Angiography in Patients with Blunt Trauma to the Chest and Abdomen

Symposium on Nonpenetrating Thoracoabdominal Injuries

Angiography in Patients with Blunt Trauma to the Chest and Abdomen

Robert C. Lim, Jr., MD.,* Morton G. Glickman, M.D.,** and Thomas K. Hunt, M.D.*** INTRODUCTION

Although abdominal trauma constitutes only 7 per cent of all injuries caused by automobile accidents, the mortality and morbidity in this group of patients is inordinately high. This is due in part to the high incidence of multi-system involvement. In addition to the routine history, physical findings, and laboratory tests to assess the extent of injury in the immediate post injury period, peritoneal lavage has been of great help in assessing blunt abdominal trauma for intra-abdominal bleeding in selected cases. However, lavage is inadvisable in comatose patients or in patients who have had previous laparotomies with intra-abdominal adhesions. Improvements in radiographic techniques and equipment have permitted the use of angiography to visualize the anatomic integrity of the thoracic and abdominal viscera. 3 Angiography, although a valuable adjunct in the evaluation of the trauma patient, does not replace careful history taking and physical examination. The usual noninvasive methods of diagnosis should be performed first. If the diagnosis is still in doubt and the indications for surgery equivocal, then selective angiography will be helpful. INDICATIONS Abdominal Injuries Aortography and selective celiac, superior mesenteric and renal angiography are indicated in blunt trauma to the abdomen when injury *Assistant Professor of Surgery, University of California School of Medicine; Coordinatorin-Charge, Emergency Service, San Francisco General Hospital ""Assistant Professor of Radiology, University of California School of Medicine; Chief, Vascular Procedures, San Francisco General Hospital "**Associate Professor of Surgery, University of California School of Medicine; Assistant Chief, Surgical Service, San Francisco General Hospital Supported by National Institutes of Health Grant GM-18470.

Surgical Clinics of North America- Vol. 52, No.3, June 1972

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to the spleen, liver, kidney, or pancreas is suspected but the physical findings and the usual laboratory and roentogenographic studies are equivocal. In most patients with severe blunt abdominal trauma the need for operation is made quite evident by physical examination. Abdominal roentgenograms may show perisplenic rib fractures, splenic enlargement, or obliteration of perisplenic fat planes. Distention of the stomach with gas via the nasogastric tube prior to taking the abdominal roentgenogram adds to their value in demonstrating the size of the spleen. An intravenous urogram can be rapidly and easily performed if the patient has hematuria or if a renal injury is suggested by physical examination or abdominal roentgenograms. In patients with pelvic trauma a cystogram should be performed and interpreted within an hour after the patient is admitted to the hospital. During cystography the patient should be manipulated as little as possible. In patients with equivocal findings, peritoneal lavage is a sensitive method of detecting intra-abdominal bleeding. Angiography is not indicated in patients with clinical indications for laparotomy. In patients who have severe persistent pain in the left upper quadrant or who have roentgenographic evidence of fractures of the left lower ribs or splenic enlargement, the diagnosis of splenic hematoma must be considered. If the hematocrit level remains stable and if peritoneal lavage fails to disclose intraperitoneal hemorrhage angiography should be performed to evaluate the possibility of splenic injury. Most patients with significant liver injuries arrive at the emergency room in hypovolemic shock. However, when the patient is comatose or has a history of minimal trauma and clinical findings, one is justified in observing him and periodically re-evaluating his condition. If clinical signs are localized in the right upper quadrant the surgeon is hard pressed to rule out any hepatic injuries that may be potentially life threatening, especially when associated injuries such as head injury or flail chest make evaluation of the patient difficult. Angiography is very helpful in defining the upper abdominal organs. Postoperative angiography may be indicated in patients with hepatic injury. Suspected complications such as abscess, infarction, hematobilia, biliary cyst, hepatic artery aneurysm, or arteriovenous fistula are indications for selective angiography. Prompt detection of these complications may lead to early appropriate therapy. Postoperative angiography should be considered in all patients who have been treated surgically for hepatic injury and whose postoperative course is protracted. Renal contusions and lacerations resulting from blunt abdominal trauma are usually treated conservatively. However, extensive renal lacerations with active bleeding require immediate surgical intervention. Intravenous urography usually provides sufficient information for diagnosis of lesions that must be operated upon immediately. Angiography should be performed, however, in patients with evidence of renal trauma who are treated conservatively. Renal artery aneurysm, renal arteriovenous fistula, and infarction of renal tissue resulting in hypertension have been reported in such patients. 4 These lesions are rarely detected by intravenous urography or retrograde pyelography. If

