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Endovascular Techniques in the Damage Control Setting¹

¹ From the Department of Radiology, Section of Vascular and Interventional Radiology, Harborview Medical Center, 325 9th Ave, Seattle, WA 98104. From the Plenary Session, Friday Imaging Symposium: Acute Radiology—Where Minutes Count, at the 1998 RSNA scientific assembly. Received March 25, 1999; revision requested April 30 and received May 19; accepted May 19. Address reprint requests to E.K.H.

View larger version (156K): [in a new window]   Figure 1a.   Pelvic hematoma in a 42-year-old woman who was ejected from an automobile when it hit a tree. (a) Initial CT scan shows a large pelvic hematoma with evidence of active extravasation (arrow). During transfer to surgery, the patient received 10 units of blood and continued to require fluids to maintain systolic blood pressure above 90 mm Hg. Five liters of blood were discovered in the pelvis at surgery, and the only identified sources were the lateral cervical stalks. These stalks were ligated, and the wound was packed. A large hematoma was discovered arising from the pelvis. On arrival at the angiography suite, the patient was hypothermic with coagulopathy. (b) Early image from pelvic angiography demonstrates right ileolumbar extravasation (arrow). (c) Late image demonstrates additional foci of extravasation at multiple sites of pubic ramus fracture (arrows). (d) Angiogram demonstrates embolization of the internal iliac arteries with absorbable gelatin sponge particles (Gelfoam; Pharmacia & Upjohn, Kalamazoo, Mich). Although there were additional areas of probable extravasation, deterioration in the patient's respiratory status prompted immediate transfer to the intensive care unit. The patient was resuscitated, and the hypothermia and coagulopathy were treated successfully. However, transfusion requirements remained unchanged, and the patient underwent further angiographic intervention. (e) Angiogram demonstrates interval recanalization of the majority of the right internal iliac artery distribution. Extravasation from right ileolumbar branches (arrows) (cf b) and from a branch of the left internal iliac artery is seen. These vessels were selectively catheterized and embolized with absorbable gelatin sponge particles. The patient's condition stabilized, and the next day she underwent complete hysterectomy.

View larger version (113K): [in a new window]   Figure 1b.   Pelvic hematoma in a 42-year-old woman who was ejected from an automobile when it hit a tree. (a) Initial CT scan shows a large pelvic hematoma with evidence of active extravasation (arrow). During transfer to surgery, the patient received 10 units of blood and continued to require fluids to maintain systolic blood pressure above 90 mm Hg. Five liters of blood were discovered in the pelvis at surgery, and the only identified sources were the lateral cervical stalks. These stalks were ligated, and the wound was packed. A large hematoma was discovered arising from the pelvis. On arrival at the angiography suite, the patient was hypothermic with coagulopathy. (b) Early image from pelvic angiography demonstrates right ileolumbar extravasation (arrow). (c) Late image demonstrates additional foci of extravasation at multiple sites of pubic ramus fracture (arrows). (d) Angiogram demonstrates embolization of the internal iliac arteries with absorbable gelatin sponge particles (Gelfoam; Pharmacia & Upjohn, Kalamazoo, Mich). Although there were additional areas of probable extravasation, deterioration in the patient's respiratory status prompted immediate transfer to the intensive care unit. The patient was resuscitated, and the hypothermia and coagulopathy were treated successfully. However, transfusion requirements remained unchanged, and the patient underwent further angiographic intervention. (e) Angiogram demonstrates interval recanalization of the majority of the right internal iliac artery distribution. Extravasation from right ileolumbar branches (arrows) (cf b) and from a branch of the left internal iliac artery is seen. These vessels were selectively catheterized and embolized with absorbable gelatin sponge particles. The patient's condition stabilized, and the next day she underwent complete hysterectomy.

View larger version (122K): [in a new window]   Figure 1c.   Pelvic hematoma in a 42-year-old woman who was ejected from an automobile when it hit a tree. (a) Initial CT scan shows a large pelvic hematoma with evidence of active extravasation (arrow). During transfer to surgery, the patient received 10 units of blood and continued to require fluids to maintain systolic blood pressure above 90 mm Hg. Five liters of blood were discovered in the pelvis at surgery, and the only identified sources were the lateral cervical stalks. These stalks were ligated, and the wound was packed. A large hematoma was discovered arising from the pelvis. On arrival at the angiography suite, the patient was hypothermic with coagulopathy. (b) Early image from pelvic angiography demonstrates right ileolumbar extravasation (arrow). (c) Late image demonstrates additional foci of extravasation at multiple sites of pubic ramus fracture (arrows). (d) Angiogram demonstrates embolization of the internal iliac arteries with absorbable gelatin sponge particles (Gelfoam; Pharmacia & Upjohn, Kalamazoo, Mich). Although there were additional areas of probable extravasation, deterioration in the patient's respiratory status prompted immediate transfer to the intensive care unit. The patient was resuscitated, and the hypothermia and coagulopathy were treated successfully. However, transfusion requirements remained unchanged, and the patient underwent further angiographic intervention. (e) Angiogram demonstrates interval recanalization of the majority of the right internal iliac artery distribution. Extravasation from right ileolumbar branches (arrows) (cf b) and from a branch of the left internal iliac artery is seen. These vessels were selectively catheterized and embolized with absorbable gelatin sponge particles. The patient's condition stabilized, and the next day she underwent complete hysterectomy.

