1. Multidetector CT of Blunt Traumatic Venous Injuries in the Chest, Abdomen, and Pelvis
A Cilliers
27/01/2012

2. Introduction
Rare
High morbidity and mortality due to associated injuries
Primary attention to more common and obvious injuries
MDCT protocols designed to evaluate arterial and solid organ injuries

3. MDCT trauma protocol
IV material–enhanced multidetector CT of the neck, chest, abdomen, and pelvis
Arterial phase
90-second delayed imaging through the abdomen and pelvis (PV phase)
Delayed phase imaging is not routinely included
Concern about an injury to the renal collecting system or
Findings from the initial whole-body CT reveal a renal injury that is associated with an increased likelihood of a collecting system injury

6. Direct signs: Diagnostic 1. Thrombosis and/or occlusion
2. Avulsion and/or complete tear/rupture
3. Active extravasation
4. Pseudoaneurysm

7. Indirect signs 1. Perivascular hematoma 2. Fat stranding
3. Vessel wall irregularity
These indirect signs can often be seen in association with other adjacent injuries

9. Discussion of specific veins:
Brachiocephalic Vein
Azygos Vein
Superior Vena Cava
Pulmonary Vein
Inferior Vena Cava
Main Portal Vein
Hepatic Veins
Mesenteric Veins
Splenic Vein
Renal Vein
Iliac Vein

10. Brachiocephalic Vein Rare
Most commonly in iatrogenic penetrating trauma
Posterior dislocation of the clavicular head

11. Posterior sternoclavicular dislocation in a 43-year-old woman after blunt trauma. Evaluation of the right subclavian and brachiocephalic veins was limited because of contrast material injection from the left side.

12. Venographic image depicts occlusion (solid arrow) of the right subclavian vein secondary to the posteriorly dislocated clavicle. The occlusion causes dilation of the collateral veins (open arrows)

13. Azygos Vein Mediastinal hematomas:
Aorta or aortic arch vessel
Venous injuries
Small vessel injuries
Fractures of the sternum
Azygos vein injuries
Rare
Adjacent spinal fractures
Evaluation in multiple planes is often helpful for localizing a focus of active bleeding or a pseudoaneurysm

14. Mediastinal hematoma and azygos vein injury in a 34-year-old man after blunt trauma. Pseudoaneurysm present.

15. Superior vena cava Extremely rare:
Die because of SVC injuries and other associated injuries
Most commonly in the setting of penetrating trauma
Blunt injuries:
Near its insertion into the right atrium, where it is enveloped by the pericardium
Coexisting injury to the right atrium is common

16. Superior vena cava injury: Mediastinal hemorrhage (closed arrows) and a linear defect in the superior vena cava with an adjacent pseudoaneurysm (open arrow) Superior vena cavogram: pseudo-aneurysm (arrows) along the lateral wall of the superior vena cava

17. Pulmonary Vein
Strongly associated with severe comorbid injuries (injuries to the atria, ventricles, main-stem bronchi, pericardium, and aorta)
Patients present with hypotension, hypovolemia, and massive hemothorax
Intrapericardial or extrapericardial
Intrapericardial:
Hemopericardium with or without cardiac tamponade
Extrapericardial:
Hemothorax

18. Inferior Vena Cava High morbidity and mortality
Any subtle abnormality should prompt
(a) further evaluation with oblique nonstandard multiplanar reformatted images or
(b) additional imaging
Imaging options:
Conventional venography
CT venography
Few to no data exist to compare conventional venography to CT venography of the IVC in the setting of trauma
Each case should be considered individually:
patient’s clinical presentation
renal function
likelihood of intervention needed

19. IVC injuries:
Associated with severe hepatic injuries and other adjacent injuries
Retrohepatic IVC injuries:
Special case - complicated surgical approach including both a laparotomy and thoracotomy
Identifying the location of the IVC injury aid in surgical planning
Imaging pitfall:
Mixing of unenhanced blood with contrast material
Simulate a thrombosis or vessel injury
Hemopericardium
Rare manifestation of an IVC injury
Differential diagnosis

