3. Leading cause of death in young people
Uncontrolled bleeding causes 30-40% of
trauma-related deaths
IR intervention can be life-saving
4. Hemodynamically stable, or Hemodynamically
mildly unstable but unstable, not
responding to resuscitation responding to
resuscitation
Bowel, pancr
eas, diaphra
CT gm injury Ex lap
Renal, hepat Pelvic injury Pelvic
ic, splenic with bleeding, retroperit
injury extravasation oneal
hematoma, hepatic
bleeding
Observe, ex lap, or
angio, depending Angiography
on nature of injury
6. Causes more deaths than any other
skeletal trauma
3 sources of pelvic hemorrhage
Arterial
Venous
Cancellous bone
Over 70% of unstable patients with pelvic
fractures will have arterial bleeding
7. Pelvic trauma with active extravasation on CT
Pelvic bleeding which cannot be controlled at
surgery
Major pelvic fracture with signs of bleeding in
whom nonpelvic bleeding sources have been
excluded
13. Pelvic aortogram (12/36)
Selective internal iliac angiography – Cobra-2 or
Roberts (6/18)
Contralateral oblique: lays out anterior division branches
Ipsilateral oblique: good visualization of superior gluteal
Consider external iliac angiograms
Corona mortis (replaced obturator artery)
Inferior epigastric
Deep iliac circumflex
14. Subselective embolization when possible
Coils for injury to large arteries, AV
fistulae, pseudoaneurysms
Gelfoam for most other injuries
Fails in about 10% of patients
○ Missed arterial bleeding due to temporary spasm
○ Venous bleeding
Nonselective gelfoam slurry embolization of
bilateral internal iliac arteries if
Hemodynamically unstable
Continued bleeding despite apparently successful
subselective embolization
Multiple bleeding sites bilaterally
15. 30 patients had nonselective gelfoam slurry embolization of
bilateral internal iliac arteries for pelvic trauma
Clinical control of bleeding in 90% (97% with repeat embolization)
No severe in-hospital morbidity related to embolization
No evidence of pelvic or soft tissue ischemia on CT or autopsy
Complications are uncommon, and are usually related to injury
No long-term effects on urogenital function
Slightly increased risk of buttock, thigh or perineal paresthesia
Occasional skin sloughing or necrosis
Nonselective bilateral internal iliac embolization is safe and
effective, and should be used when selective embolization fails
or is not possible
Velmahos GC, et al (2000) Angiographic embolization of bilateral internal iliac arteries to control life-threatening hemorrhage after blunt trauma
to the pelvis. Amer Surg 66:858-862.
Ramirez J, et al (2004) Male sexual function after bilateral internal iliac artery embolization for pelvic fracture. J Trauma 56:734-741.
Travis T, et al (2008) Evaluation of short-term and long-term complications after emergent internal iliac artery embolization in patients with
pelvic trauma. J Vasc Interv Radiol 19:840-847.
16. Focal bleeding detected from internal
pudendal artery.
Bleeding confirmed with superselective
microcatheterization.
Superselective gelfoam embolization
performed.
Case courtesy of Christopher Loh, MD
17. Incidental note of spinal
artery arising from injured
right L1 artery.
Embolization deferred.
Internal iliac angiograms show diffuse bleeding on left. Both internal iliac
arteries were occluded with gelfoam (insets)
23. Most commonly injured organ in
abdominal trauma
Unstable patients should go to surgery
Direct control of bleeding and packing
Bleeding may be difficult to control
>50% operative mortality in complex injuries
Steichen FM (1975) Hepatic trauma in adults. Surg Clin North Am 55:387-407.
24. Stable (or mildly unstable but
responding to resuscitation) patient with
hepatic injury and extravasation on CT
Uncontrolled hepatic bleeding at surgery
25. Levin-1, Cobra, or Simmons catheter
Selective angiograms
Common hepatic (6/30, extend to venous phase)
Celiac and/or superior mesenteric (for variant anatomy)
Focal injuries
Subselect with microcatheter, embolize with coils, particles or gelfoam
Diffuse injury (especially if unstable)
Lobar embolization with gelfoam slurry
Pseudoaneurysm
Coil distal and proximal if possible
Do not pack aneurysm sac (may rupture)
26.
27. Free extravasation with common Anterior division Gelfoam and coil embolization of
hepatic artery injection subselected, multiple sites of anterior division
bleeding noted
28. Technical success 90-100%
Usually well-tolerated
Patent portal vein decreases risk of infarction
Rare complications
Rebleeding
Infarction
Abscess
Biliary necrosis
Gallbladder necrosis
Hagiwara A, Yukioka T, Ohta S, et al (1997) Nonsurgical management of patients with blunt hepatic injury: efficacy of transcatheter arterial
embolization. AJR Am J Roentgenol 169:1151-1156.