View larger version (96K): [in a new window]   Figure 1d.   Pelvic hematoma in a 42-year-old woman who was ejected from an automobile when it hit a tree. (a) Initial CT scan shows a large pelvic hematoma with evidence of active extravasation (arrow). During transfer to surgery, the patient received 10 units of blood and continued to require fluids to maintain systolic blood pressure above 90 mm Hg. Five liters of blood were discovered in the pelvis at surgery, and the only identified sources were the lateral cervical stalks. These stalks were ligated, and the wound was packed. A large hematoma was discovered arising from the pelvis. On arrival at the angiography suite, the patient was hypothermic with coagulopathy. (b) Early image from pelvic angiography demonstrates right ileolumbar extravasation (arrow). (c) Late image demonstrates additional foci of extravasation at multiple sites of pubic ramus fracture (arrows). (d) Angiogram demonstrates embolization of the internal iliac arteries with absorbable gelatin sponge particles (Gelfoam; Pharmacia & Upjohn, Kalamazoo, Mich). Although there were additional areas of probable extravasation, deterioration in the patient's respiratory status prompted immediate transfer to the intensive care unit. The patient was resuscitated, and the hypothermia and coagulopathy were treated successfully. However, transfusion requirements remained unchanged, and the patient underwent further angiographic intervention. (e) Angiogram demonstrates interval recanalization of the majority of the right internal iliac artery distribution. Extravasation from right ileolumbar branches (arrows) (cf b) and from a branch of the left internal iliac artery is seen. These vessels were selectively catheterized and embolized with absorbable gelatin sponge particles. The patient's condition stabilized, and the next day she underwent complete hysterectomy.

View larger version (162K): [in a new window]   Figure 1e.   Pelvic hematoma in a 42-year-old woman who was ejected from an automobile when it hit a tree. (a) Initial CT scan shows a large pelvic hematoma with evidence of active extravasation (arrow). During transfer to surgery, the patient received 10 units of blood and continued to require fluids to maintain systolic blood pressure above 90 mm Hg. Five liters of blood were discovered in the pelvis at surgery, and the only identified sources were the lateral cervical stalks. These stalks were ligated, and the wound was packed. A large hematoma was discovered arising from the pelvis. On arrival at the angiography suite, the patient was hypothermic with coagulopathy. (b) Early image from pelvic angiography demonstrates right ileolumbar extravasation (arrow). (c) Late image demonstrates additional foci of extravasation at multiple sites of pubic ramus fracture (arrows). (d) Angiogram demonstrates embolization of the internal iliac arteries with absorbable gelatin sponge particles (Gelfoam; Pharmacia & Upjohn, Kalamazoo, Mich). Although there were additional areas of probable extravasation, deterioration in the patient's respiratory status prompted immediate transfer to the intensive care unit. The patient was resuscitated, and the hypothermia and coagulopathy were treated successfully. However, transfusion requirements remained unchanged, and the patient underwent further angiographic intervention. (e) Angiogram demonstrates interval recanalization of the majority of the right internal iliac artery distribution. Extravasation from right ileolumbar branches (arrows) (cf b) and from a branch of the left internal iliac artery is seen. These vessels were selectively catheterized and embolized with absorbable gelatin sponge particles. The patient's condition stabilized, and the next day she underwent complete hysterectomy.

