Broken Bones and Bleeding Vessels; Emergency Embolization Explored

Broken Bones and Bleeding Vessels; Emergency Embolization Explored Poster No.: C-1827 Congress: ECR 2015 Type: Educational Exhibit Authors: W. Mubarak, A. sayedin, O. Almokdad, J. Al Rayahi, V. chavan, A. Barah, A. derwish, A. Omar; Doha/QA Keywords: Interventional vascular, Emergency, Catheter arteriography, CTAngiography, Embolisation, Acute, Trauma DOI: 10.1594/ecr2015/C-1827 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 18

Learning objectives -In this presentation, we aim to fulfill the following objectives: *Demonstrate radiologic findings in multiple imaging modalities used in diagnosing and treating vascular injuries, namely CT and angiography. *Illustrate the effective use of different embolization agents. Background Interventional radiology has become a corner stone in life-saving treatment of trauma patients with actively bleeding vessels using different embolization agents. The success rate of the embolization depends on effective communication with the trauma team and highly trained interventional radiologists, as well as the prescence of different embolizing agents. Embolization of the actively bleeding vessles under image guidance in selected patients can be a minimally invasive, lifesaving procedure. With recent advances in imaging technology, and advents in embolizing agents, there has been an increase in the technical and clinical success rates of embolization. However, the presence of a highly qualified interventional radiologist, a modern angio suite as well as the proper materials and embolizing agents plays a huge role in the outcome of the procedure. In this poster we will provide 14 cases with different causes of bleeding. Most of them have undergone a CT scan which identified the site of bleeding. Also pre-embolization images will be provied to visualize the active bleeding as well as post embolization angiogram to assure proper haemostasis. We only have a single angio suite in the country used for trauma cases and that is a Siemens Zeego. Different embolizing agents has been used, and that will be highlighted for each case. Page 2 of 18

Findings and procedure details CASE NUMBER 1: -CLINICAL HISTORY: 21 years old male patient presented with blunt trauma to the abdomen (MVC). -CT FINDINGS: CT scan showed shattered kidney and active bleeding from left renal vessels. -ANGIOGRAPHY FINDINGS:Active bleeding from left renal vessels -EMBOLIC AGENT: Gel-Foam. -POST EMBOLIZATION FINDINGS: Successful cessation of the bleeding. CASE NUMBER 2: -CLINICAL HISTORY: 33 years old male patient presented with crush injury to the pelvis. -CT FINDINGS: No CT-Scan done for this patient. -ANGIOGRAPHY FINDINGS: Significant contrast extravasations from the left external iliac artery -AGENT: Balloon inflation. -POST EMBOLIZATION FINDINGS: Successful cessation of the bleeding. The patient was temporarily stabilized but unfortunately he passed away while being shifted to the operating theatre. CASE NUMBER 3: -CLINICAL HISTORY: 55 years old male patient, presented to the emergency after falling from height (3 m) -CT FINDINGS: Fractures of the L2/L3/L4/L5 transverses processes on the left side with associated large retroperitoneal hematoma -ANGIOGRAPHY FINDINGS: Active bleeding from the left lumbar vessels at the level of L3 vertebral body. -EMBOLIC AGENT: Gel-Foam. -POST EMBOLIZATION FINDINGS: Successful cessation of the bleeder vessel. Page 3 of 18

CASE NUMBER 4: -CLINICAL HISTORY: 26 years old male presented with splenic injury. -CT FINDINGS: Splenic injury with active bleeding and peri-splenic hematoma ANGIOGRAPHY FINDINGS: Active bleeding from the splenic artery. -EMBOLIC AGENT: 3mm x 2 cm coils. -POST EMBOLIZATION FINDINGS: Successful cessation of the bleeding vessel. CASE NUMBER 5: -CLINICAL HISTORY: 30 years old male patient presented with motor vehicle accident. -CT FINDINGS: Fractures of the transverse process of the L2-L3 on the left side with hematoma and focal blush at the level of L3 in the left psoas muscle. -ANGIOGRAPHY FINDINGS: Bleeding from the left L3 lumbar artery. -EMBOLIC AGENT: 3mm x 2 cm coils. -POST EMBOLIZATION FINDINGS: Successful cessation of the bleeding vessel. CASE NUMBER 6: -CLINICAL HISTORY: 30 years old male patient, presented to the emergency after falling from height. -CT FINDINGS: Burst fracture of L1 vertebral body with extensive hematoma and evidence of active bleeding from the left L1 artery. -ANGIOGRAPHY FINDINGS: Active bleeding from the left lumbar vessel at the level of L1 vertebral body. -EMBOLIC AGENT: Gel-Foam. -POST EMBOLIZATION FINDINGS: Successful cessation of the bleeding. CASE NUMBER 7: -CLINICAL HISTORY: 43 years old female patient, presented to the emergency after motor vehicle accident. Page 4 of 18

