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Prospective Diagnosis of Corona Mortis Hemorrhage in Pelvic Trauma
Volume 23 䡲 Number 4 䡲 April 䡲 2012
571
Figure 1. Sagittal T2-weighted fat-saturated MR images before UAE (a) and 6 months after UAE (b). Note the dramatic decrease in uterine size with only a few small fibroids remaining after spontaneous fibroid expulsion.
Figure 2. Cell-phone photograph taken by the patient of spontaneously expulsed necrotic fibroids collected in an aluminum pan. The size of the largest fibroid tumor near the top of the image was reportedly the size of a pear. (Available in color online at www.jvir.org.)
her large fibroid tumor burden. During the first month after UAE, the patient reported dark bloody vaginal discharge with tissue-like fragments and significant improvement in menorrhagia. She also reported occasional pelvic cramping controlled with nonsteroidal antiinflammatory drugs and a heating pad. During the second month after UAE, the patient reported passing multiple large fibroid tumors over the course of a week, accompanied by a foul-smelling discharge and severe pelvic cramping. Most of these expulsed necrotic fibroids were recovered and collected in an aluminum pan, and a photograph taken by the patient of the expulsed fibroid tumors was submitted to us (Fig 2). The largest fibroid tumor, as reported by the patient, was the size of a pear. No fever or chills were reported, no antibiotics were
prescribed, and no gynecologic fibroid extirpation was required. A follow-up MR imaging study of the pelvis was performed 6 months after UAE (Fig 1b). There was a decrease in overall uterine size from 18 ⫻ 13 ⫻ 18.5 cm before UAE to 9.5 ⫻ 7.5 ⫻ 6.5 cm after UAE. The majority of previously visualized fibroids were no longer present, and the residual fibroids were smaller in size and no longer exhibited contrast enhancement. Our patient’s clinical course concurs with the conclusions of Shlansky-Goldberg and colleagues (1) in that most women experiencing fibroid expulsion after UAE do well. Our patient was able to spontaneously pass multiple large necrotic fibroids without operative intervention. Subsequently, she has experienced only very light menstrual cycles with no pelvic pain, and remains extremely satisfied with her result.
REFERENCES 1. Shlansky-Goldberg RD, Coryell L, Stavropoulos SW, et al. Outcomes following fibroid expulsion after uterine artery embolization. J Vasc Interv Radiol 2011; 22:1586 –1593. 2. Radeleff B, Eiers M, Bellemann N, et al. Expulsion of dominant submucosal fibroids after uterine artery embolization. Eur J Radiol 2010; 75:e57– e63.
Prospective Diagnosis of Corona Mortis Hemorrhage in Pelvic Trauma From: Uei Pua, MBBS, MMed, FRCR, FAMS Li Tserng Teo, MBBS (S’pore), MMed (Surg) FRCS (Edin), FAMS Departments of Diagnostic Radiology (U.P.) and General Surgery (L.T.T.) Tan Tock Seng Hospital 11 Jalan Tan Tock Seng Singapore 308433
572 䡲 Letters to the Editor
Pua and Teo 䡲 JVIR
Figure. (a) CT scan shows hematoma over the right obturator canal (asterisk) and bilateral CM (curved arrows). The latter is in the typical location, crossing over the anterior lip of the acetabulum. Pubic rami fractures and diastasis of the right sacroiliac joint were present (not shown). (b) Right external iliac angiogram shows right CM with the aberrant right obturator artery (white arrow) arising from the right inferior epigastric artery. An area of extravasation over the superior pubic rami is noted (black arrow) and seen more clearly with superselective catheterization of the CM artery (inset). Embolization of the aberrant obturator artery was successfully performed (not shown).