View larger version (123K): [in a new window]   Figure 2a.   Motor vehicle crash victim with hypotension. The patient responded to fluid resuscitation but remained tachycardic. Intraperitoneal blood was seen at diagnostic peritoneal lavage, and the patient underwent laparotomy, during which a liter of blood was removed and a nearly complete avulsion of the right lateral inferior segment of the liver was treated with partial hepatectomy. The right upper quadrant was packed, and the patient underwent angiography for evaluation of a large left retroperitoneal hemorrhage associated with a complex left acetabular fracture. (a) Angiogram demonstrates a small hemorrhage from a branch of the left internal iliac artery (arrow). The hemorrhage was thought to be insignificant. (b) Flush aortogram obtained to evaluate the abdominal vasculature shows a transient area of increased opacity centrally in the left renal hilum (arrow). (c) On a late image from angiography (cf b), the area of increased opacity is no longer visible; therefore, it was not considered significant. However, over the next 10 hours the patient continued to require blood. Repeat angiography demonstrated persistent extravasation from the small left superior gluteal branch, which was embolized with absorbable gelatin sponge particles. (d) Selective angiogram of the left renal artery demonstrates segmental branch extravasation (arrow). The artery was selectively embolized with steel coils, and the patient's condition stabilized.

View larger version (122K): [in a new window]   Figure 2b.   Motor vehicle crash victim with hypotension. The patient responded to fluid resuscitation but remained tachycardic. Intraperitoneal blood was seen at diagnostic peritoneal lavage, and the patient underwent laparotomy, during which a liter of blood was removed and a nearly complete avulsion of the right lateral inferior segment of the liver was treated with partial hepatectomy. The right upper quadrant was packed, and the patient underwent angiography for evaluation of a large left retroperitoneal hemorrhage associated with a complex left acetabular fracture. (a) Angiogram demonstrates a small hemorrhage from a branch of the left internal iliac artery (arrow). The hemorrhage was thought to be insignificant. (b) Flush aortogram obtained to evaluate the abdominal vasculature shows a transient area of increased opacity centrally in the left renal hilum (arrow). (c) On a late image from angiography (cf b), the area of increased opacity is no longer visible; therefore, it was not considered significant. However, over the next 10 hours the patient continued to require blood. Repeat angiography demonstrated persistent extravasation from the small left superior gluteal branch, which was embolized with absorbable gelatin sponge particles. (d) Selective angiogram of the left renal artery demonstrates segmental branch extravasation (arrow). The artery was selectively embolized with steel coils, and the patient's condition stabilized.

View larger version (139K): [in a new window]   Figure 2c.   Motor vehicle crash victim with hypotension. The patient responded to fluid resuscitation but remained tachycardic. Intraperitoneal blood was seen at diagnostic peritoneal lavage, and the patient underwent laparotomy, during which a liter of blood was removed and a nearly complete avulsion of the right lateral inferior segment of the liver was treated with partial hepatectomy. The right upper quadrant was packed, and the patient underwent angiography for evaluation of a large left retroperitoneal hemorrhage associated with a complex left acetabular fracture. (a) Angiogram demonstrates a small hemorrhage from a branch of the left internal iliac artery (arrow). The hemorrhage was thought to be insignificant. (b) Flush aortogram obtained to evaluate the abdominal vasculature shows a transient area of increased opacity centrally in the left renal hilum (arrow). (c) On a late image from angiography (cf b), the area of increased opacity is no longer visible; therefore, it was not considered significant. However, over the next 10 hours the patient continued to require blood. Repeat angiography demonstrated persistent extravasation from the small left superior gluteal branch, which was embolized with absorbable gelatin sponge particles. (d) Selective angiogram of the left renal artery demonstrates segmental branch extravasation (arrow). The artery was selectively embolized with steel coils, and the patient's condition stabilized.

View larger version (126K): [in a new window]   Figure 2d.   Motor vehicle crash victim with hypotension. The patient responded to fluid resuscitation but remained tachycardic. Intraperitoneal blood was seen at diagnostic peritoneal lavage, and the patient underwent laparotomy, during which a liter of blood was removed and a nearly complete avulsion of the right lateral inferior segment of the liver was treated with partial hepatectomy. The right upper quadrant was packed, and the patient underwent angiography for evaluation of a large left retroperitoneal hemorrhage associated with a complex left acetabular fracture. (a) Angiogram demonstrates a small hemorrhage from a branch of the left internal iliac artery (arrow). The hemorrhage was thought to be insignificant. (b) Flush aortogram obtained to evaluate the abdominal vasculature shows a transient area of increased opacity centrally in the left renal hilum (arrow). (c) On a late image from angiography (cf b), the area of increased opacity is no longer visible; therefore, it was not considered significant. However, over the next 10 hours the patient continued to require blood. Repeat angiography demonstrated persistent extravasation from the small left superior gluteal branch, which was embolized with absorbable gelatin sponge particles. (d) Selective angiogram of the left renal artery demonstrates segmental branch extravasation (arrow). The artery was selectively embolized with steel coils, and the patient's condition stabilized.

