1. Vascular and Solid Organ Trauma - Interventional Radiology
John Kuo, MD
Chief, Interventional Radiology

2. Background: Interventional Radiology (IR) & Trauma
Interventional radiologists are subspecialized physicians with 6 years formal residency and fellowship training who specialize in minimally invasive, targeted treatments performed using imaging for guidance. Their procedures are less invasive and have less risk, less pain and less recovery time compared to open surgery.
First description of transcatheter embolization of the internal iliac artery to control hemorrhage associated with pelvic fractures published in 1972.
Since that time, the role of IR in trauma has evolved from the initial diagnosis of vascular and solid organ injuries to temporizing or definitive treatment.

3. Diagnostic imaging, angiography & transcatheter therapy
Technical innovations in imaging and angiography & new developments in transcatheter therapy, have paved this trend in minimally invasive management.
State-of-the-art digital subtraction angiography
Helical, spiral, multislice (multidetector) CT
Microcatheters, steerable and hydrophilic guidewires, and coaxial guiding catheters and sheaths
New embolization materials and delivery systems
Stents and covered stents (stent-grafts)

4. Technical innovations in imaging and angiography & new developments in transcatheter therapy
<Angiography suite
CT scanner>
<Angiographic catheters, guidewires, & microcatheters
Angiography catheters, guidewires, & microcatheters

5. CT: Imaging study of choice in trauma
Grading of solid organ injuries
High-attenuation focus may represent extravasation of contrast or active bleeding
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

6. Multi-slice CT and image reconstruction

7. Transcatheter embolization TCE: EMBOLOTHERAPY
Transcatheter embolization TCE (embolotherapy) is the intentional occlusion of a vessel by deposition of thrombogenic materials directly into the vessel via an angiographic catheter under remote control (femoral or brachial access)

8. EMBOLOTHERAPY: Mainstay of modern interventional trauma radiology.
Treated arteries must be expendable or supply a relative infarction resistant vascular bed or must be associated with distal collateral vessels. If end arteries, they must have adequate parenchymal reserve. Typically these are arteries which can be ligated surgically.
Transcatheter embolization of active hemorrhage or vascular injury often may be preferable to surgical alternatives in the following instances:
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

9. Embolization agents Embolization coils > <gelfoam sponge
polyvinyl alcohol PVA >
<Embospheres >

10. Embolic agents of choice in trauma: metallic coils and gelatin sponge
Coils are made of various metals and usually are fortified with soft fabric material to increase thrombogenicity.
Features of coils include:
Permanent occluding agents that remain at the site of deposition
Applied best in single vessel injuries
Placed quickly with a high degree of accuracy
Available in a wide variety of sizes, diameters, lengths, and shapes
Detachable coils include mechanical and electrolytic mechanisms of detachment
Ideal for occluding aneurysm sac
May be retrieved if placement is suboptimal

11. Gelatin sponge (gelfoam)
Temporary occluding agent. Artery often recanalizes in weeks to months, though occlusion may be permanent due to inflammatory reaction.
Applied best in injuries of smaller arterial branches
Useful when more distal occlusion is necessary or when multiple collateral channels are present
Administered as a slurry by mixing gelatin sponge with nonionic contrast material or as pledgets of various sizes

12. Other embolic agents
PVA is a permanent occluding agent available in small particle sizes and administered in a suspension with contrast material.
Embosphere is a starch polymer more finely calibrated than other particles in small sizes from 50 microns to over 1000 microns in diameter
Tissue glue is a tissue adhesive that is injected and polymerizes into a solid state when exposed to an ionized fluid, such as blood, and causes a permanent occlusion.