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untreated, renal injuries may result in hypertension and may require subsequent nephrectomy. By angiography these lesions can be detected early before they are clinically evident. Immediate treatment of aneurysms or arteriovenous fistulas frequently can save the kidney. Prompt recognition of renal devitalization surrounding a laceration or segmental renal infarct may permit heIninephrectomy to be performed now rather than total nephrectomy at a future date. In patients with multiple injuries the physical signs are frequently confusing or are completely lacking. If the patient has a head injury, the depressed level of consciousness or coma makes assessment of his condition difficult. During observation in the emergency room, these patients may decompensate and go into shock. Angiography should be performed promptly after the initial evaluation of the patient if there is any possibility of intra-abdominal injury.

Chest Injuries Thoracic injuries from blunt trauma are usually caused by rapid deceleration as in head-on collision. Shearing forces are created by the relative mobility of portions of the aorta against points of fixation of the heart and aorta. The two most common sites of injury are lacerations of the root of the aorta just distal to the aortic valve and at the descending thoracic aorta where the aorta is fixed at the ligamentum arteriosum and left subclavian artery. These injuries cause intrathoracic bleeding and are detectable by obvious clinical signs of hypovoleInic shock. Serial roentgenograms of the chest are helpful in detecting widening of the mediastinum in suspected cases of major vascular injuries. However, if the force is such that one suspects an aortic laceration, time may be important. The symptoms of patients with aortic laceration or laceration of one of the major vessels from the aortic arch is often masked by pain of thoracic cage injury. In massive trauma when vascular injury is suspected aortic arch study should be performed promptly. Aortic arch study after blunt trauma to the chest is indicated in several circumstances: (1) when injuries of the aorta or its branches are suspected, (2) when blunt trauma is sufficient to cause multiple rib fractures, especially to the first rib, and (3) when progressive mediastinal widening occurs.

METHODS Angiography is performed by percutaneous catheterization of a femoral or an axillary artery. If the abdoIninal viscera are to be examined, catheterization of the femoral artery is preferable to the axillary artery, since it provides easier and faster access to the celiac and renal arteries. If pelvic or hip injuries or extensive arteriosclerotic occlusive disease rule out femoral artery puncture, the axillary artery provides a safe alternate route. In patients with suspected thoracic injuries the axillary approach may be used to avoid passing the catheter by the site of laceration. A thin-walled red Kifa catheter (O.D. 0.086 inch, I.D. 0.055 inch) is

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used for visceral angiography and a thickwalled green Formacath pigtail catheter (O.D. 0.094 inch, 1.0. 0.054 inch) with an end hole and several side holes is used for thoracic aortography. If possible, the abdominal organs should be examined by selective arteriography. Selective celiac and renal angiography, and superselective hepatic and splenic angiography where indicated can be performed quickly and safely by an experienced angiographic team. Selective and superselective catheterization provides sufficiently superior vascular visualization to justify its use in preference to midstream aortography. Selective renal arteriography is performed by injecting 6 to 8 ml. of Hypaque 50 per cent or Renografin 60 per cent by hand. For other vessels Hypaque M75 or Renografin M76 is injected by a pressure injection machine in the following doses: thoracic or abdominal aorta, 40 to 50 ml.; celiac artery, 60 to 80 ml.; common hepatic or splenic artery, 40 ml. The injection rate for aortography is 20 ml. per second. For selective catheterization, the injection rate should be as rapid as possible without causing recoil of the catheter. To determine the appropriate injection rate, test injections of 1f2 second duration are made under fluoroscopy using varying injection rates. The relatively high volume of contrast medium used to demonstrate the visceral arteries of the abdomen requires a prolonged injection time (5 to 10 seconds). This results in a dense parenchymal blush following the arterial phase. The parenchymal blush, along with the appearance of the arteries and the veins, is diagnostically useful. We have seen no evidence of specific organ toxicity or systemic reaction in any of our patients when these doses and injection rates were used.