View larger version (145K): [in a new window]   Figure 3a.   Motor vehicle crash victim with hypotension. The patient responded to initial fluid resuscitation. CT demonstrated no signs of intraperitoneal fluid, and the patient underwent angiographic evaluation of pelvic and lower extremity fractures. Two sites of extravasation from the right internal pudendal and obturator arteries were identified and embolized with absorbable gelatin sponge particles. The patient then underwent surgery for lower extremity fractures. During the next 5 hours, she required an additional 6 units of blood. The patient underwent repeat pelvic angiography, which showed no additional sites of hemorrhage. (a) Findings on the celiac angiogram suggest a false aneurysm of a segmental splenic artery branch (arrow). Findings at selective angiography (magnified oblique view) (not shown) confirmed the diagnosis. (b) Angiogram demonstrates coil embolization of the proximal splenic artery (arrow indicates coils, arrowhead indicates distal reconstituted splenic artery). The patient's condition stabilized after the procedure.

View larger version (140K): [in a new window]   Figure 3b.   Motor vehicle crash victim with hypotension. The patient responded to initial fluid resuscitation. CT demonstrated no signs of intraperitoneal fluid, and the patient underwent angiographic evaluation of pelvic and lower extremity fractures. Two sites of extravasation from the right internal pudendal and obturator arteries were identified and embolized with absorbable gelatin sponge particles. The patient then underwent surgery for lower extremity fractures. During the next 5 hours, she required an additional 6 units of blood. The patient underwent repeat pelvic angiography, which showed no additional sites of hemorrhage. (a) Findings on the celiac angiogram suggest a false aneurysm of a segmental splenic artery branch (arrow). Findings at selective angiography (magnified oblique view) (not shown) confirmed the diagnosis. (b) Angiogram demonstrates coil embolization of the proximal splenic artery (arrow indicates coils, arrowhead indicates distal reconstituted splenic artery). The patient's condition stabilized after the procedure.

View larger version (157K): [in a new window]   Figure 4a.   Motor vehicle crash victim with pelvic fractures and a declining hematocrit. Findings at diagnostic peritoneal lavage were negative for intraperitoneal blood. (a) Pelvic angiogram demonstrates hemorrhage of the left internal pudendal artery (arrow). The hemorrhage was confirmed with a selective study, and the artery was embolized with absorbable gelatin sponge particles. (b) Selective angiogram of the right hypogastric artery demonstrates extravasation at the site from collateral contralateral branches (arrow). These branches were also embolized, and the patient subsequently recovered.

View larger version (160K): [in a new window]   Figure 4b.   Motor vehicle crash victim with pelvic fractures and a declining hematocrit. Findings at diagnostic peritoneal lavage were negative for intraperitoneal blood. (a) Pelvic angiogram demonstrates hemorrhage of the left internal pudendal artery (arrow). The hemorrhage was confirmed with a selective study, and the artery was embolized with absorbable gelatin sponge particles. (b) Selective angiogram of the right hypogastric artery demonstrates extravasation at the site from collateral contralateral branches (arrow). These branches were also embolized, and the patient subsequently recovered.

View larger version (104K): [in a new window]   Figure 5a.   Motor vehicle crash victim (pedestrian) with hemodynamic instability and extensive pelvic fractures. Findings at abdominal US were normal, and the patient underwent angiography following intubation and bilateral chest tube placement. (a) Lower abdominal aortogram demonstrates hemorrhage from three avulsed left lumbar arteries (arrows). A selective study of the lumbar region at L4 (not shown) allowed localization of the lesion at the origin of the lumbar artery. An occlusion balloon was placed in the infrarenal aorta. (b) Aortogram demonstrates the occlusion balloon in the infrarenal aorta (arrow). The patient underwent reparative surgery but died during the procedure. A future treatment option for this injury would consist of a covered stent placed across the origins of the three lumbar arteries.

View larger version (113K): [in a new window]   Figure 5b.   Motor vehicle crash victim (pedestrian) with hemodynamic instability and extensive pelvic fractures. Findings at abdominal US were normal, and the patient underwent angiography following intubation and bilateral chest tube placement. (a) Lower abdominal aortogram demonstrates hemorrhage from three avulsed left lumbar arteries (arrows). A selective study of the lumbar region at L4 (not shown) allowed localization of the lesion at the origin of the lumbar artery. An occlusion balloon was placed in the infrarenal aorta. (b) Aortogram demonstrates the occlusion balloon in the infrarenal aorta (arrow). The patient underwent reparative surgery but died during the procedure. A future treatment option for this injury would consist of a covered stent placed across the origins of the three lumbar arteries.