13. Stent grafts
The advent of stent-grafts or covered stents provides for the salvage of injured or hemorrhaging arteries and increases transcatheter treatment options.
Bare stents have been used with some success in the treatment of intimal dissection and pseudoaneurysm, as well as acute rupture.
Stent grafts are promising alternatives for treating arterial rupture or pseudoaneurysm in a suitable vessel.
US Vice-President Dick Cheney had stent graft placement 9/05 for bilateral popliteal artery anerurysm

14. Stent-graft features
Stents are covered with vein or synthetic materials, such as polytetrafluoroethylene, polyethylene terephthalate (eg, Dacron), polycarbonate urethane compounds, or other proprietary materials.
The balloons are expandable or self-expandable.
Stents exclude and effectively repair the injured arterial segment

15. ACUTE THORACIC AORTIC INJURY (ATAI)
Incidence and natural history
Acute thoracic aortic injury (ATAI) aka aortic transection, aortic traumatic pseudoaneurysm, aortic rupture, aortic laceration, and aortic tear.
ATAIs are responsible for 10-20% of high-speed traffic accident fatalities. More than 8000 cases per year in the US. Most ATAIs represent full-thickness tears, and most cases ATAIs are fatal at the scene of the accident
Only 10-23% survive long enough to present to the hospital. Of those patients, approximately 30% are fatal within 6 hours and 40% are fatal within 24 hours if undiagnosed and left untreated. Only 2-10% of untreated patients survive longer than 6 months.

16. Pathophysiology of ATAI
ATAIs caused by rapid deceleration forces produced by high-speed MVA or falls from great heights.
During acute deceleration, the thoracic aorta is relatively fixed in position at the aortic root, isthmus, and diaphragm.
Movement of the aorta about these fixation points causes stress and tethering, resulting in a tear at these locations.
Among patients who survive with ATAI, the locations of tears are:
Aortic isthmus, 80-90%
Ascending aorta, 5-9%
Diaphragmatic aorta, 1-3%
Of ATAI cases fatal at the scene, a higher percentage of lacerations involve the aortic root.
Pathologically, a transverse tear of the aortic intima and media is found, and the adventitia is intact in approximately 60% of patients.
Multiple sites of ATAI occur in 6-20% of patients, and aortic arch branch artery injuries occur in 4-10% of patients.

17. Imaging studies of ATAI
Imaging of ATAIs consists of plain radiography, CT, conventional thoracic aortography, transesophageal echocardiography, intravascular ultrasound, MRI, and magnetic resonance angiography. Of these, the 3 most commonly used modalities in the assessment of ATAI are plain radiography, CT, and conventional thoracic aortography.

18. Plain chest radiography for ATAI
Negative predictive value of 98%
Nonspecific and quality dependent
Findings
Widened mediastinum
Obscured aortic knob or aortopulmonary window
Deviation of nasogastric tube or trachea
Depressed left mainstem bronchus
Apical pleural cap
Left hemothorax
Abnormal aortic contour
Wide paraspinal stripe
First and second rib fractures
Thick paratracheal stripe

19. CT - Detection of thoracic aortic injury and mediastinal hematoma
Findings for thoracic aortic injury
Intraluminal low-attenuation focus
Contour abnormality
Pseudoaneurysm
Intramural hematoma
Localized dissection
Isolated aortic injury without a mediastinal hematoma is rare.
Screening for mediastinal hematoma by CT can increase the positive conventional thoracic aortogram rate.
CT demonstrates a sensitivity of nearly 100% in aortic injury but is slightly nonspecific.

20. CT scan shows mediastinal hemorrhage, extravasation at the aortic isthmus and large pseudoaneurysm

21. CT Angiography: The future

22. Conventional catheter aortography for ATAI
Sensitivity of almost 100%, specificity of 98%
Advantages
Good evaluation of ascending thoracic aorta and brachiocephalic arteries
Can be used in conjunction with intravascular ultrasound
Necessary for endovascular (stent-graft) treatment planning
Caveat - To detect a subtle injury, two or more views required
Findings
Intimal irregularity
Linear defect
Intimal flap
Contour abnormality
Pseudoaneurysm
Extravasation
Thickened wall
Pitfalls
Anatomic variants
Atheromatous plaque
True aneurysm (ductus aneurysm)
Ductus diverticulum
Aortic spindle
Infundibulum of intercostal artery
Digital subtraction artifacts

23. Treatment of ATAI
Treatment of ATAI should follow the diagnosis promptly. Most patients require surgical repair of the thoracic aorta, usually with an interposition graft. Some patients are not good operative candidates because of concomitant injuries or comorbidities.
In the past, patients who were poor operative risks were treated with medical control of blood pressure and observation in some centers; however, selected patients currently are treated with endovascular aortic stent-grafts, which can avoid the risk associated with a thoracotomy

24. Aortogram shows a focal isthmus traumatic pseudoaneurysmThere is an anteromedial bulge, intimal flap, acute-angle transition, and irregular contour.