Editor: We read the article, “The Corona Mortis, a Frequent Vascular Variant Susceptible to Blunt Pelvic Trauma: Identification at Routine Multidetector CT,” by Smith et al (1) with much interest. In the article, the authors described the incidence and detection of corona mortis (CM) on multidetector computed tomography (CT) in normal subjects and alluded to the possibility of a positive impact on treatment if CM is detected prospectively in blunt abdominal trauma. A 55-year-old man involved in a motor vehicle accident sustained a pelvic fracture involving the right superior and inferior pubic rami and diastasis of the right sacroiliac joint. During admission, he presented with several episodes of hypotension, and 64-slice multidetector CT at 2.5-mm collimation was performed. Multidetector CT showed the presence of bilateral CM and hematoma in the right obturator canal (Fig, a) with active contrast extravasation from the aberrant right obturator artery, which arose from the right CM. Based on multidetector CT findings, pelvic embolization via a left common femoral artery approach was performed. Angiography confirmed the presence of an aberrant
Neither of the authors has identified a conflict of interest. DOI: 10.1016/j.jvir.2011.12.018
right obturator artery arising from the CM, as a branch distal to the right inferior epigastric artery with active bleed, as per multidetector CT findings (Fig, b). Embolization of the aberrant right obturator artery was performed beyond the origin of the right inferior epigastric artery using gelatin sponge slurry followed by coil embolization (2 mm ⫻ 3 mm VortX coil; Boston Scientific, Natick, Massachusetts) achieving complete stasis. In addition, embolization of active extravasation from a small branch arising from the profunda femoris was performed until stasis using a gelatin sponge slurry followed by coil embolization. Angiography of the right internal iliac artery (IIA) showed no focus of arterial bleeding, and prophylactic embolization using a gelatin sponge slurry was performed until stasis, to avoid collateral flow to the site of the hemorrhage. The patient’s condition stabilized after embolization. He was discharged 4 days later. Our case confirmed the postulation by Smith et al (1) that multidetector CT can detect CM prospectively in patients with blunt abdominal trauma with important treatment implications. First, preoperative knowledge of a CMrelated hemorrhage aids in the decision regarding the site of vascular access; for instance, a “crossover” or contralateral approach may facilitate cannulation of the CM, given that the CM arises in close proximity to the common femoral artery. Second, because the CM arises from the external
Volume 23 䡲 Number 4 䡲 April 䡲 2012
iliac artery (EIA) and not the IIA, prior knowledge of a CM-related bleed helps direct initial angiography toward the EIA territory rather than the IIA territory, the latter being the traditional approach for pelvic embolization in trauma (2). Identification and embolization of the bleeding vessel are expedited, saving crucial time in the context of severe trauma. From our case, interrogation of the EIA territory in the presence of lower pelvic fractures (acetabulum and rami) would seem to be mandatory, regardless of the findings of IIA angiography. This finding is particularly important given that CM can be seen in 30% of patients (1). Further studies using newer “on-table” angiographic techniques such as cone-beam CT or hybrid CT angiography for detection of CM in trauma would be relevant.
REFERENCES 1. Smith JC, Gregorius JC, Breazeale BH, Watkins GE. The corona mortis, a frequent vascular variant susceptible to blunt pelvic trauma: identification at routine multidetector CT. J Vasc Interv Radiol 2009; 20:455– 460. 2. Travis T, Monsky WL, London J, et al. Evaluation of short-term and long-term complications after emergent internal iliac artery embolization in patients with pelvic trauma. J Vasc Interv Radiol 2008; 19:840 – 847.
Early Endovascular Salvage of a Bovine Pericardial Superior Vena Cava Graft From: Charles Ross Tapping, FRCR, MB, ChB (Hons), Bsc (Hons) Shaheen Dixon, FRCR Laura Dias, MRCS Edward Black, FRCS Mark J. Bratby, MRCP, FRCR Departments of Interventional Radiology (C.R.T., S.D., M.J.B.) and Cardiothoracic Surgery (E.B.) Oxford University Hospitals John Radcliffe Hospital, Headington Oxford, OX3 9DU Department of Ear Nose and Throat Surgery (L.D.) Wexham Park Hospital Berkshire United Kingdom
Editor: Thymomas are typically asymptomatic, locally invasive, slow-growing tumors of thymic epithelial cell origin. Better survival in patients with superior vena cava (SVC) involvement has been reported among patients treated with complete resection and reconstruction of the SVC compared with patients with incomplete resection (1). However, complete excision of the tumor and reconstruction of the great vessels is technically difficult. We present a case of combined surgical thrombectomy and endovascular salvage of a bovine pericardial SVC graft with maintained patency at
None of the authors have identified a conflict of interest. DOI: 10.1016/j.jvir.2011.12.019
573