-CT FINDINGS: A large heterogeneous appearing hematoma is seen involving the right lobe of the liver with evidence of active hematoma. -ANGIOGRAPHY FINDINGS: Active bleeding from the right hepatic artery. -EMBOLIC AGENT: Gel-Foam. -POST EMBOLIZATION FINDINGS: Successful cessation of the bleeder vessel. CASE NUMBER 8: -CLINICAL HISTORY: 17 years old female patient presenting after a motor vehicle accident. -CT FINDINGS: Hyper density is noted within bowel lumen in absence of oral contrast/ oral medication this was suspected to represent an intra-luminal hemorrhage. ANGIOGRAPHY FINDINGS: Blush from a segmental artery arising from the superior mesenteric artery. -EMBOLIC AGENT: Gel-Foam. -POST EMBOLIZATION FINDINGS: Successful cessation of the bleeding with no consequent bowel necrosis. CASE NUMBER 9: -CLINICAL HISTORY: 29 years old male presented to the emergency department with pelvic fracture. -CT FINDINGS: Pelvic fracture associated with active contrast leak / pseudo aneurysm in relation to the deep branches of the internal iliac artery on the right side. -ANGIOGRAPHY FINDINGS: Right internal iliac artery pseudo aneurysm. -EMBOLIC AGENT: 3mm x 2 cm coils -POST EMBOLIZATION FINDINGS: Successful cessation of the bleeding. CASE NUMBER 10: -CLINICAL HISTORY: 14 years old male presented to the emergency department with abdominal trauma. -CT FINDINGS: Splenic pseudo-aneurysm on background of splenic lacerations Page 5 of 18

-ANGIOGRAPHY FINDINGS: Splenic artery pseudo-aneurysm. -EMBOLIC AGENT: 3mm x 2 cm coils -POST EMBOLIZATION FINDINGS: Successful occlusion. CASE NUMBER 11: -CLINICAL HISTORY: 24 years old male patient presented with fall from height. -CT FINDINGS: Splenic tear with evidence of splenic artery active extravasation/pseudo aneurysm. ANGIOGRAPHY FINDINGS: Splenic tear with evidence of splenic artery pseudo aneurysm. -EMBOLIC AGENT: 3 mm x 2 cm coils. -POST EMBOLIZATION FINDINGS: Successful occlusion. CASE NUMBER 12: -CLINICAL HISTORY: 32 years old male patient presented with stab to the back. -CT FINDINGS: An evidence of active extravasation/pseudo aneurysm within the erector spinae muscle in the right lumbar region -ANGIOGRAPHY FINDINGS: Right lumbar artery pseudo-aneurysm. -EMBOLIC AGENT: Gel-Foam. -POST EMBOLIZATION FINDINGS: Successful occlusion of the bleeder. CASE NUMBER 13: -CLINICAL HISTORY: 21 years old male patient presented after a heavy object fell over his abdomen. -CT FINDINGS: Large liver laceration with active arterial bleeding. -ANGIOGRAPHY FINDINGS: No evidence of active bleeding which is suggestive of venous bleeding -EMBOLIC AGENT: No embolization done. The patient responded well to supportive therapy. Page 6 of 18

CASE NUMBER 14: -CLINICAL HISTORY: 28 years old male patient presented after heavy object fell over his body. -CT FINDINGS: Splenic laceration and abnormal enhancing lesion suspected to be a pseudo-aneurysm. -ANGIOGRAPHY FINDINGS: Pseudo aneurysm from the superior branches of the splenic artery -EMBOLIC AGENT: 3 mm x 2 cm coils. -POST EMBOLIZATION FINDINGS: Successful occlusion of the bleeder. CASE NUMBER 15: -CLINICAL HISTORY: 25 years old male patient presented with history of motor vehicle accident. -CT FINDINGS: Multiple bony facial fractures. No active bleeding noted as no intravenous contrast was given. *24 hours, the patient developed bleeding from his nose and right ear. The oral and maxillofacial surgeon could not stop the bleeding. The patient was shifted to the angio suite where angiography was done. -ANGIOGRAPHY FINDINGS: Active bleeding from the terminal small branch of the right internal maxillary artery. -EMBOLIC AGENT: Gel-Foam. -POST EMBOLIZATION FINDINGS: Successful cessation of the bleeding. Images for this section: Page 7 of 18