25. Digital subtraction catheter aortogram (late phase) of a typical acute traumatic aortic injury

26. Stent-graft repair of pseudoaneurysm of the descending thoracic aorta

27. SPLENIC TRAUMA
Traditional treatment of blunt splenic trauma has been surgical splenectomy.
Splenic salvage through nonoperative management emerging due to recognition of the role the spleen plays in preventing sepsis by encapsulated organisms such as pneumococcus
CT is the imaging modality of choice to make the diagnosis of splenic injury and can help grade the degree of splenic injury.
Up to 60% to 70% of patients with blunt splenic injuries may be treated nonoperatively, with success rates of 71-97%.

28. American Association for the Surgery of Trauma Organ Injury Severity Scale Spleen grading system
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 (>25%)
Grade V - Shattered spleen; hilar injury that devascularizes the spleen

29. Splenic trauma: Imaging studies
Helical CT can predict which hemodynamically stable patients may fail nonoperative management if extravasation or posttraumatic splenic vascular injury is identified.
Some investigators have recommended liberal use of conventional angiography and transcatheter splenic artery embolization to increase the number of patients successfully managed nonoperatively.
Embolization with coils gelfoam or a combination is typically performed depending on intra or extrasplenic location of the arterial injury.
If isolated distal intraparenchymal injury, superselective embolization and sparing of noninjured splenic parenchyma can be performed

30. Transcatheter embolization of blunt splenic trauma
Indication - Extravasation or vascular injury
Techniques
Proximal coil embolization just distal to the dorsal pancreatic artery to decrease head of pressure and to preserve distal collateral flow
Nonselective distal embolization using Gelfoam pledgets
Superselective distal embolization using microcatheter and microcoils, pva, or microspheres at bleeding site
Combination of proximal and distal embolization
Grade IV splenic injuries
Sclafani et al reported 84% salvage rate; Shanmuganathan et al, 94% salvage rate using splenic embolization.
In comparison, Brasel et al found only a 4% salvage rate using only nonoperative treatment.
Complications of splenic embolization: Inadvertent embolization, splenic infarction/abscess, splenic artery dissection

31. CoCT of the abdomen in a hemodynamically stable patient with evidence of persistent hemorrhage following a motor vehicle accident. Arrow points to contrast extravasation in a lacerated spleen

32. Celiac angiogram showing 3 foci of extravasation in spleen, 2 in the upper pole (arrow) and 1 in the lateral aspect of the mid spleen

33. Post superselective embolization splenic angiogram demonstrating microcoils in good position and no evidence of further extravasation

34. HEPATIC TRAUMA
Grade of hepatic injury does not necessarily correlate with the rate of nonoperative treatment success. In grade III and IV liver injuries, a wide range of nonoperative management successes have been reported. Overall, the nonoperative success rate in patients with liver trauma has been reported to be as high as 90% or more.
Patients who are hemodynamically stable but show ongoing signs of hemorrhage or have extravasation on CT of the liver should undergo conventional angiography of the liver. If these patients have angiographic extravasation, pseudoaneurysm, arteriovenous fistula, or arteriobiliary fistula, transcatheter embolization of the abnormal site should be performed

35. American Association for the Surgery of Trauma Organ Injury Severity Scale Liver grading system
Grade I - Capsular tear; 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

36. Transcatheter embolization of the liver
The dual blood supply of the liver makes postembolization infarction less likely. Portal vein occulsion is a relative contraindication.
Subselective and superselective embolization with Gelfoam or coils typically used. PVA, microspheres and tissue glue have been used as well.
Hagiwara et al and Ciraulo et al have shown high technical and clinical success rates with embolization in hepatic trauma. A low complication rate is seen.
Penetrating injuries of the liver from stab and gunshot wounds have been managed successfully with embolotherapy using similar criteria as those in blunt hepatic injuries