RADIOGRAPHIC FINDINGS Splenic Injuries The most specific angiographic sign of splenic hematoma is extravasation of contrast medium (Fig. 1). In the absence of extravasation the hematoma will be seen as a radiolucent defect. 5 • 7 The defect may be irregular or it may be sharp and linear. A linear defect in the splenogram may result from congenitallobulations of the spleen which may be identical to the defect caused by a splenic laceration (Fig. 2). In splenic lobulations the capsule that demarcates the lobules may extend rather deeply into the splenic parenchyma. In this case the arteriogram may show arteries extending to but not across the lobulations. Splenic infarction also may simulate the appearance of a splenic laceration showing a lucent defect in the parenchymal phase. The occluded vessels may appear to be displaced in the arterial phase. If there is a through and through laceration of the splenic capsule into the pulp, extravasation of contrast medium either into the splenic capsule or into the peritoneal cavity will be seen. Increased tortuosity, displacement, and spasm of the splenic artery have been also reported in splenic laceration.5 Arteriovenous shunting within the spleen may also be seen in splenic

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Figure 1. Delayed splenic rupture. A, Intrasplenic arterial branches are splayed and are separated from one another (arrows). Multiple small collections of extravasated contrast medium are present in the upper and lower poles of the spleen. B, Collections of extravasated contrast medium remain opacified in the splenic parenchyma. Numerous areas of relative radiolucency are present, representing intrasplenic hematoma. Indentations in the splenic contour (white arrows) suggest subcapsular hematoma. The diaphragmatic contour is interrupted in the upper pole (black arrow), defining at least one location of splenic capsular rupture.

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Figure 2. Splenic lobulations simulating splenic rupture. A, In the parenchymal phase the splenic contour in the upper and lower thirds is well defined and the blush is homogeneous in the arterioposterior position. A radiolucent defect extends deep within the middle third of the splenic parenchyma ('lrrows). B, In the right posterior oblique projection, the parenchymal phase shows a linear lucency across the middle of the spleen (arrows). In this projection it is very thin and regular, strongly suggesting a splenic lobulation rather than a laceration.

Figure 3. Subcapsular splenic hematoma in a patient following an automobile accident. The splenic vein (arrows) is opacified on selective splenic arteriogram in the right posterior oblique position three seconds after the beginning of injection.

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hematoma (Fig. 3). The splenic vein normally is visualized 5 to 8 seconds after the injection has begun. In arteriovenous communication, the splenic vein will be opacified 1 or 2 seconds after injection of contrast medium in the splenic artery. Displacement of the spleen from the diaphragm or from the flank has been described as a sign of perisplenic hematoma on a plain film of the abdomen. This is a rather unreliable sign, since the normal position of the spleen is quite variable. In a subcapsular hematoma there is an irregular border of the parenchyma with a large area void of capillary vessels to the edge of the splenic silhouette (Fig. 1). There mayor may not be medial displacement of the pulp along with disruption of the normal splenic artery and vein pattern. At least two views of the splenic artery should be obtained in the evaluation of trauma patients. In addition to the routine supine position an additional injection should be made in the left anterior or left posterior position, depending on whether trauma occurred anteriorly or posteriorly. The oblique position pennits visualization of small injuries along the contour of the visualized spleen, where they are more easily identified and evaluated than if they were seen "en face" in the supine position. The oblique position frequently darifies the differentiation between splenic lobulation and splenic laceration. Angiographic signs of splenic hematoma should be apparent in all projections, although they may be seen better in one than in the other. These angiographic findings of splenic injury must be correlated with the clinical picture of the patient. False positives have been reported when adequate views have not been taken for interpretation. The clinical presentation must always be considered when deciding whether an exploratory laparotomy is indicated. Hepatic Injuries Angiographic signs of hepatic injuries have the same degree of reliabilityas splenic angiography.2 Displacement of hepatic arteries and veins with defects in the hepatic parenchyma are seen with intrahepatic hematoma. The usual hepatic architecture is displaced. The vessels are stretched in an abnormally wide arch and some areas are devoid of blood vessels and capillary phase. In any major laceration of the liver, extravasation of the contrast medium indicates significant bleeding, and immediate operation is indicated (Fig. 4). Vessel spasm and arteriovenous shunting can also be seen, usually between the hepatic artery and the portal vein. However, communication between the hepatic artery and the hepatic veins has been reported. 8 Early filling of the portal venous system is indicative of an arteriovenous communication secondary to intraparenchymal damage. Postoperative angiographic evaluation of patients with hepatic injury is directed primarily toward detecting residual deep hematomas, abscesses, and areas of devitalized tissue (Fig. 5). If a hypervascular rim is present around a lucent defect, an intrahepatic abscess should be suspected. In addition to selective hepatic artery injection, splenic artery or su-

