(Radiographics. 1999;19:1340-1348.)
© RSNA, 1999
1998 PLENARY SESSION: IMAGING SYMPOSIUM |
Endovascular Techniques in the Damage Control Setting1
Eric K. Hoffer, MD ,
John J. Borsa, MD ,
Robert D. Bloch, MD and
Arthur B. Fontaine, MD
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.
Index Terms: Angiography, 95.12, 98.12 • Arteries, transluminal angioplasty, 95.128, 98.128 • Catheters and catheterization, 95.1264, 98.1264 • Embolism, therapeutic, 95.1264, 98.1264 • Interventional procedures, 95.12, 98.12 • Liver, injuries, 761.41 • Retroperitoneal space, hemorrhage, 98.41 • Trauma, 95.41, 98.41 • Veins, transluminal angioplasty, 95.128, 98.128
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INTRODUCTION
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High-energy blunt trauma that results in severe injury often involves multiple systems (1–4). Effective treatment mandates a multispecialty team effort that is usually led by the trauma surgeon and includes vascular surgery, orthopedics, and, increasingly, interventional radiology (5–9). The focus on hemorrhage control and the angiographer's unique access to vascular structures gives interventional radiology an important and increasingly recognized role in the treatment of patients with hemodynamic instability (6–9). In these patients, resuscitation and diagnosis proceed simultaneously. Immediate resuscitation to ensure oxygenation of end-organs allows time for identification and treatment of life-threatening injuries. This urgency is embodied in the concept of damage control, which consists of staged surgical intervention with a focus on controlling hemorrhage and contamination, rapid resuscitation, and a second surgery for definitive repair.
In this article, we discuss the role of the angiographer at different phases of the damage control process, with particular attention given to the identification and treatment of pelvic bleeding and splenic injuries and to the potential use of angiography in minimally invasive therapy for large-vessel injury. The practice of angiography in the damage control setting is illustrated in several cases of victims of severe trauma.
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RATIONALE FOR DAMAGE CONTROL SURGERY
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The theory of damage control was developed in an effort to improve outcome in patients with vascular and multiorgan injuries, who had 40%–60% morbidity and mortality rates. The rationale for damage control is that, although control of hemorrhage and contamination is necessary, the time required for formal resections and reconstruction may aggravate the cycle of coagulopathy, acidosis, and hypothermia (10–14).
Damage control is intended to limit the amount of time a patient spends in surgery and involves ongoing triage, in which the coagulopathy-acidosis-hypothermia complex is viewed as a single entity and the most life-threatening problems are given priority when therapies cannot proceed concurrently. Damage control is formally divided into three phases: (a) initial surgery (ligation, packing, and temporary closure) to achieve complete control of hemorrhage and contamination; (b) resuscitation in the intensive care unit (rewarming, correction of coagulopathy, hemodynamic stabilization); and (c) reexploration to remove packs and perform definitive repairs (12).
Packing of hepatic injuries was a common technique for achieving hemostasis at the beginning of this century but was condemned after World War II due to an excessive complication rate (15). In the early 1980s, the concept was revived by Stone et al (10) and Feliciano et al (11), reappearing as damage control or abdominal packing coupled with staged removal or second-look procedures for definitive repair. Rotondo et al (12) reviewed the effects of this approach in a subset of high-risk patients who presented with a combination of major vascular injuries and two visceral organ injuries. The mortality rate was 89% in patients who underwent definitive laparotomy compared with 23% in those treated with a damage control approach. Success in the setting of complex abdominal injury led to application of this approach beyond the confines of the abdominal cavity (9,13,14,16).