37. Contrast-enhanced CT demonstrating a liver laceration in a patient who sustained blunt abdominal trauma

38. Vascular and solid organ trauma
Vascular and solid organ trauma. Hepatic angiogram showing a pseudoaneurysm of a branch of the left hepatic artery (arrow) located in the region of the hepatic laceration

39. Postembolization angiogram of left hepatic branch artery pseudoaneurysm. The coil (arrow) is in satisfactory position and is occluding the pseudoaneurysm

40. Contrast-enhanced CT of a 65-year-old woman with a remote history of blunt abdominal trauma and severe abdominal pain. A large pseudoaneurysm is present and is associated with an infarcted segment of the liver

41. Hepatic angiogram demonstrates large bilobed pseudoaneurysm of right hepatic artery. Notice the "jet effect" of contrast material extending from the lower to the upper pseudoaneurysm sac. In addition, an aneurysm of the proper hepatic artery and diffuse ectasia of the proximal right hepatic artery are apparent

42. Fluoroscopic image shows a catheter in the lower component of the bilobed pseudoaneurysm. Multiple stainless steel embolization coils have been deposited into the pseudoaneurysm

43. Immediate postembolization hepatic angiogram demonstrating complete occlusion of the right hepatic artery pseudoaneurysm, and thrombosis of the entire right hepatic artery

44. Contrast-enhanced 5-month follow-up CT demonstrating coils in shrunken pseudoaneurysm sac and scarring in region of previous hepatic infarction

45. RENAL TRAUMA
85-90% of kidney injuries are attributed to blunt trauma while 10-15% are penetrating injuries. Management of blunt trauma increasingly conservative, most grade I and grade II injuries are treated nonoperatively. Embolotherapy for patients may be performed with evidence of hemorrhage, CT evidence of extravasation or vascular injury, persistent or recurrent hematuria, or large retroperitoneal hematomas
Treatment of more severe renal injuries controversial. In more severe kidney injuries, surgery often performed and results in nephrectomy in a significant percentage of patients. Embolization of the renal bleeding sites may be considered.

46. Renal Trauma
Surgical exploration for PENETRATING renal trauma esp. if the peritoneum has been transgressed. Angiography and embolization in limited cases
Nonvascular percutaneous intervention such as percutaneous nephrostomy for urinary diversion, ureteral stent for ureteral injury and drainage catheters for urinoma

47. American Association for the Surgery of Trauma Organ Injury Severity Scale Kidney grading system
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

48. Transcatheter embolization of renal injuries
The kidney is an end-artery organ with minor transcapsular collaterals.
Superselective distal embolization with Gelfoam pledgets or microcoils is desirable.
Transcatheter embolization of branch artery injuries is successful in % of patients.

49. Selective renal angiogram reveals a pseudoaneurysm of the distal main renal artery with an avulsed/occluded renal artery branch, multiple renal artery branch occlusions, and inhomogeneous nephrogram but no active extravasation. The patient had signs of persistent hemorrhage and was hypotensive.

50. Immediate postembolization renal angiogram demonstrates a satisfactory position of stainless steel coils effectively occluding the main right renal artery. A surgical nephrectomy was planned

51. Selective left renal angiogram in an older man with an expanding retroperitoneal hematoma. This was secondary to penetrating trauma to the flank following an encounter with an angry bull. The arrow delineates the avulsed left renal artery branch to the upper pole of the left kidney

52. Angiogram obtained immediately before deployment of a stent -graft across the origin of the avulsed left renal artery branch. The balloon-mounted stent-graft is in a good position and is ready to be deployed

53. Post–stent-graft deployment left renal angiogram The avulsed branch artery has been excluded effectively

54. Contrast-enhanced CT in a 9-year-old boy who sustained blunt abdominal injury after falling onto the handle bar of his bicycle. He presented with exsanguinating hematuria caused by a fractured left kidney. CT demonstrates a pseudoaneurysm (arrow) off of an intrarenal artery branch

55. Left renal angiogram shows the faint opacification of a pseudoaneurysm (arrow), which correlates with the CT finding.
Left renal angiogram (late phase) shows the faint opacification of a pseudoaneurysm (arrow), which correlates with the CT finding.