clinical and radiologic follow-up 12 months after the procedure. A 34-year-old man presented in November 2009 with an extensive anterior mediastinal mass with concentric soft tissue deposits throughout the right pleural surfaces and compression of mediastinal vascular structures and major bronchi. After an inadequate response to chemotherapeutics for the type B1 thymoma (stage IV), the patient underwent a right pneumonectomy (extrapleural), thymectomy and removal of SVC, SVC bypass graft (bovine pericardium [Synovis Supple Pericardium; Euromed, Vienna, Austria]) from brachiocephalic vein to right atrial appendage, and resection of the right hemidiaphragm. The patient experienced significant blood loss during the procedure and was transfused with 15 units of packed red blood cells, 4 units of fresh frozen plasma, and 2 units of platelets. The patient’s clinical condition deteriorated 24 hours after the procedure with classic signs and symptoms of SVC obstruction (upper limb and facial swelling). The patient underwent a contrast-enhanced computed tomography (CT) scan, which confirmed thrombosis of the SVC graft (Fig 1, a). A surgical balloon embolectomy was performed, after which he was transferred to the interventional radiology suite. Right cephalic and femoral vein access was established. Venography revealed anastomotic stenoses at the SVC graft with near-static flow. A right internal jugular vein approach was used to traverse the SVC owing to tortuosity. The distal anastomosis was treated with a 28mm-diameter, 60-mm-long sinus-Repo stent (Optimed GmbH, Ettingen, Germany), and the proximal anastomosis was treated with a similar 20-mm-long, 60-mm-long selfexpanding uncovered stent (Fig 1, b). No balloon dilation was performed to minimize risk of disruption of the recent surgical anastomoses (Fig 1, c). The patient’s initial clinical recovery was complicated by an episode of acute respiratory distress syndrome and a right-sided empyema, which was treated successfully with video-assisted thoracic surgery. At 12-month follow-up, the patient remained dyspneic but was able to climb a flight of stairs. Repeat contrast-enhanced CT showed patent stents (Fig 1, d). Various biologic and synthetic materials have been used to reconstruct the SVC, including autologous vein, bovine pericardium, polyester, and polytetrafluoroethylene. Endoprosthetic thromboses have been reported to be as high as 86% at 3 years (2) and are often related to anastomotic techniques and type and diameter of prosthesis. Our initial surgical procedure had resulted in highvolume blood loss, and re-exploration of the anastomoses was thought to be hazardous. We thought the thrombus within the SVC might be too extensive to remove by endovascular thrombectomy and that such a device might cause damage to the recently formed anastomoses. Stent placement without thrombus clearance also risked embolization to the left pulmonary artery. A combined approach with surgical thrombectomy, heparinization, and immediate transfer to interventional radiology for primary stent de-
571
Figure 1. Sagittal T2-weighted fat-saturated MR images before UAE (a) and 6 months after UAE (b). Note the dramatic decrease in uterine size with only a few small fibroids remaining after spontaneous fibroid expulsion.
Figure 2. Cell-phone photograph taken by the patient of spontaneously expulsed necrotic fibroids collected in an aluminum pan. The size of the largest fibroid tumor near the top of the image was reportedly the size of a pear. (Available in color online at www.jvir.org.)
her large fibroid tumor burden. During the first month after UAE, the patient reported dark bloody vaginal discharge with tissue-like fragments and significant improvement in menorrhagia. She also reported occasional pelvic cramping controlled with nonsteroidal antiinflammatory drugs and a heating pad. During the second month after UAE, the patient reported passing multiple large fibroid tumors over the course of a week, accompanied by a foul-smelling discharge and severe pelvic cramping. Most of these expulsed necrotic fibroids were recovered and collected in an aluminum pan, and a photograph taken by the patient of the expulsed fibroid tumors was submitted to us (Fig 2). The largest fibroid tumor, as reported by the patient, was the size of a pear. No fever or chills were reported, no antibiotics were
prescribed, and no gynecologic fibroid extirpation was required. A follow-up MR imaging study of the pelvis was performed 6 months after UAE (Fig 1b). There was a decrease in overall uterine size from 18 ⫻ 13 ⫻ 18.5 cm before UAE to 9.5 ⫻ 7.5 ⫻ 6.5 cm after UAE. The majority of previously visualized fibroids were no longer present, and the residual fibroids were smaller in size and no longer exhibited contrast enhancement. Our patient’s clinical course concurs with the conclusions of Shlansky-Goldberg and colleagues (1) in that most women experiencing fibroid expulsion after UAE do well. Our patient was able to spontaneously pass multiple large necrotic fibroids without operative intervention. Subsequently, she has experienced only very light menstrual cycles with no pelvic pain, and remains extremely satisfied with her result.