The capacity of angiography to help identify and treat arterial hemorrhage in a minimally invasive manner without disruption of the tamponade afforded by intact tissue planes and existing hematoma make it the preferred method for control of arterial pelvic bleeding (6,8,17,18). The extensive collateral vasculature in the pelvis accounts for the poor results with traditional surgical attempts at control (19). External fixation is rapidly performed in the emergency room and may assist in achieving hemostasis (7); however, the extent and significance of this additional tamponade of venous bleeding is not clear (4,8,20,21). Conventional wisdom holds that the patient with hypotension and hemodynamic instability should not undergo angiography. However, transcatheter embolization is the most rapid, effective, and noninvasive method of controlling active pelvic retroperitoneal hemorrhage (6–8,18,19). After blood bank support, the availability of transcatheter embolization is perhaps the most essential element in achieving hemostasis in pelvic retroperitoneal hematomas (8,17). Angiography may also prove useful in identifying and controlling delayed or recurrent abdominal intraperitoneal and retroperitoneal sources of bleeding (22–24). The availability of adequate personnel and life support equipment ensures that resuscitation as well as monitoring of the patient's physiologic response continue uninterrupted. Intravenous fluids and contrast material are warmed, and a rapid-infusion blood warmer is used early in the procedure (9).
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ROLE OF THE ANGIOGRAPHER AND THE DAMAGE CONTROL SETTING
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The interventional radiologist becomes involved when the need for ongoing hemodynamic support indicates continued hemorrhage and the suspected source is not amenable to direct surgical control. This may occur at any phase of the damage control process. Often, the angiographer becomes involved when findings at chest radiography are normal and those at diagnostic peritoneal lavage, computed tomography (CT), or ultrasonography (US) are negative for intraperitoneal blood and suggest the pelvis as a source of blood loss. Open pelvic fractures may be packed acutely and the patient sent directly to angiography (9). Patients may also be transferred directly from surgery to the angiography suite if a large or expanding retroperitoneal hematoma is identified at laparotomy. In some patients, laparotomy may result in hemorrhage from a ruptured pelvic hematoma; this warrants rapid packing of the pelvis and immediate transfer to the angiography suite for transcatheter embolization (7,9). If transfusion requirements continue unabated in the intensive care unit, angiography may be performed prior to reexploration.
A heightened level of clinical awareness is required on the part of the angiographer. Throughout the course of patient care, management decisions are made on the basis of patient physiology and adequacy of resuscitation. Hematocrit and even blood pressure are relatively crude assessments of the adequacy of perfusion in the acute trauma patient (25). Because of the potential for rapid changes in the patient's status, the interventional radiologist must maintain a continuous dialogue with the nursing and surgical staff during the angiographic phase of treatment. The threat of acute destabilization dictates that angiography be performed expeditiously with emphasis on the most likely sites of bleeding.
In addition to participating in the multispecialty coordination necessary for optimal treatment of the polytrauma patient, the radiologist may invoke the principles of damage control. In the ideal environment, open surgery, angiography, and resuscitation may all proceed concurrently without patient transfer; however, most hospitals are not designed this way. Instead, patients are transferred to and from the operating room, angiography suite, and intensive care unit to optimize each phase of intervention. Often, in cases of initial rapid nonselective embolization of a hypogastric artery for extravasation from distal branches, the patient's hemodynamic status will improve rapidly and complete evaluation and subsequent embolization of small branches may be performed. If, however, ventilation becomes difficult or hemodynamic instability increases during the procedure, the prudent course may be to temporize with nonselective internal iliac artery embolization and transfer the patient to the intensive care unit. Afterward, planned repeat angiography can be performed for selective embolization of lumbar, lateral sacral, ileolumbar, or replaced obturator arteries that may require additional time for subselective catheterization (Fig 1).
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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.
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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.
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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.
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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.
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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.
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Many institutions have developed "endovascular suites" for treatment of abdominal aortic aneurysms. These suites are built to operating room specifications and are suitable for the performance of open surgical and interventional angiographic procedures. This type of facility has the potential to streamline the care of the acute polytrauma patient and optimize resuscitation efforts in that nearly concurrent open surgical and transcatheter diagnostic and therapeutic procedures can be performed without the added time constraints of closure and transfer.