56. Postembolization left renal angiogram shows stainless steel embolization coil (arrow) completely occluding the renal artery branch previously containing the pseudoaneurysm

57. PELVIC TRAUMA
Hemorrhage associated with pelvic trauma, +/- pelvic fracture, is common and can arise from venous, osseous, or arterial sources or any combination
Pelvic hemorrhage is treated first using external fixation, which usually is successful in treating venous and osseous bleeding through a tamponade effect
Continued bleeding may indicate an arterial source and is associated with a high morbidity and mortality rate. Intractable hemorrhage associated with pelvic fracture is a large contributor to the overall mortality rate.

58. PELVIC TRAUMA
Surgical exploration and intervention of a pelvic hematoma often is complex because of difficulties in visualizing the hemorrhaging artery or arteries within the extraperitoneal hematoma and in gaining arterial control.
Risk of increased blood loss through the surgical disruption of the pelvic fascia, which may be important in tamponade of the hematoma

59. Transcatheter embolization of pelvic trauma
Early transcatheter embolization of pelvic trauma, within 3 hours of presentation, shown to lower the mortality rate. Angiography required in fewer than 10% of patients with pelvic trauma
When angiography performed, extravasation is documented in about 50% of patients and warrants transcatheter embolization.

60. Imaging and Pelvic trauma
The sensitivity and specificity demonstrated by CT of active extravasation pelvic trauma is 80-84% and 85-98%, respectively
All branches of the internal iliac artery are at risk of bleeding. Arterial bleeding most frequently occurs from superior gluteal, internal pudendal, and obturator arteries. The fascia of the piriformis muscle can lacerate the superior gluteal artery, even without fracture.
Pelvic and retroperitoneal hemorrhage also may arise from the lumbar, inferior epigastric, deep circumflex iliac, and middle sacral arteries

61. Pelvic angiography
Initially nonselective pelvic angiogram from a femoral artery catheter contralateral to the trauma with tip in the lower abdominal aorta.
Select the contralateral and subsequently the ipsilateral internal iliac artery of interest and perform selective internal iliac angiography.
Microcatheters occasionally are needed for superselective angiography and embolization.
Brisk hemorrhage may be evident on nonselective pelvic angiogram but subtle extravasation may require selective or subselective angiography for detection

62. Pelvic transcatheter embolization technique
If the source of extravasation is defined, superselective embolization with gelatin sponge pledgets of 1-2 mm in diameter or slurry is optimal
Proximial coil embolization for proximal internal iliac artery injury or following distal gelatin sponge pledget embolization.
With clinical and CT evidence of massive hemorrhage, emperic nonselective gelfoam embolization of both internal iliac arteries is acceptable and can arrest bleeding quickly

63. Pelvic transcatheter embolization efficacy
Postembolization nonselective angiogram to exclude additional extravasation sites or collateral vessels causing retrograde (backfill) hemorrhage requiring further embolization
The success rate of stopping hemorrhage is %.
Despite high technical success rates, the mortality rate is significant because of concomitant injuries

64. Pelvic transcatheter embolization 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

65. Digital subtraction right iliac angiogram demonstrating acute extravasation (arrows) from the right superior and inferior lateral sacral arteries, arising off of the posterior division of the right internal iliac artery

66. Right iliac artery angiogram (early phase) following transcatheter embolization of lateral sacral arteries showing no further extravasation from these vessels.

67. Patient with straddle injury presents with priapism
Patient with straddle injury presents with priapism. Selective injection of the left internal pudendal demonstrates extravasation at the base of the penis.

68. Left internal pudendal artery after embolization with gelfoam demonstrates distal occlusion of the vessel with no extravasation.