REFERENCES 1. Shlansky-Goldberg RD, Coryell L, Stavropoulos SW, et al. Outcomes following fibroid expulsion after uterine artery embolization. J Vasc Interv Radiol 2011; 22:1586 –1593. 2. Radeleff B, Eiers M, Bellemann N, et al. Expulsion of dominant submucosal fibroids after uterine artery embolization. Eur J Radiol 2010; 75:e57– e63.
Prospective Diagnosis of Corona Mortis Hemorrhage in Pelvic Trauma From: Uei Pua, MBBS, MMed, FRCR, FAMS Li Tserng Teo, MBBS (S’pore), MMed (Surg) FRCS (Edin), FAMS Departments of Diagnostic Radiology (U.P.) and General Surgery (L.T.T.) Tan Tock Seng Hospital 11 Jalan Tan Tock Seng Singapore 308433
572 䡲 Letters to the Editor
Pua and Teo 䡲 JVIR
Figure. (a) CT scan shows hematoma over the right obturator canal (asterisk) and bilateral CM (curved arrows). The latter is in the typical location, crossing over the anterior lip of the acetabulum. Pubic rami fractures and diastasis of the right sacroiliac joint were present (not shown). (b) Right external iliac angiogram shows right CM with the aberrant right obturator artery (white arrow) arising from the right inferior epigastric artery. An area of extravasation over the superior pubic rami is noted (black arrow) and seen more clearly with superselective catheterization of the CM artery (inset). Embolization of the aberrant obturator artery was successfully performed (not shown).
Editor: We read the article, “The Corona Mortis, a Frequent Vascular Variant Susceptible to Blunt Pelvic Trauma: Identification at Routine Multidetector CT,” by Smith et al (1) with much interest. In the article, the authors described the incidence and detection of corona mortis (CM) on multidetector computed tomography (CT) in normal subjects and alluded to the possibility of a positive impact on treatment if CM is detected prospectively in blunt abdominal trauma. A 55-year-old man involved in a motor vehicle accident sustained a pelvic fracture involving the right superior and inferior pubic rami and diastasis of the right sacroiliac joint. During admission, he presented with several episodes of hypotension, and 64-slice multidetector CT at 2.5-mm collimation was performed. Multidetector CT showed the presence of bilateral CM and hematoma in the right obturator canal (Fig, a) with active contrast extravasation from the aberrant right obturator artery, which arose from the right CM. Based on multidetector CT findings, pelvic embolization via a left common femoral artery approach was performed. Angiography confirmed the presence of an aberrant
Neither of the authors has identified a conflict of interest. DOI: 10.1016/j.jvir.2011.12.018
right obturator artery arising from the CM, as a branch distal to the right inferior epigastric artery with active bleed, as per multidetector CT findings (Fig, b). Embolization of the aberrant right obturator artery was performed beyond the origin of the right inferior epigastric artery using gelatin sponge slurry followed by coil embolization (2 mm ⫻ 3 mm VortX coil; Boston Scientific, Natick, Massachusetts) achieving complete stasis. In addition, embolization of active extravasation from a small branch arising from the profunda femoris was performed until stasis using a gelatin sponge slurry followed by coil embolization. Angiography of the right internal iliac artery (IIA) showed no focus of arterial bleeding, and prophylactic embolization using a gelatin sponge slurry was performed until stasis, to avoid collateral flow to the site of the hemorrhage. The patient’s condition stabilized after embolization. He was discharged 4 days later. Our case confirmed the postulation by Smith et al (1) that multidetector CT can detect CM prospectively in patients with blunt abdominal trauma with important treatment implications. First, preoperative knowledge of a CMrelated hemorrhage aids in the decision regarding the site of vascular access; for instance, a “crossover” or contralateral approach may facilitate cannulation of the CM, given that the CM arises in close proximity to the common femoral artery. Second, because the CM arises from the external
Volume 23 䡲 Number 4 䡲 April 䡲 2012
iliac artery (EIA) and not the IIA, prior knowledge of a CM-related bleed helps direct initial angiography toward the EIA territory rather than the IIA territory, the latter being the traditional approach for pelvic embolization in trauma (2). Identification and embolization of the bleeding vessel are expedited, saving crucial time in the context of severe trauma. From our case, interrogation of the EIA territory in the presence of lower pelvic fractures (acetabulum and rami) would seem to be mandatory, regardless of the findings of IIA angiography. This finding is particularly important given that CM can be seen in 30% of patients (1). Further studies using newer “on-table” angiographic techniques such as cone-beam CT or hybrid CT angiography for detection of CM in trauma would be relevant.