30. 2nd most commonly injured solid organ
in abdominal trauma
Splenic injury traditionally managed with
laparotomy and splenectomy
Recent trends have favored non-
operative management with or without
angiography
31. Monitoring and resuscitation in splenic
injury has failure rate up to 34%
Adjunctive embolization increases the
success rate of non-operative
management
Sabe A, et al (2009) The effects of splenic artery embolization on nonoperative management of blunt splenic injury: a 16 year experience. J
Trauma 67:565-572.
Velmahos G, et al (2003) Nonoperative treatment of blunt injury to solid abdominal organs: a prospective study. Arch Surg 138:844-851.
Hagiwara A, et al (2005) Blunt splenic injury: usefulness of transcatheter arterial embolization in patients with a transient response to fluid
resuscitation. Radiology 235:57-64.
32. Free peritoneal extravasation
Relative indications:
Pseudoaneurysm
AV fistula
Contained extravasation
Hemoperitoneum
Hemodynamically unstable patients should
have surgical repair or splenectomy
33. Levin-1, Cobra, or Simmons catheter
Selective splenic angiography – 5/25, extend to venous phase
Embolization – optimal approach is controversial
Superselective embolization
○ Microcatheterize each bleeding branch and embolize with coils, glue or
gelfoam
○ Acceptable treatment for focal extravasation, AV fistulae,
pseudoaneurysms
Proximal splenic artery embolization
○ Catheterize main splenic artery just beyond the dorsal pancreatic artery
(prior to pancreatica magna)
○ Embolize with coils or Amplatzer plug
○ May be the preferred treatment for splenic extravasation, especially if
diffuse
34. Proximal embolization Superselective embolization Gelfoam scatter embolization
Goal: Decrease splenic Goal: Directly embolize only Goal: Nonselectively
pressure, allowing bleeding the bleeding vessels embolize entire spleen
to stop
Best for: Best for:
Best for: One or two focal bleeding Infarcting spleen
Diffuse splenic bleeding vessels Producing abscesses
Multiple focal bleeds Relatively stable patient
Unstable patient Generally not recommended
Selective embolization Advantages:
difficult Repeat embolization easier
May preserve more splenic
Advantages: function
Faster
Lower risk of infarct and
abscess
35. CT shows contained extravasation Control angiogram for sizing. Note pancreatica magna (arrow)
Amplatzer deployed just prior to pancreatica magna Delayed phase shows late filling of intrasplenic branches
Case courtesy of Geogy Vatakencherry, MD
36. Left: CT shows contained extravasation. Angiogram confirms
extravasation with pseudoaneurysm.
Above: Selective embolization of affected vessel with NBCA glue
Case courtesy of David Liu, MD
37. Clinical success rate of splenic embolization (patient
avoids splenectomy) is >90% in most studies
Two studies suggest better success rates with proximal
rather than superselective embolization
Complication rate is 6-20%
Persistent bleeding or rebleeding (11%)
Missed injury (3%)
Splenic abscess (4%)
Coil migration (2%)
Infarctions occur in about 20%
More with distal embolization
Most are asymptomatic
Kaseje N, et al. Short-term outcomes of splenectomy avoidance in trauma patients. Am J Surg 196:213-217.
Haan JM, Biffl W, Knudson M. Splenic embolization revisited: a multicenter review. J Trauma 2004;56:542-547.
Hagiwara A, Fukushima H, Murata A, et al. Blunt splenic injury: usefulness of transcatheter arterial embolization in patients with a transient
response to fluid resuscitation. Radiology 2005;235:57-64.
39. Renal injury in 7% of penetrating and
5% of blunt abdominal trauma
1-2% of biopsies and nephrostomies
Surgery for renal injury is often
difficult, and often results in
nephrectomy
40. Be as conservative as possible
Monitor closely for hypotension, hematocrit
drop, other signs that require intervention
Pedicle injuries and avulsions need
surgery
Revascularization within 12 hours, if at all
41. Active extravasation on CT, especially if
unstable
Persistent or recurrent hematuria
Large retroperitoneal hematoma seen at
surgery
Vascular pedicle injury, if not going to
surgery
42. Abdominal aortogram
Detect multiple renal arteries (30% of patients)
Detect associated retroperitoneal injury (lumbar arteries)
Identify renal vascular pedicle injury
Selective renal angiography (Cobra or Simmons) – 6/12
Two projections, one being ipsilateral anterior oblique (best
evaluation of parenchyma)
Rapid imaging for AVF or pseudoaneurysm evaluation
Embolization
Microcatheterization with embolization as distal as possible
Gelfoam, particles or microcoils
Occlusion of renal branch vessels will cause parenchymal
infarction proportionate to the size of the vessel
45. Technical and clinical success rate of renal
embolization is 82-100%
Complications are uncommon
Infection
Sepsis
Renal infarction (small infarcts usually
asymptomatic)
Nontarget embolization
May have transient hypertension
Sofocleous C, et al (2005) Angiographic findings and embolotherapy in renal arterial trauma. Cardiovasc Intervent Radiol 28:39-47.