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ANGIOGRAPHIC EVALUATION FOR DAMAGE CONTROL
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The basic techniques of embolization are simple modifications of selective catheterization and have been well described (7,18,22). Once a catheter is positioned in a vessel that supplies a more distal bleeding site, flow-directed particulate emboli are used to rapidly (albeit nonselectively) occlude small peripheral branches. Accessible focal lesions in larger arteries may be treated with precise placement of proximal and distal coil emboli, which exclude the lesion from the circulation.
In the damage control setting, patients in extremis should undergo orotracheal intubation for airway control, which also permits suspension of respiration during contrast material injection for maximum diagnostic sensitivity.
The manifestations of arterial injury have been described (18,26) but essentially may consist of any arterial abnormality. Extravasation is the clearest and most obvious finding in arterial injury. The typical, increasingly dense extravascular collection of contrast material may be transitory if it dissipates into a large hematoma. Transient areas of increased opacity seen at nonselective imaging require further evaluation (Fig 2). Hemorrhage from injured smaller vessels (1–2 mm in diameter) is often self-limited in normothermic patients with normal coagulation parameters; in trauma patients with hypothermia and coagulopathy, this may not occur (Fig 2). A corollary is that the angiographic abnormality is not always proportional to the actual amount of blood loss from the injury. False aneurysms, or well-circumscribed collections of contrast material that extend beyond the confines of the arterial wall, may appear stable. However, after an acute injury, these collections are not confined by chronic fibrotic tissue and are best characterized as pulsatile hematomas that require treatment (Fig 3) (22,23). Occlusions may be stable injuries, but bleeding may be intermittent and may depend on the changing parameters of coagulation, blood pressure, and motion of fracture fragments. Larger branch occlusions may warrant embolization (7).
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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.
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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.
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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.
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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.
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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.
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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.
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A systematic diagnostic approach to assessment of the retroperitoneum is needed to avoid missing multiple sites of hemorrhage (27). This systematic survey includes (at a minimum) nonselective angiography of the lower abdominal aorta and pelvis and selective study of the internal iliac arteries. Hemorrhage is identified and treated, after which the diagnostic evaluation is resumed. Once a vessel is embolized for distal branch extravasation, the local potential collateral vessels are evaluated to identify additional supply to the injured vascular bed. In particular, evaluation of the ipsilateral and contralateral potential collateral supply follows embolization of internal iliac anterior division visceral branches or lateral sacral branches (Fig 4). Similarly, after treatment of extravasation in pubic ring fractures, the common femoral artery is evaluated for injury to a replaced obturator or external pudendal artery.
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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.
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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.
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After a search for retroperitoneal sources of hemorrhage, selective study of the liver or spleen may be warranted in the setting of intraoperative packing for hepatic bleeding, positive diagnostic peritoneal lavage by cell count, identification of a hematoma at CT, or a suspicious pattern of injury (22–24). Focal hepatic or renal arterial branch lesions identified on the basis of extravasation, false aneurysm (pulsatile hematoma after acute injury), or arteriovenous fistula are treated with subselective catheterization and embolization (Fig 2). Splenic injuries are treated with proximal coil embolization, which decreases inflow pressure, preserves parenchymal blood supply via collateral flow, and allows delayed recovery of immunologic function (Fig 3) (22,23). In the absence of angiographic evidence of vascular injury, splenic trauma is successfully managed with observation (22).
Conduit vessel injuries are rare but carry a high mortality risk (28). Conduit vessels provide blood to end-organs or limbs and have minimal collateral supply; consequently, they are not candidates for therapeutic embolization or occlusion. These injuries are usually managed with open repair; however, if they are identified at evaluation for retroperitoneal hematoma, temporary tamponade with an occlusion or angioplasty balloon may be life-saving and permit a more expeditious transfer to the operating room (Fig 5).