REFERENCES 1. Smith JC, Gregorius JC, Breazeale BH, Watkins GE. The corona mortis, a frequent vascular variant susceptible to blunt pelvic trauma: identification at routine multidetector CT. J Vasc Interv Radiol 2009; 20:455– 460. 2. Travis T, Monsky WL, London J, et al. Evaluation of short-term and long-term complications after emergent internal iliac artery embolization in patients with pelvic trauma. J Vasc Interv Radiol 2008; 19:840 – 847.
Early Endovascular Salvage of a Bovine Pericardial Superior Vena Cava Graft From: Charles Ross Tapping, FRCR, MB, ChB (Hons), Bsc (Hons) Shaheen Dixon, FRCR Laura Dias, MRCS Edward Black, FRCS Mark J. Bratby, MRCP, FRCR Departments of Interventional Radiology (C.R.T., S.D., M.J.B.) and Cardiothoracic Surgery (E.B.) Oxford University Hospitals John Radcliffe Hospital, Headington Oxford, OX3 9DU Department of Ear Nose and Throat Surgery (L.D.) Wexham Park Hospital Berkshire United Kingdom
Editor: Thymomas are typically asymptomatic, locally invasive, slow-growing tumors of thymic epithelial cell origin. Better survival in patients with superior vena cava (SVC) involvement has been reported among patients treated with complete resection and reconstruction of the SVC compared with patients with incomplete resection (1). However, complete excision of the tumor and reconstruction of the great vessels is technically difficult. We present a case of combined surgical thrombectomy and endovascular salvage of a bovine pericardial SVC graft with maintained patency at
None of the authors have identified a conflict of interest. DOI: 10.1016/j.jvir.2011.12.019
573
clinical and radiologic follow-up 12 months after the procedure. A 34-year-old man presented in November 2009 with an extensive anterior mediastinal mass with concentric soft tissue deposits throughout the right pleural surfaces and compression of mediastinal vascular structures and major bronchi. After an inadequate response to chemotherapeutics for the type B1 thymoma (stage IV), the patient underwent a right pneumonectomy (extrapleural), thymectomy and removal of SVC, SVC bypass graft (bovine pericardium [Synovis Supple Pericardium; Euromed, Vienna, Austria]) from brachiocephalic vein to right atrial appendage, and resection of the right hemidiaphragm. The patient experienced significant blood loss during the procedure and was transfused with 15 units of packed red blood cells, 4 units of fresh frozen plasma, and 2 units of platelets. The patient’s clinical condition deteriorated 24 hours after the procedure with classic signs and symptoms of SVC obstruction (upper limb and facial swelling). The patient underwent a contrast-enhanced computed tomography (CT) scan, which confirmed thrombosis of the SVC graft (Fig 1, a). A surgical balloon embolectomy was performed, after which he was transferred to the interventional radiology suite. Right cephalic and femoral vein access was established. Venography revealed anastomotic stenoses at the SVC graft with near-static flow. A right internal jugular vein approach was used to traverse the SVC owing to tortuosity. The distal anastomosis was treated with a 28mm-diameter, 60-mm-long sinus-Repo stent (Optimed GmbH, Ettingen, Germany), and the proximal anastomosis was treated with a similar 20-mm-long, 60-mm-long selfexpanding uncovered stent (Fig 1, b). No balloon dilation was performed to minimize risk of disruption of the recent surgical anastomoses (Fig 1, c). The patient’s initial clinical recovery was complicated by an episode of acute respiratory distress syndrome and a right-sided empyema, which was treated successfully with video-assisted thoracic surgery. At 12-month follow-up, the patient remained dyspneic but was able to climb a flight of stairs. Repeat contrast-enhanced CT showed patent stents (Fig 1, d). Various biologic and synthetic materials have been used to reconstruct the SVC, including autologous vein, bovine pericardium, polyester, and polytetrafluoroethylene. Endoprosthetic thromboses have been reported to be as high as 86% at 3 years (2) and are often related to anastomotic techniques and type and diameter of prosthesis. Our initial surgical procedure had resulted in highvolume blood loss, and re-exploration of the anastomoses was thought to be hazardous. We thought the thrombus within the SVC might be too extensive to remove by endovascular thrombectomy and that such a device might cause damage to the recently formed anastomoses. Stent placement without thrombus clearance also risked embolization to the left pulmonary artery. A combined approach with surgical thrombectomy, heparinization, and immediate transfer to interventional radiology for primary stent de-