46. Occur in only 1-4% of renal injuries
Consider covered stents for main renal
artery or large branch artery injuries
Dissection
Arteriovenous fistula
Use of stenting should be weighed
against surgical options
51. 85% of GI bleeding comes from the upper GI tract (above
ligament of Treitz)
Differential for nonvariceal upper GI bleeding
Peptic ulcer disease
Mallory-Weiss tear
Hemorrhagic gastritis
Tumor
Arteriovenous malformation
Hemobilia
Aortoduodenal fistula
Endoscopy is 95% successful in identifying the source of upper
GI bleeding
52. Medical management
Volume replacement
H2 blockers or proton pump inhibitors
Correction of coagulopathy
Early endoscopy
Determine etiology
Attempt treatment (place clip if unsuccessful)
Angiography if medical management and endoscopy fail
to control bleeding (5-10% of patients)
Surgery if all other treatment modes fail
30-day mortality higher with surgery (14%) than angiography
(3%)
Eriksson LG, et al (2008) Transcatheter arterial embolization versus surgery in the treatment of upper gastrointestinal bleeding after
therapeutic endoscopy failure. J Vasc Interv Radiol 19:1413-1418.
53. Massive bleeding Hemodynamic
Transfusion instability
requirement of at least OR
Systolic BP <100 mm Hg
4 units in 24 hours
Heart rate >100
AND
Bleeding has failed to respond to conservative medical
therapy
Bleeding has failed to respond to endoscopic control
54. Celiac angiogram (Cobra, Simmons, Levin-1) – 6/30
If negative, then perform subselective angiograms
Gastroduodenal artery
Left gastric artery
Splenic artery
Superior mesenteric angiogram
Especially if repeat hemorrhage after prior embolization
Positive findings (seen in 60%)
Extravasation of contrast into bowel lumen
Pseudoaneurysm
Abnormal blush (if correlated with endoscopic findings)
55. Acceptable techniques
Superselective catheterization with embolization
○ Gelfoam, coils, particles, glue
Sandwich technique (especially in GDA)
○ Coil distal and proximal to injury site
○ May add gelfoam or particles if desired
Scatter embolization
○ If cannot reach bleeding site
○ Gelfoam, glue or particles (at least 300-500 micron)
Evaluate for dual blood supply and back-door supply–
embolize both if present
Superior pancreaticoduodenal – inferior pancreaticoduodenal
Right gastroepiploic – left gastroepiploic
Right gastric – left gastric
56. If no extravasation
seen, consider empiric
embolization of most likely
bleeding territory (GDA or
left gastric)
Coils +/- particles or gelfoam
Guide by endoscopy
Clinical success is equal
to targeted embolization
57. Study # Technical Clinical Empiric Ischemia
patients success success treatment
Aina 2001 75 99% 76% 38% 4%
Schenker 163 95% 58% 63% 1%
2001
Poultsides 57 94% 51% 38% 7%
2008
Loffroy 2009 60 95% 72% - 0%
Aina R, et al (2001) Arterial embolotherapy for upper gastrointestinal hemorrhage: outcome assessment. J Vasc Interv Radiol 12:195-200.
Schenker M, et al (2001) Upper gastrointestinal hemorrhage and transcatheter embolotherapy: clinical and technical factors impacting success
and survival. J Vasc Interv Radiol 12:1263-1271.
Poultsides G, et al (2008) Angiographic embolization for gastroduodenal hemorrhage: safety, efficacy and predictors of outcome. Arch Surg
143:457-461.