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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.
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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.
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In the near future, percutaneous methods will permit transcatheter repair of conduit vessel injury. The use of intravascular covered stents is currently being investigated. Balloon-expandable or self-expanding metallic stents are coated with an expandable polymer or covered with a thin layer of expanded polytetrafluoroethylene (Gortex; Gore, Flagstaff, Ariz). Once a guide wire has been advanced beyond the lesion, a sheath is advanced across the arterial wall defect. The covered stent is then advanced to the distal portion of the guiding sheath. Retraction of the sheath exposes the device, and the stent fixes the graft in position, reconstituting an intact arterial lumen. Nonaortic injuries may be treated percutaneously, whereas aortic injuries require a cut down for femoral or iliac artery access due to the current size of the delivery device. Compared with the current options of ligation or temporary shunt, which usually require a second definitive repair procedure, the stent-graft allows more rapid control and definitive repair of conduit vessel lesions. Future applications include transcatheter deployment to exclude lacerations, repair an arteriovenous fistula, or exclude a false aneurysm (29,30).
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CONCLUSIONS
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Because it allows minimally invasive access and advanced methods of endovascular repair, interventional angiography can play a unique diagnostic and therapeutic role in the management of acute major trauma. The emergence of new equipment has expanded the capabilities of interventional angiography in the damage control setting, and integrated endovascular suites may remove one of the major obstacles to implementation of transcatheter techniques. Selective catheterization and flow-directed particulate embolization may allow control of bleeding from small arteries at fracture edges. The development of stent-graft technology has enlarged the scope of interventional therapy to include the rapid and definitive repair of conduit vessel injury. Involvement by the interventional angiographer can enhance the effectiveness of the multispecialty approach to polytrauma patient care, an approach that requires reliable communication, cooperation, and coordination between services.
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Footnotes
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LEARNING OBJECTIVE • Describe the phases of damage control surgery and appropriate endovascular interventions for acute trauma patients.
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References
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Naam NH, Brown WH, Hurd R, Burdge RE, Kaminski DL. Major pelvic fractures. Arch Surg 1983; 118:610-615.[Abstract]
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Moreno C, Moore EE, Rosenberger A, Cleveland HC. Hemorrhage associated with major pelvic fracture: a multispecialty challenge. J Trauma 1986; 26:987-994.[Medline]
-
Dalal SA, Burgess AR, Siegel JH, et al. Pelvic fracture in multiple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements, and outcome. J Trauma 1989; 29:981-1002.[Medline]
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Gylling SF, Ward RE, Holcroft JW, et al. Immediate external fixation of unstable pelvic fractures. Am J Surg 1985; 150:721-724.[Medline]
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Routt MLC, Simonian PT, Swiontkowski MF. Stabilization of pelvic ring disruptions. Orthop Clin North Am 1997; 28:369-388.[Medline]
-
Gilliland MG, Ward RE, Flynn TC, Miller PW, Ben-Menachem Y, Duke JH, Jr. Peritoneal lavage and angiography in the management of patients with pelvic fractures. Am J Surg 1982; 144:744- 747.[Medline]
-
Panetta T, Sclafani SJA, Goldstein AS, et al. Percutaneous transcatheter embolization for massive bleeding from pelvic fractures. J Trauma 1985; 25:1021-1029.[Medline]
-
Bassam D, Cephas GA, Ferguson KA, Beard LN, Yong JS. Protocol for the initial management of unstable pelvic fractures. Am Surg 1998; 64:862-867.[Medline]
-
Henry SM, Tornetta P, III, Scalea TM. Damage control for devastating pelvic and extremity injuries. Surg Clin North Am 1997; 77:879-895.[Medline]
-
Stone HH, Strom PR, Mullins RJ. Management of the major coagulopathy with onset during laparotomy. Ann Surg 1983; 197:532-535.[Medline]
-
Feliciano DV, Mattox KL, Jordan GL. Intra-abdominal packing for control of hepatic hemorrhage: a reappraisal. J Trauma 1981; 21:285-290.[Medline]
-
Rotondo MF, Schwab CW, McGonigal MD, et al. 'Damage control': an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma 1993; 35:375-382.[Medline]
-
Talbert S, Trooskin SZ, Scalea T, et al. Packing and reexploration for patients with non-hepatic injuries. J Trauma 1992; 33:121-125.[Medline]
-
Carrillo EH, Spain DA, Wilson MA, Miller FB, Richardson JD. Alternatives in the management of penetrating injuries to the iliac vessels. J Trauma 1998; 44:1024-1029.[Medline]
-
Madding GF, Lawrence KB, Kennedy DA. Forward surgery of the severely injured. Second Aux Surg Group 1942–1945; 1:307-310.
