Interventional Radiology in Arterial Trauma
Andrew Holden
Outline
Interventional Radiology in Arterial Trauma
Dr Andrew Holden
Department of Radiology
Auckland City Hospital
Introduction
There are 2 major IR techniques for the management of arterial injuries:
-Embolisation (coils, particles, gelfoam)
-Covered Stenting (endografts)Embolic Agents
Coils
Produce permanent occlusion
Medium to large arteries
Controlled deployment
Particles
Various particle diameters (eg 100, 300, 500, 700µ)
Permanently block various levels of arterial bed
Small particles produce tissue necrosis
Embolic Agents
Gelatin
Can be used in pleglets or a slurry
Temporary embolisation (24-48 hours)
Catheter Directed Embolisation
Solid abdominal organ embolisation
IIA branch artery embolisation following pelvic trauma
Iatrogenic injury – penetrating injury, inadvertent arterial injury during venous catheter placement etc
AE in Abdominal Trauma
AE has a well established role in abdominal trauma
Haemodynamically unstable patients are still managed with urgent laparotomy
However, more stable patients are imaged with MD-CT
Patients with solid organ injuries may have CT features that indicate a high risk of re-bleeding. AE should be considered in these cases:
High grade injury
Contrast extravasation
Pseudoaneurysm
Arteriovenous fistula
AE in Abdominal Trauma
AE in Pelvic Trauma
• Haemodynamic instability as a result of pelvic fracture may be due to arterial, venous or osseous surface bleeding
• There are a number of proposed management algorithms for unstable patients with pelvic fracture (in whom other causes of bleeding have been excluded)
• The point of difference in these algorithms is the relative timing and role of arterial embolisation versus orthopaedic intervention (external fixation, fracture reduction)
• At ACH, we believe early arteriography +/- embolisation is important in unstable patients
Technical Points
• Incidence of arterial bleeding highest with vertical shear, APC III fractures
• Contralateral groin approach
• Subselective angiography important to exclude active bleeding
• Coil blockade technique
Covered Stenting in Arterial Trauma
Endograft repair is now the treatment of choice in thoracic aortic injury (TAI)
Expanding applications are being reported at other sites
Iatrogenic arterial injuries can also be managed with covered stents
Iliac Artery Rupture
Thoracic Aortic Injury
Terms include rupture, laceration, tear, dissection, transection, false aneursym
Pathologically, a range of lesions are seen including:
Intimal haemorrhage
Intimal laceration
Medial laceration
Complete laceration with false aneurysm (40%)
Extrinsic medial/adventitial laceration
CT for Aortic Injury
Thoracic Aortic Injury
Angiography
Endoluminal Repair in Acute Thoracic Aortic Rupture
Initially considered in patients in whom open repair is relatively contraindicated: - cerebral injuries (hypotension contraindicated)
- right lung injuries (intolerant of single right lung ventilation)
Now considered treatment of choice in all patients
Requires rapid availability of graft system
Outcomes of Endovascular Repair of Acute Thoracic Aortic Injury: Interrogation of the New Zealand Thoracic Aortic Stent Database.
C.P.Day, T.M.Buckenham
Results from the Database
27 patients underwent endovascular repair of TAI
Primary technical success 96%, no open conversions
Great vessels covered in intentionally in 85% of cases
Procedure related complications in 4 cases (15%) with one case of posterior fossa ischaemia
No cases of spinal cord ischaemia
Met-analysis of endovascular vs open repair for traumatic descending thoracic aortic rupture.
Xenos et al. J Vasc Surg 2008;48:1343-51
Results from the Meta-analysis
17 retrospective cohort studies, 589 patients
369 open repairs, 220 stent grafts
No significant difference in patient age or delay to treatment
Injury severity score higher for endoluminal group
30 day mortality significantly lower after endoluminal repair (p = 0.005)
Risk of post-operative paraplegia significantly lower in the endoluminal group (p = 0.037)
Endograft Repair of Supra-aortic Branch Artery Trauma
Incidence is much less common than TAI
Most common sites for endoluminal repair have been brachiocephalic, carotid and vertebral arteries
Endograft repair of subclavian and axillary artery injuries have been reported but challenges include osseous compression and kinking
ADHB Case
MVA, blunt thoracic trauma
Endograft Repair of Trauma to other Peripheral Arteries
Covered stents can be used to treat ruptured visceral arteries (eg renal) and upper and lower limb arteries
Conclusions
Endograft treatment of TAI is well established
Stent graft treatment of arterial injuries at other locations should also be considered
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Ministry
of Health