Loffroy R, et al (2009) Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early
rebleeding. Clin Gastroenterol Hepatol [Epub ahead of print]
58. Perform angiography early
Delay in angiography, multiorgan failure and high
transfusion requirement are all predictors of clinical failure
Clinical failure is common in coagulopathic patients
Do not use coils alone in these patients
Empiric embolization is effective if no extravasation
is seen
Ischemia is rare
Usually self-limited
Higher risk in post-operative patients
60. 15% of gastrointestinal hemorrhage comes
from the lower GI tract (beyond the
ligament of Treitz)
Resolves spontaneously in 80% of cases
Differential diagnosis for lower GI bleeding
Older: Diverticulosis, angiodysplasia,
hemorrhoids, tumor, ischemia
Younger: IBD, infection
61. Nonmassive Intermittent bleeding:
bleeding, stable patient Colonoscopy
Conservative management Consider tagged RBC scan
with 24 hour images
Elective colonoscopy Consider angiography +/-
provocation
Massive Massive
bleeding, stable patient bleeding, unstable
Tagged RBC scan or MDCT patient
○ Positive: Angiography Prompt angiography
○ Negative: Colonoscopy
Or, just go to angio Surgery if angiography fails
62. Superior mesenteric angiogram (Cobra, Sos, Levin-1) – 6/30
Inferior mesenteric angiogram (Sos, Simmons, Mikaelsson) –
2-3/15
If negative, celiac angiogram
About 15% of hematochezia has upper GI source
Variant middle colic artery (from dorsal pancreatic)
If all are negative, consider internal iliac angiograms
Inferior and middle rectal arteries (from internal iliac)
If repeated angiograms have been negative, consider
provocation
Heparin 5000 units, nitroglycerin 200 ug, tPA 4 mg
Repeat angio in 5-10 minutes; can repeat dosing if negative
Successful in 31%, no hemorrhagic complications
Kim CY, Suhocki PV, Miller MJ, et al (2010) Provocative mesenteric angiography for lower gastrointestinal hemorrhage: results from a single-
institution study. J Vasc Interv Radiol 21:477-483.
63. Microcatheterize bleeding vessel
If distal vasa recta can be reached
Proceed with superselective embolization
Microcoils or particles
If distal vasa recta cannot be reached
Selective coil embolization at marginal artery level (likely
increases ischemic risk)
-or-
Vasopressin
○ Park catheter in proximal SMA or IMA
○ 0.2 units/minute, repeat angio at 20 minutes
○ Can increase to 0.4 units/minute
64. 65 y/o male with massive bleeding – superselective coil embolization
65. 52 y/o with intermittent rectal bleeding, endoscopies negative
67. Patient began having right
abdominal pain
Lactate remained normal
CT with mild wall thickening
but no pneumatosis
Colonoscopy 2 weeks later
showed ascending colon
ulcer, no bleeding
Managed expectantly with
gradual resolution
68. Study # Primary embolic Technical Clinical success Major
patients success (immediate/durable) ischemia
Bandi 2001 48 PVA particles* 73% 69/44% 0%
Gordon 1997 17 Microcoils* 82% 76/76% 0%
Kuo 2003 22 Microcoils** 100% 86/86% 0%
Funaki 2001 27 Microcoils** 93% 96/81% 7%
D’Othee 2006 19 Microcoils** 89% 89/68% 11%
* Embolization only performed if distal vasa recta could be reached
** Embolization performed at vasa recta or marginal artery
Gordon R, et al (1997) Selective arterial embolization for the control of lower gastrointestinal bleeding. Am J Surg 174:24-28.
Kuo W, et al (2003) Superselective microcoil embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol 14:1503-9.
Bandi R, Shetty PC et al (2001) Superselective arterial embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol
12:1399–1405.
Funaki B, Kostelic JK et al (2001) Superselective microcoil embolization of colonic hemorrhage. AJR 177:829–836.
d’Othée BJ, Surapaneni P et al (2006) Microcoil embolization for acute lower gastrointestinal bleeding. Cardiovasc Intervent Radiol 29:49–58
69. Frequency of positive angiograms is low
Consider tagged RBC scan to improve yield
Superselective embolization
Embolize at distal vasa recta whenever possible
Embolization at marginal artery level is usually
safe if necessary
Microcoils or particles
Less collateral supply than upper GI tract
But, ischemia remains relatively uncommon
71. CT is extremely helpful if patient stability permits
No longer the “doughnut of death”
If angiography is indicated, don’t wait
Consider anesthesia support
The liver, upper GI tract and pelvis tolerate extensive
embolization well
Don’t get overly concerned about radiation time or
contrast dose in dying patients
“Most complications are acceptable alternatives to
exsanguination”
72.
73. Overall sensitivity of angiography for LGIB is about 50%
Positive tagged RBC study increases yield from 22 to 53%
Technical success rates of embolization are high
Vasa recta only: Technical success 73-82%, major ischemia 0%
Vasa recta or marginal artery: technical success 89-100%, major
ischemia 0-11%
Complications
Early rebleeding (within 30 days) in 21%
Severe ischemic complication (surgery required) in 2%
Minor ischemic complication (pain or asymptomatic stricture) in
10%
Kuo W, et al (2003) Superselective microcoil embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol 14:1503-9.
Bandi R, Shetty PC et al (2001) Superselective arterial embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol
12:1399–1405.
Funaki B, Kostelic JK et al (2001) Superselective microcoil embolization of colonic hemorrhage. AJR 177:829–836.
d’Othée BJ, Surapaneni P et al (2006) Microcoil embolization for acute lower gastrointestinal bleeding. Cardiovasc Intervent Radiol 29:49–58