-
Porter JM, Ivatury RR, Nassoura ZE. Extending the horizons of "damage control" in unstable trauma patients beyond the abdomen and gastrointestinal tract. J Trauma 1997; 42:559-561.[Medline]
-
Mucha P, Jr, Welch TJ. Hemorrhage in major pelvic fractures. Surg Clin North Am 1988; 68:757-773.[Medline]
-
Sclafani SJA, Becker JA. Interventional radiology in the treatment of retroperitoneal hematoma. Urol Radiol 1985; 7:219-230.[Medline]
-
Peltiere LF. Complications associated with fractures of the pelvis. J Bone Joint Surg [Am] 1965; 47:1060-1069.[Abstract/Free Full Text]
-
Riemer BL, Butterfield SL, Diamond DL, et al. Acute mortality associated with injuries to the pelvic ring: the role of early patient mobilization and internal fixation. J Trauma 1993; 35:671-677.[Medline]
-
Grimm MR, Vrahas MS, Thomas KA. Pressure-volume characteristics of the intact and disrupted pelvic retroperitoneum. J Trauma 1998; 44:454-459.[Medline]
-
Sclafani SJA, Shaftan GW, Scalea TM, et al. Nonoperative salvage of computed tomography–diagnosed splenic injuries: utilization of angiography for triage and embolization for hemostasis. J Trauma 1995; 39:818-825.[Medline]
-
Davis KA, Fabian TC, Croce MA, et al. Improved success in nonoperative management of blunt splenic injuries: embolization of splenic artery pseudoaneurysms. J Trauma 1998; 44:1008-1015.[Medline]
-
Gorich J, Rilinger N, Brado M, et al. Non-operative management of arterial liver hemorrhages. Eur Radiol 1999; 9:85-88.[Medline]
-
Scalea TM, Holman M, Fuortes M, et al. Central venous oxygen saturation: an early accurate measurement of volume during hemorrhage. J Trauma 1988; 28:725-732.[Medline]
-
Hoffer EK, Sclafani SJA, Herskowitz MM, Scalea TM. The natural history of arterial injuries diagnosed by arteriography. JVIR 1997; 8:43-53.[Medline]
-
O'Neill PA, Riina J, Sclafani S, Tornetta P, III. Angiographic findings in pelvic fractures. Clin Orthop Rel Res 1996; 329:60-67.
-
Rothenberger DA, Fischer RP, Perry JF, Jr. Major vascular injuries secondary to pelvic fractures: an unsolved clinical problem. Am J Surg 1978; 136:660-662.[Medline]
-
Marin ML, Veith FJ, Panetta TF, et al. Transluminally placed endovascular stented graft repair for arterial trauma. J Vasc Surg 1994; 20:466-472.[Medline]
-
Kato N, Dake MD, Miller DC, et al. Traumatic thoracic aortic aneurysm: treatment with endovascular stent-grafts. Radiology 1997; 205:657-662.[Abstract/Free Full Text]
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INTRODUCTION
RATIONALE FOR DAMAGE CONTROL...