69. PERIPHERAL VASCULAR TRAUMA
Peripheral vascular trauma is relatively common in urban settings where penetrating injuries often occur
Elsewhere, nonpenetrating peripheral vascular injuries, such as occur with blunt trauma, crush injuries, injuries associated with displaced skeletal fractures and joint dislocations, and degloving injuries, are seen more often

70. Penetrating peripheral vascular trauma
Direct penetration of the object through the vessel, with resulting disruption, or by dissipation of kinetic energy within the tissues adjacent to the vessel
Low-velocity objects such as knives, the object must traverse the vessel, and the object must penetrate it to cause injury
High-velocity weapons e.g. rifles, kinetic energy expelled and dissipated within the surrounding tissues as object decelerates. This causes shock waves and cavitation, which produce injury to vessels distant from the trajectory
Any of these mechanisms may cause laceration, pseudoaneurysm formation, transection, arteriovenous fistula, or thrombosis of the vessel.

71. Blunt peripheral vascular trauma
Direct compression or crushing force may produce vascular injury such as a vascular mural contusion
Shearing mechanism, which occurs with stretching or traction forces, produces complete transection or intimal or medial dissection, which may result in a pseudoaneurysm formation
Severe extrinsic compression, such as from adjacent hematoma, fracture fragment, dislocation, or edema, may cause severe narrowing of the vessel, which in turn may result in thrombosis
Vasospasm may occur as an isolated injury or as an associated response to the above-mentioned vascular insults

72. Catheter angiography peripheral vascular injury
Indicated in peripheral vascular injury when the location of injury not certain, when multiple injury sites may be present, when the diagnosis requires confirmation, or when transcatheter treatment may be the therapy of choice
Some peripheral vascular injuries may be treated by transcatheter embolization or with stent or stent-graft placement.

73. Catheter angiography indications peripheral vascular injury
Major indications
Active arterial bleeding or expanding hematoma
Peripheral pulse deficit
Bruit over the site of injury
Isolated neurologic deficit
Hypotension or other sign of ongoing hemorrhage
Minor indications
Proximity of a wound or trajectory to a major blood vessel
Nonexpanding hematoma
Posterior dislocation of the knee joint and anterior dislocation of the elbow joint

74. Catheter angiography technique peripheral vascular injuries
Examination of inflow and outflow.
A minimum of two angiographic views centered on the region of injury usually is required.
Examine outflow to exclude a distal embolization from a proximal injury site.
In gunshot injuries, perform angiography or fluoroscopy of the entire extremity to exclude embolization of metallic gunshot, shrapnel, or fragments.

75. Transcatheter treatment peripheral vascular trauma
The artery to be embolized must be nonessential, ie artery may be surgically ligated.
This provides optimal treatment when surgical access difficult.
Embolization can be performed for pseudoaneurysm and arteriovenous fistula.
Embolize proximally and distally to the lesion to prevent backfilling through collateral vessels.
Consider embolizing the neck of a pseudoaneurysm or arteriovenous fistula to preserve the parent vessel.
Direct percutaneous thrombin injection of pseudoaneurysm
-- A success rate of % is reported
-- Stents and Stent graft have the potential for preservation
of the injured vessel

76. Cut-film angiogram of a young man with an expanding hematoma following a stab wound to the left thigh. Extravasation (arrow) is identified from a medial muscular branch of the left profunda femoral artery

77. Postembolization angiogram of descending left profunda femoral artery branch demonstrating successful embolic occlusion of the medial muscular branch with a microcoil (arrow). The contrast material extravasation occurred prior to the embolic occlusion

78. Left lower extremity angiogram of a struck pedistrian s/p faciotomy who presented with continuous hemorrhage from open wounds of his left calf. Pseudoanerusym (arrow) from the proximal left peroneal artery is present. The peroneal artery provides the only arterial runoff down the leg.

79. Unsubtracted left lower extremity angiogram demonstrating the pseudoaneurysm from the left peroneal artery (arrow) and the extension into the calf

80. Final postembolization left lower extremity angiogram following placement of a detachable microcoil (arrow) within the neck of the left peroneal artery pseudoaneurysm, which preserved flow down the left leg. No further extravasation is identified

81. Large pseudoaneurysm with large hematoma involving high bifurcating right ulnar artery
Catheter injection within the pseudoaneurysm involving high bifurcating right ulnar artery
Cather injection within the pseudoaneurysm with large hematoma involving high bifurcating right ulnar artery

82. Right brachial arteriogram after two initially successful US guided percutaneous thrombin injection procedures reveals recurrent right ulnar artery pseudoaneurysm due to severe tear or transection of the artery