Fig. 1: 1st case: -CT FINDINGS: CT scan showed shattered kidney and active bleeding from left renal vessels. -ANGIOGRAPHY FINDINGS:Active bleeding from left renal vessels -EMBOLIC AGENT: Gel-Foam. -POST EMBOLIZATION FINDINGS: Successful cessation of the bleeding. Fig. 2: 2nd case: -CT FINDINGS: No CT-Scan done for this patient. -ANGIOGRAPHY FINDINGS: Significant contrast extravasations from the left external iliac artery -AGENT: Balloon inflation. -POST EMBOLIZATION FINDINGS: Successful cessation of the bleeding. The patient was temporarily stabilized but unfortunately he passed away while being shifted to the operating theatre. Page 8 of 18

Fig. 3: 3rd: -CT FINDINGS: Fractures of the L2/L3/L4/L5 transverses processes on the left side with associated large retroperitoneal hematoma -ANGIOGRAPHY FINDINGS: Active bleeding from the left lumbar vessels at the level of L3 vertebral body. -EMBOLIC AGENT: Gel-Foam. -POST EMBOLIZATION FINDINGS: Successful cessation of the bleeder vessel. Fig. 4: 4th case: -CLINICAL HISTORY: 26 years old male presented with splenic injury. -CT FINDINGS: Splenic injury with active bleeding and peri-splenic hematoma ANGIOGRAPHY FINDINGS: Active bleeding from the splenic artery. -EMBOLIC AGENT: 3mm x 2 cm coils. -POST EMBOLIZATION FINDINGS: Successful cessation of the bleeding vessel. Page 9 of 18

Fig. 5: 5th case: -CT FINDINGS: Fractures of the transverse process of the L2-L3 on the left side with hematoma and focal blush at the level of L3 in the left psoas muscle. ANGIOGRAPHY FINDINGS: Bleeding from the left L3 lumbar artery. -EMBOLIC AGENT: 3mm x 2 cm coils. -POST EMBOLIZATION FINDINGS: Successful cessation of the bleeding vessel. Fig. 6: 6th case: -CT FINDINGS: Burst fracture of L1 vertebral body with extensive hematoma and evidence of active bleeding from the left L1 artery. -ANGIOGRAPHY FINDINGS: Active bleeding from the left lumbar vessel at the level of L1 vertebral body. -EMBOLIC AGENT: Gel-Foam. -POST EMBOLIZATION FINDINGS: Successful cessation of the bleeding. Page 10 of 18

Fig. 7: 7th case: -CT FINDINGS: A large heterogeneous appearing hematoma is seen involving the right lobe of the liver with evidence of active hematoma. -ANGIOGRAPHY FINDINGS: Active bleeding from the right hepatic artery. -EMBOLIC AGENT: Gel-Foam. -POST EMBOLIZATION FINDINGS: Successful cessation of the bleeder vessel. Fig. 8: 8th case: -CT FINDINGS: Hyper density is noted within bowel lumen in absence of oral contrast/oral medication this was suspected to represent an intra-luminal hemorrhage. -ANGIOGRAPHY FINDINGS: Blush from a segmental artery arising from the superior mesenteric artery. -EMBOLIC AGENT: Gel-Foam. -POST EMBOLIZATION FINDINGS: Successful cessation of the bleeding with no consequent bowel necrosis. Page 11 of 18

Fig. 9: 9th case: -CT FINDINGS: Pelvic fracture associated with active contrast leak / pseudo aneurysm in relation to the deep branches of the internal iliac artery on the right side. -ANGIOGRAPHY FINDINGS: Right internal iliac artery pseudo aneurysm. EMBOLIC AGENT: 3mm x 2 cm coils -POST EMBOLIZATION FINDINGS: Successful cessation of the bleeding. Fig. 10: 10th case: -CT FINDINGS: Splenic pseudo-aneurysm on background of splenic lacerations -ANGIOGRAPHY FINDINGS: Splenic artery pseudo-aneurysm. -EMBOLIC AGENT: 3mm x 2 cm coils. -POST EMBOLIZATION FINDINGS: Successful occlusion. Page 12 of 18

Fig. 11: 11th case:-ct FINDINGS: Splenic tear with evidence of splenic artery active extravasation/pseudo aneurysm. -ANGIOGRAPHY FINDINGS: Splenic tear with evidence of splenic artery pseudo aneurysm. -EMBOLIC AGENT: 3 mm x 2 cm coils. POST EMBOLIZATION FINDINGS: Successful occlusion. Fig. 12: 12th case: -CT FINDINGS: An evidence of active extravasation/pseudo aneurysm within the erector spinae muscle in the right lumbar region -ANGIOGRAPHY FINDINGS: Right lumbar artery pseudo-aneurysm. -EMBOLIC AGENT: Gel-Foam. POST EMBOLIZATION FINDINGS: Successful occlusion of the bleeder. Page 13 of 18