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Figure 4. Hepatic laceration and retroperitoneal and pelvic hematoma in a patient with multiple injuries following an automobile accident. A, Arch study showed no abnormality in the aortic arch or descending aorta. However, an extravascular collection of contrast medium is seen superimposed on the liver (arrows) 1 second after opacification of the hepatic artery (vertical arrows). It was not certain from the arteriogram whether the extravasation was within the liver or from injury to intercostal arteries. B, The lumbar arteries on the right side follow a normal undulating course, but on the left they are straightened and depressed (upper black arrows). Several branches of the internal iliac arteries are tortuous and appear to end abruptly (white arrows). Extravasated contrast medium (lower black arrows) appears to be arising from a branch of the right internal iliac artery.

Figure 5. Subcapsular and intraparenchymal hepatic hematoma. A, The arteries to the right lobe of the liver are stretched and attenuated as they reach the periphery of the liver. A dense parenchymal blush is seen near the liver hilus early in the arterial phase. B, The lateral border of the parenchymal blush is quite ill defined and is separated from the flank. A large subcapsular hematoma was present lateral and posterior to the liver.

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perior mesenteric artery injection should be made to establish the patency of the portal venous system within the liver. Potential collateral circulation to the liver is available through the intercostal and lumbar arteries, the left gastric artery, and the inferior phrenic arteries. These vessels may be evaluated by direct selective injection or by midstream aortography.

Renal Injuries The most common method of assessing renal injuries is by intravenous urography. If there is an intrarenal hematoma the renal pelvis may be deformed and the pattern of the renal collecting system may be abnormal. However, in recent years the evaluation of renal injuries with angiography has gained acceptance, especially in patients with generalized blunt trauma to the chest and abdomen and multiple organ injuries. Patients with renal trauma may also have thrombosis of the renal artery or vein (Fig. 6). With angiography, the vascular pattern in the paren-

Figure 6. Traumatic renal artery occlusion. Midstream aortogram shows the stump of the right renal artery which ends abruptly (arrows). An overlying lumbar artery partially obscures the occluded end of the renal artery. Prompt diagnosis of traumatic renal artery injury may permit vascular reconstruction.

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Figure 7. Renal laceration following auto accident. Intravenous urogram showed the injury but did not indicate its extent. A, Arterial phase shows displacement of intrarenal arteries about a broad lucent defect. B, The parenchymal phase shows that the edges of the renal parenchyma adjacent to the defect are fairly sharp superiorly and inferiorly. A renal capsular artery (arrows) is separated from the renal contour indicating subcapsular hematoma. Because of the absence of arteriographic evidence of devitalized tissue, this was interpreted as a renal laceration with intrarenal and subcapsular hematoma without extensi ve devitalization of renal tissue.

chyma and the collecting system is readily outlined with one injection. The vascular pattern is evaluated for any irregularities or displacement of the arterial branches (Fig. 7). As with evaluation of splenic injury, extravasation of contrast medium is pathognomonic of bleeding from a major laceration (Fig. 8). Displacement or compression of major renal vessels may be seen with intraparenchymal or subcapsular hematoma. A nephrographic phase is helpful to define the size and displacement of the kidney from its usual anatomical position. The knowledge that a contralateral kidney is present and functioning is also helpful, since angiography also provides an excretory urogram. Renal trauma can usually be managed without operation unless there is active bleeding. The presence of hematuria is usually not sufficient grounds for exploration of the kidneys. However, angiograms which show renal parenchymal laceration and bleeding will prevent undue delay in operation. Prompt surgery for renal artery occlusion or for renal arteriovenous fistula may avoid irreversible renal ischemia (Fig. 9).