20. IVC injuries in a 38-year-old woman after blunt trauma - subtle contour irregularity (arrow) of the IVC

21. Multiplanar reformatted image shows a small intimal flap (arrow) Follow-up cavogram helps confirm an abnormality (arrow) of the IVC, a finding consistent with a small intimal tear and formation of a small pseudoaneurysm

22. IVC injuries in a 27-year-old man after blunt trauma: hematoma (arrow) around the IVC A more inferior axial CT image from the same study shows a laceration through the IVC just proximal to the bifurcation, with associated intimal flaps and intraluminal thrombi (arrow)

23. Large hemopericardium and IVC injury in a 63-year-old woman after severe blunt chest and abdominal trauma. (a) Axial contrast-enhanced CT image obtained in the arterial phase shows a small focus of hyperattenuation (arrow) in the right inferior pericardial space. (b) Axial contrast-enhanced CT image obtained in the portal venous phase shows enlargement of the focus of hyperattenuation (arrow).

24. Main Portal Vein Associated injuries:
Liver
Pancreatic duct
Bile duct
Require aggressive surgical treatment
Injury to the intrahepatic portal veins:
Traumatic arteriovenous fistula
Manifest with early filling of the portal veins with contrast
Arteriography indicated to determine diagnostic and therapeutic options

25. Main portal vein injuries in a 63-year-old woman after blunt abdominal trauma: Contour abnormality and an intimal flap (black arrow) in the portal vein Trace surrounding fat stranding (white arrows) indicates a hematoma

26. Main portal vein dissection in a 30-year-old man after blunt abdominal trauma: Periportal and perihepatic hematoma (arrowheads) Intimal flap (arrow) is depicted in the main portal vein

27. Hepatic Veins
Small hepatic venous injuries are relatively common in the setting of liver parenchymal injuries, and bleeding typically stops spontaneously
Bleeding from hepatic venous injuries closer to the liver hilum or from one of the major hepatic veins is less likely to be controlled without intervention
Early filling of hepatic veins should raise concern for an associated arteriovenous fistula
Additional signs:
Hepatic laceration extending into or through a hepatic or portal vein
Vessel irregularity
Abrupt cutoff

28. Mesenteric Veins
Unusual but are associated with considerable morbidity and mortality (60%)
Frequently associated with bowel injuries
Clinical signs and symptoms of mesenteric or bowel injury are nonspecific
Difficult or impossible to differentiate whether the source is arterial or venous

29. Mesenteric vein injury in a 53-year-old man after blunt trauma from a motor vehicle collision. (a, b) Axial (a) and coronal (b) contrast-enhanced CT images obtained in the portal venous phase show a large mesenteric hematoma (arrowheads). An abnormal focus of high-attenuation contrast material (arrow in a) is depicted within the hematoma

30. Splenic Vein Exceedingly rare Usually a result of penetrating trauma
Injury to the small intrasplenic veins occurs in the setting of a blunt traumatic injury to the spleen
As in intrahepatic injuries, early filling of the splenic vein with contrast material should prompt further evaluation with arteriography

31. Renal Vein
Injuries to the pedicle are more likely to occur in association with renal parenchymal injuries
Isolated renal vein injuries are a rare
Careful evaluation of the delayed phase images for expanding hematoma is essential because this finding indicates a vascular injury with continued active bleeding

32. Axial contrast-enhanced CT image obtained in the late arterial phase shows decreased perfusion of the left kidney (arrow) and a large perirenal hematoma (arrowheads)

33. Axial contrast-enhanced CT image obtained in the delayed phase depicts accumulation of high-attenuation material (arrows) within the perirenal tissues, a finding that is consistent with active venous extravasation into the surrounding tissues

34. Iliac Vein
Pelvic fractures are typically associated with considerable blunt force trauma, and associated vascular injuries are identified frequently
Arterial injuries are more common
Pelvic CT angiography (arterial, portal venous, and delayed phases) - arterial and venous extravasation can be distinguish

35. Conclusion Rare injuries Subtle findings High index of suspicion
High morbidity and mortality
Multiplanar reformats
If in doubt, further imaging needed

36. References:
Brian P. Holly, Scott D. Steenburg: Multidetector CT of Blunt Traumatic Venous Injuries in the Chest, Abdomen, and Pelvis. RadioGraphics 2011; 31:1415–1424.
Sutton