Fig. 13: 13th case: -CT FINDINGS: Large liver laceration with active arterial bleeding. -ANGIOGRAPHY FINDINGS: No evidence of active bleeding which is suggestive of venous bleeding -EMBOLIC AGENT: No embolization done. The patient responded well to supportive therapy. Fig. 14: 14th case: -CT FINDINGS: Splenic laceration and abnormal enhancing lesion suspected to be a pseudo-aneurysm. -ANGIOGRAPHY FINDINGS: Pseudo aneurysm from the superior branches of the splenic artery -EMBOLIC AGENT: 3 mm x 2 cm coils. -POST EMBOLIZATION FINDINGS: Successful occlusion of the bleeder. Page 14 of 18

Fig. 15: 15th case: -CT FINDINGS: Multiple bony facial fractures. No active bleeding noted as no intravenous contrast was given. *24 hours, the patient developed bleeding from his nose and right ear. The oral and maxillofacial surgeon could not stop the bleeding. The patient was shifted to the angio suite where angiography was done. -ANGIOGRAPHY FINDINGS: Active bleeding from the terminal small branch of the right internal maxillary artery. -EMBOLIC AGENT: Gel-Foam. -POST EMBOLIZATION FINDINGS: Successful cessation of the bleeding. Page 15 of 18

Conclusion Arterial embolization has proven to be a minimally invasive procedure with a high success rate. Proper utilization of embolic agents aids in achieving satisfactory results with low morbidity and mortality. CT is an excellent tool to localize the site of bleeding, and plan for embolization. Gel foam is a cheap, safe readily available embolic agent that can be used in many situations to achieve haemostasis. Balloon inflation in a severed artery can be used as a temporary measure to stop bleeding until vascular surgeons intervene. Acknowledgments: We would like to acknowledge the efforts of all radiology staff, and staff of other services within our hospital that have helped to achieve these results. We would also like to thank the HMC Medical Research Center for their continuous educational and financial support. Personal information 1-W. Mubarak. Interventional Radiology Fellow, Hamad General Hospital, Doha, Qatar; WMUBARAK@hamad.qa 2-A. Sayedin, MBBCH. Radiology Resident, Department of radiology, Hamad General Hospital, Hamad medical corporation, Doha, Qatar. ; asayedin@hamad.qa Page 16 of 18

3-Ahmad J. Omar, MD, FFR, RCSI, Chairman and Program Director of Clinical Imaging and Interventional Radiology senior consultant, Hamad Medical Corporation, DohaQatar. Aomar@hamad.qa; Radiology@hamad.qa 4-A. Barah. Interventional Radiology Consultant, Hamad General Hospital, Doha, Qatar. ; ABarah@hamad.qa 5-Ahmed Almuzrakchi, Senior Radiology Consultant, Department of Clinical imaging, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar. 6-Venugopal NKC, Interventional Radiology Consultant, Hamad General Hospital, Doha, Qatar; vchavan@hamad.qa 7-O. Almokdad. Interventional Radiology Fellow, Hamad General Hospital, Doha, Qatar; oalmokdad@hamad.qa 8-J. Al-Rayahi, M.D, Pediatric radiology Fellow, Hamad General Hospital, Hamad Medical Corporation, Qatar. JAlRayahi1@hamad.qa References 1-Velmahos, George C. MD; Toutouzas, Konstantinos G. MD; Vassiliu, Pantelis MD; Sarkisyan, Grant MD; Chan, Linda S. PhD; Hanks, Sue H. MD; Berne, Thomas V. MD; Demetriades, Demetrios MD, PhD. A Prospective Study on the Safety and Efficacy of Angiographic Embolization for Pelvic and Visceral Injuries. 2-Haan, James M. MD; Biffl, Walter MD; Knudson, M. Margaret MD; Davis, Kimberly A. MD; Oka, Tomomi MD; Majercik, Sarah MD; Dicker, Rochelle MD; Marder, Shelley MD; Scalea, Thomas M. MD; for the Western Trauma Association Multi-Institutional Trials Committee. Splenic Embolization Revisited: A Multicenter Review. Page 17 of 18

3-TS Matalon, CA Athanasoulis, MN Margolies, AC Waltman, RA Novelline, AJ Greenfield and SE Mille. Hemorrhage with pelvic fractures: efficacy of transcatheter embolization. 4-Mohr, Alicia M. MD; Lavery, Robert F. MA; Barone, Allison MD; Bahramipour, Philip MD; Magnotti, Louis J. MD; Osband, Adena J. MD; Sifri, Ziad MD; Livingston, David H. MD. Angiographic Embolization for Liver Injuries: Low Mortality, High Morbidity. 5-George C. Velmahos, Santiago Chahwan, Andres Falabella, Sue Ellen Hanks, Demetrios Demetriades. Angiographic Embolization for Intraperitoneal and Retroperitoneal Injuries Page 18 of 18