Other Injuries Other injuries often seen in blunt trauma to the abdomen are lesions of the pancreas and duodenum. These organs are fixed in the retroperitoneal space overlying the vertebral column and are usually injured secondary to a blow to the midepigastric area. Direct trauma to this area may cause pancreatic lacerations, traumatic pancreatitis and pseudocyst formation, or intramural hematoma and laceration of the duodenum.

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Figure Figure 8.8. Twenty Twenty year year old old man man with with hematuria hematuria following following blunt blunt trauma tmuma to to his his right rightflank. fianh. .A, A,Intravenous Intravenous urogram urogram shows shows aa decreased decreaseddensity densityof ofcontrast contrast medium medium excreexcretion tion on on the the right. right. This This finding finding isis equivocal, equivocal, since since there there appears appears to to be be no no interruption interruption of of the the renal renal parenchyma parenchyma or or collecting collecting strucstructures, tures, although although the the kidney kidney isis not not optimally optimally visualized. visualized. Because Because of of the the level level of of clinical clinical concern, concern, an an arteriogram artmogram was was performed. performed. B, B, Right Right renal renal arteriogram aTteriogTam anteroposterior anteroposterior projection. projection.AAlaceration lacerationisis present presentacross across the the midportion midportion of of the the kidney. kidney. The The edges edges of of the the renal renal parenchyma parenchyma are are irregular, irregular, suggesting suggesting devitalized devitalized renal renal tissue. tissue. Mottled Mottled lucencies lucencies on on the the nephrogram nephrogram are are seen, seen, particularly particularly in in the the lower lower pole, pole, suggesting suggesting extensive extensive renal renal injury. injury. C, C, Right Right posterior posteTiOT oblique oblique projecprojection. tion. In In aa steep steep obliquity obliquity itit becomes becomes clear clear that thatthe theinjury injury toto the theanterior anterior surface surface of of the the kidney kidneyisis quite quite extensive, extensive, with with considerable considerable devitalization devitalization of ofrenal renal tissue, tissue, and and extravasaextravasation tionof ofcontrast contrast medium medium isis seen seen outside outside the the kidney kidney(arrows). (aTTOWS ).

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Figure 9. Renal arteriovenous fistula. Aortography shows opacification of a large renal vein simultaneously with opacification of the left renal artery. The peripheral renal arteries are poorly opacified, because of arteriovenous shunting of the contrast medium. The renal vein (solid arrows) takes an anomalous course down toward the pelvis before emptying into the inferior vena cava. Beginning opacification of the inferior vena cava (open arrows) is seen on this film.

Angiography defining the gastroduodenal artery, the superior and inferior pancreatic duodenal artery, and the vascular pattern of both the pancreas and the duodenum is helpful in delineating any injuries to this area. The usual vascular pattern is sought for and any deviation from it is interpreted as probable injury. Disruption of the usual vascular pattern in the parenchyma of the pancreas raises the possibility of rupture of the pancreas.

Chest Injuries Angiographic evidence of aortic laceration consists of extravasation of contrast medium outside the confines of the intraluminal space into the adventitia and surrounding tissue. A double lumen anywhere along the course of the aortic arch or the descending thoracic aorta suggests a dissecting aneurysm. There will be a narrow, irregular true lumen if the intramural dissection is not filled by contrast medium. The true lumen will be narrowed by the non-opacified false channel. There will be widening or thickening of the soft tissue of the wall of the injured aorta. If the injury is old, a fusiform or saccular pseudoaneurysm may be

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Figure 10. Traumatic aortic aneurysm. Two weeks following an auto accident, widening of the mediastinum was noted by chest roentogenography. Aortography showed a localized saccular aneurysm distal to the origin of the left subclavian artery (arrow).

seen at the site of aortic laceration (Fig. 10). Traumatic arteriovenous fistula is possible with rib fractures in the thoracic inlet, but is extremely rare.

