Arterial
Procedure Guide
Indications
Hemodynamically stable patient with traumatic/iatrogenic vascular or solid organ injury and clinically significant bleeding or risk there of. See SIR Position Statement for Endovascular Intervention for Trauma.
Contraindications
No absolute contraindication.
Hemodynamic instability with evidence of solid organ injury - generally managed operatively but there is increasing use of endovascular management in the setting of patients starting to become unstable with known injury that was being managed conservatively (e.g. known splenic laceration with evidence of ongoing bleeding the next day)
Spontaneous or traumatic coagulopathic bleed, e.g., retroperitoneal hematoma with multifocal active bleeding. Most coagulopathic bleeds resolve spontaneously with correction of the coagulopathy. For example, in this small study, spontaneous coagulopathic retroperitoneal bleeds had better clinical outcomes with conservative management rather than embolization, even in those who were hemodynamically unstable.
Superficial or extremity hematoma with active bleeding - often amenable to external compression with angiography as needed for major vascular injury often for surgical planning.
Efficacy and alternatives
Aortic injury
Majority that survive to the hospital involve the proximal descending thoracic aorta or aortic isthmus. Often no active extravasation just an irregularity of the intima/thrombus (<10 mm = grade 1, >10 mm = grade 2), pseudoaneurysm (grade 3), or rupture with hematoma and hemothorax (grade 4).
Endovascular repair is often favored for anatomically favorable grade 3-4 injuries with TEVAR to avoid open repair which has a 28% mortality and 16% paraplegia rate. Grade 1-2 can be managed conservatively with serial imaging.
Liver
Generally conservative management is recommended for lower AAST grade (1-3) injuries with endovascular intervention for higher AAST grade (4-5) injuries in hemodynamically stable patients.
Data is mixed across small retrospective studies for outcomes of endovascular management, though a recent meta-analysis found 93% technical success for embolization of delayed hemorrhage.
Spleen
Generally conservative management is recommended for lower AAST grade (1-3) injuries with endovascular intervention for higher AAST grade (4-5) injuries in hemodynamically stable patients.
Embolization is well supported to reduce need for splenectomy with higher grade injuries. Reported failure rates range from 4-25% though this work predates the modern AAST grading system.
Kidney
Generally conservative management is recommended for lower AAST grade (1-2) injuries and nephrectomy required for AAST grade 5 injuries.
Endovascular management is well supported for AAST grade 3-4 injuries to help preserve renal function, particularly those with perirenal hematoma or active extravasation.
Pelvis
Often bleeding in setting of pelvic fracture, which can be arterial or venous. Mortality as high as 56% in those with fracture and hemodynamic instability.
Endovascular management generally preferred over surgery even in unstable patients as it can be difficult to localize and treat the damaged vasculature operatively. Immediate clinical improvement after embolization is seen in 84-100% of patients.
Recurrent bleeding with repeat intervention reported in 0-23% possibly due to unmasking additional vascular injury after treatment of the main injury (less vasoconstriction) or technique.
Pre-procedure care
Often led by trauma team with initial primary and secondary surveys to determine need to proceed emergently to operative management.
CTA can be helpful for procedural planning but is not strictly needed. Some centers (e.g. Harborview in Seattle) proceed with angiography without CTA for unstable patients and radiographs showing pelvic ring injury.
Anesthesia support as needed, particularly for unstable patients.
procedure
Arterial access, often CFA with 4/5 Fr sheath but can do radial or others as needed.
Select catheter for selecting target vessel. Examples below.
Aorta - pigtail or Omni flush
Celiac/SMA - C2, Sim, Sos
IMA, intercostals, and lumbar - Mickaelson
Renals - Mickaelson, RDC, Sim, Sos, C2
Internal iliac - RUC, C2 with Waltman loop
Thoracic branches - Vert, Sim
If no pre-procedure imaging, important to be systematic, e.g, initial survey runs of the thoracic aorta -> abdominal aorta with upper abdomen -> abdominal aorta and iliacs to identify most significant injuries to treat first prior to more select angiography.
Select bleeding vessel and confirm with DSA.
Treat the injury
Embolization is good for bleeding/vascular injury where the vessel can be sacrificed.
If a focal lesion or bleed is visualized, it is often helpful to be selective and embolize near the site of injury, particularly for organs like the kidney where preserving function is important.
If extensive multifocal bleeding, it is likely better to embolize more proximally.
Spleen - proximal coil or plug embolization of the splenic artery is often sufficient unless there is a very focal injury. This decreases perfusion pressure and bleeding while allowing collateral supply to preserve splenic function.
Liver and pelvis - if extensive injury or high concern for injury without visualized bleeding, it is often safe to embolize the internal iliacs, right hepatic, or left hepatic artery with gelfoam.
If placing coils or plugs, it is often good to oversize by 1-2 mm as vasospasm during bleeding can lead to undersizing and coil/plug migration as the patient stabilizes.
Stent graft is good for vascular injury where the vessel cannot be sacrificed, e.g., aortic or iliac injury.
Post-treatment DSA to confirm adequate treatment.
Access closure vs leaving sheath in place if needed by ICU/trauma team
Complications
Varies widely based on specific anatomy and site of injury. Generally, complications related to the endovascular therapy itself are rare beyond aortic stent graft placement which has higher complication rates discussed separately. Complications include non-target embolization, non-target vascular injury (e.g. dissection), and access site complications.
High AAST grade solid organ injuries have significant rates of complications such as bilomas with liver injuries and superinfection of injuried/necrotic tissue regardless of intervention. One study estimated that the adverse event rate for no intervention with high grade solid organ injury is 9xs higher than the adverse event rate with intervention.
Post-procedure care & Follow Up
Often return care to primary ICU/trauma team for continued close hemodynamic monitoring.
Additional Resources
Backtable Podcasts on Solid Organ/Pelvic Trauma, Evolution of Trauma Care in IR, Plugs vs Coils for Splenic Trauma, and Renal Trauma Embolization