subcapsular hematoma, without parenchymal
  laceration hematuria
• Grade II - Nonexpanding, confined, perirenal
  hematoma or cortical laceration less than 1-cm
  deep no urinary extravasation
• Grade III - Parenchymal laceration extending more
  than 1 cm into cortex no collecting system
  rupture or urinary extravasation
• Grade IV - Parenchymal laceration extending
  through the renal cortex, medulla, and collecting
  system
• Grade V - Pedicle injury or avulsion of renal
  hilum that devascularizes the kidney completely
  shattered kidney thrombosis of the main renal
  artery

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Pelvis

• In many trauma centers, conventional angiography
  and potential transcatheter embolization are
  applied to patients with pelvic trauma who
  continue to hemorrhage despite external fixation
  and who already have undergone an abdominal
  exploration if an associated solid organ injury
  is known

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pelvis

• Early transcatheter embolization of pelvic
  trauma, within 3 hours of presentation, has been
  shown to lower the mortality rate. Overall,
  angiography is required in fewer than 10 of
  patients with pelvic trauma. When angiography is
  performed, extravasation is documented in
  approximately one half of patients and warrants
  transcatheter embolization.

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Efficacy

• The success rate of stopping hemorrhage is
  85-100.
• Despite high technical success rates, the
  mortality rate is approximately 50 because of
  concomitant injuries.

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complications

• Inadvertent embolization - Should be rare if
  catheter position is satisfactory and
  embolization procedure is terminated once
  occlusion is established
• Ischemic tissue necrosis or infarction - Rare if
  particle sizes remain larger than 500 mm because
  of extensive distal collateralization of pelvic
  vasculature
• Impotence in males - Difficult to differentiate
  from neurogenic causes of impotence related to
  lumbosacral plexus injuries

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