RESULTS During the past 2 years, arteriography for thoracic trauma has been performed in 70 patients at the San Francisco General Hospital. Fortyseven of these patients had penetrating injuries and arteriography was performed to detect possible lacerations of the aorta or brachiocephalic vessels. The remaining 23 patients had blunt trauma to the chest. Arteriography was within normal limits in 18 of the 23 patients. Of the remaining 5 patients, 1 had arteriographic diagnosis of a false aneurysm of the aorta at the region of the ligamentum arteriosum. One had transection of the subclavian artery, 1 had avulsion of 2 intercostal arteries, 1 had a lacerated internal mammary artery, and the last patient had findings consistent with traumatic occlusion of the internal mammary artery. During the same period, abdominal angiography was performed on 60 patients for trauma to evaluate possible splenic, renal, or hepatic inju-

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ries. Eleven of these patients had penetrating injuries and 49 had blunt trauma to the abdomen. The clinical findings of visceral injury were minimal or equivocal and arteriography was performed to confirlP- the presence or absence of any injury. Thirty of the patients who had arteriography following blunt trauma had normal arteriograms. None of these patients was operated upon, and they all remain clinically well. Eight patients had renal injuries that were detected angiographically; 4 had lacerated kidneys, 2 had occlusions of the main renal artery, 1 had intrarenal aneurysm and 1 had intrarenal infarction. Six patients had abnormalities of the liver. In 5 patients with intrahepatic hematoma demonstrated angiographically, the diagnosis was confirmed by surgery. The remaining 1 patient who was studied postoperatively had an intrahepatic abscess. The arteriographic diagnosis of splenic injury was made in 5 patients. In four cases, splenic hematoma was substantiated at surgery. In 1 patient a single splenic lobulation penetrated deep within the splenic substance. This patient also had overlying rib fractures, severe pain in the left upper quadrant, and a falling hematocrit. At surgery, a deeply penetrating splenic lobulation was found without evidence of a splenic hematoma. This was the only proven false-positive arteriogram in this group of patients.

COMMENTS Angiographic is a safe and relatively simple means of visualizing the internal structure of major organs. This technique finds its major usefulness in the investigation of suspected neoplastic or inflammatory diseases and in the preoperative evaluation of patients for vascular surgery. Angiography in trauma has been widely accepted for evaluation of brain injuries. The usefulness of angiography in the evaluation of visceral injury has been less widely recognized. We believe that, judiciously used, angiography can improve therapy in patients with thoracic and abdominal trauma. Optimal use of angiographic techniques requires close communication between the surgeon and the radiologist, both in the decision of when and how to perform angiography and in the interpretation of the radiographs. In interpreting preoperative angiograms, the emphasis should lean toward the discovery of potential abnormalities. False-positive arteriograms are acceptable, since the morbidity of exploratory laparotomy is minimal but the morbidity of undisclosed visceral injury may be quite high. In patients with equivocal physical findings, a technically satisfactory arteriogram which can be interpreted as entirely normal can prevent an unnecessary laparotomy.

REFERENCES 1. Berk, R. N., and Wholey, M. H.: The application of splenic arteriography in the diagnosis of

rupture of the spleen. Amer. J. Roentgen., 104:662,1968.

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2. Boijsen, E., Kaude, J., and Tylen, U.: Angiography in hepatic rupture. Acta RadioL (Diagn.), 11 : 363, 1971. 3. Freeark, R. J.: Role of angiography in the management of multiple injuries. Surg., Gynec. Obstet., 128:761-771, 1969. 4. Lang, E. K., Trichel, B. E., Turner, R W., Fontenot, R. A., Johnson, B., and Stmartin, E. C.: Renal arteriography in the assessment of renal trauma. Radiology, 98:103-112,1971. 5. Lepasoon, J., and Olin, T.: Angiographic diagnosis of splenic lesions following blunt abdominal trauma. Acta radioL (Diagn.), 11 :257, 1971. 6. Love, L., Greenfield, G. B., Braum, T. W., Moncada, R, Freeark, B. J., and Baker, R J.: Angiography of Splenic Trauma. RadioL, 91 :96, 1968. 7. Lundstrom, B.: Angiographic demonstration of rupture of the spleen. Acta RadioL (Diagn.), 10:145,1970. 8. Redman, H. C., Reuter, S. R, and Bookstein, J. J.: Angiography in Abdominal trauma. Ann. Surg., 169:57-66, 1969. Department of Surgery San Francisco General Hospital 1001 Potrero San Francisco, California 94110