83. The right ulnar artery pseudoaneurysm is filling from both sides of the transected artery. Thus proximal and distal coil embolization, similar to surgical ligation without the incision is required to completely occlude flow to the pseudoaneurysm
The right ulnar artery pseudoaneurysm is filling from both sides of the transected artery. Thus proximal and distal coil embolization, similar to surgical ligation without the incision is required to completely occlude flow to the pseudoaneurysm

84. After proximal and distal coil embolization there is no further flow into the pseudoaneurysm and abrupt occlusion and cut-off of the DISTAL transected end of the right ulnar artery

85. After proximal and distal coil embolization there is no further flow into the pseudoaneurysm and abrupt occlusion and cut-off of the PROXIMAL transected end of the right ulnar artery
After proximal and distal coil embolization there is no further flow into the pseudoaneurysm and complete occlusion at the level of the coils.

86. VASCULAR TRAUMA OF THE NECK
Significant penetrating injuries usually require surgical exploration
Less accessible zone 1 and zone 3 penetrating neck injuries may benefit from angiographic screening and transcatheter embolization if the injury involves a branch of the external carotid artery
Pathophysiology of blunt carotid and cervical injuries usually is dissection, which may result in a stenosis, occlusion, or pseudoaneurysm formation
Extracranial internal carotid injuries are much more common than intracranial internal carotid injuries and usually originate at the C2- to C3-vertebral level and terminate at the base of the carotid canal

87. Grading scale for blunt carotid arterial injury
Grade I - Luminal irregularity or dissection with less than 25% luminal narrowing
Grade II - Dissection or intramural hematoma with greater than or equal to 25% luminal narrowing, intramural thrombus, or raised intimal flap
Grade III - Pseudoaneurysm
Grade IV - Occlusion
Grade V - Transection with free extravasation

88. Findings associated with blunt carotid or vertebral injury
Early diagnosis and treatment of these injuries improves neurologic outcome
Expanding cervical hematoma
Hemorrhage from mouth, nose, ears, or wounds
Massive facial fractures
Cervical bruit in patients younger than 50 years
Evidence of stroke on CT
Unexplained or incongruous central or lateralizing neurologic deficit, Horner syndrome, transient ischemic attack, or amaurosis fugax
Basilar skull fracture through or near the carotid canal
Fracture through the foramen transversarium
Severe flexion or extension cervical spine fracture or subluxation

89. Imaging studies for carotid and vertebral artery injuries
Conventional catheter angiography
Accuracte, may facilitate treatment through transcatheter embolization or stent / Stent-graft placement
Invasive; small risk of catheter-induced stroke, expensive
Ultrasound
-- Quickly performed and inexpensive, portable (bedside)
-- Operator dependent Less effective in zone-1 and zone-3 injuries and vertebral artery injuries
Magnetic resonance angiography
Limited experience in the acute trauma setting. Can combine with imaging of the CNS. No iodinated contrast materia
motion artifact. Requires MRI compatible life-support devices. Not universally available
CT angiography (the future gold standard)
-- Fast imaging from aortic arch to intracerebral vasculature. Can combine with CNS and spine imaging
-- Requires iodinated contrast material. Reconstruction of images. .Not universally available

90. Left cervical carotid arteriogram demonstrates lobulated pseudoaneurysm with arterial venous fistula to the left internal jugular vein
Digital subtraction left cervical carotid arteriogram demonstrating traumatic injury of the left internal carotid artery, manifested by pseudoaneurysm formation and an intimal dissection
Left cervical carotid arteriogram demonstrates lobulated pseudoaneurysm with arterial venous fistula to the left internal jugular vein

91. There is a 5.5 mm pseudoaneurysm involving the proximal internal carotid artery treated with a covered stent (stent-graft) with complete exclusion of the pseudoaneurysm.
There is a 5.5 mm pseudoaneurysm involving the proximal internal carotid artery treated with a covered stent (stent-graft) with complete exclusion of the pseudoaneurysm.

92. CT angiography Head and Neck

93. Vascular and Solid Organ Trauma - Interventional Radiology
John Kuo, MD
Chief, Interventional Radiology

94. My son Justin