Endovascular Occlusive Intervention in the Management of Trauma

Endovascular Occlusive Intervention in the Management of Trauma Stanley R. Klein, MD, C. Mark Mehringer, MD, Frederic S. Bongard, MD, Torrance, California

This report summarizes a 10-year experience (1978-1 987) in a metropolitan hospital with 102 patients sustaining a variety of complex or inaccessible vascular injuries. Management included the application of occlusive interventional arteriographic techniques. Regional injuries included head and neck (56%), trunk (13%), and extremity (32%). Techniques of vascular occlusion were often performed in conjunction with the initial arteriographic evaluation and were comprised of particulate embolization (42%), placement of mechanical devices (36%), or tissue adhesives YO), or a combination (21%). There were no deaths in this series and the only complications included four cases of dislodgement of the occlusive agent. We demonstrate that endovascular occlusion is a useful, safe and efficacious procedure in selected patients with complex, inaccessible or life-threatening vascular trauma. (Ann Vasc Surg 1990;4:424-430).

KEY WORDS: Vascular trauma; occlusive interventional angiography; endovascular occlusion.

Traumatic vascular injuries include a spectrum of vessel disruption, false aneurysm formation, and arteriovenous fistula [I]. Such injuries may result from either closed or penetrating trauma and their presentation can be either immediate or delayed. Significant progress in the management of vascular trauma has evolved during the past three decades, largely as a result of the experience gained during military conflicts. The established principles of management for the majority of peripheral arterial injuries include, when appropriate, arteriography From the Departments of Surgery and Radiology, Harbor-UCLA Medical Center and the University of California, Los Angeles, California. Presented at the Eighth Annual Meeting of the Southern California Vascular Surgical Society, Santa Barbara, California, September 9, 1989. Reprint requests: Stanley R. Klein, MD, Division of Vascular Surgery, Department of Surgery, Box 15, Harbor-UCLA Medical Center, 1000 West Carson Street, Torrance, California 90509. 424

for localization of the lesion and either observation or surgical intervention [ 11. In many instances of vascular injury, standard surgical treatment is efficacious, but in others the location and complex nature of the injury or coexistence of remote trauma, may make surgery difficult or unacceptably hazardous. Since the initial report by Rosch in 1972 of successful clinical application of transcatheter embolic therapy in a patient with right gastroepiploic arterial bleeding, there have been many reports of successful applications of intravascular occlusive therapy [2-71. In selected circumstances of vascular trauma the failure and morbidity associated with standard surgical therapy lead us to apply a variety of endovascular occlusive techniques either as an adjunct to facilitate surgery or as definitive treatment in an effort to reduce morbidity and mortality. The present study was undertaken to analyze the factors influencing the application of endovascular occlusive techniques and to delineate the indications, expectations and potential pitfalls of this

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TABLE I.-Mechanism of injury Treatment group Nonpenetrating Penetrating Stab Gunshot

Head/Neck (n = 57) 11

Trunk (n = 13) 4

Extremity (n = 32) 9

9 37

5 4

8 15

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their presence impacted management of the vascular injury (Table 11). A total of 32 (31%) patients (19 head and neck; nine truncal; four extremity) had an initial surgical procedure prior to management of their lesion with either transcatheter occlusive therapy alone or in conjunction with a second surgical procedure. Occlusive materials and techniques

modality in the successful management of complex and otherwise inaccessible peripheral vascular injury.

PATIENTS AND METHODS Types of injury

During a 10-year period (1978-1987) 102 patients were admitted to the Harbor-UCLA Medical Center after sustaining a variety of insults resulting in a series of vascular injuries whose treatment had previously failed or had not lent themselves to correction using standard surgical management. Of this group, 57 (56%) had head and neck lesions, 13 (13%) demonstrated truncal vascular lesions, and 32 (31%) had extremity arterial injury. Hospital records, interventional arteriographic investigations, and operative procedures were analyzed for this group of patients. The majority of the patients were male (74%) and their ages ranged from 17 to 61 (mean, 34.7 years). They were evaluated and treated at varying intervals following the initial injury (range one week to five years). The mechanism of trauma for each anatomic region is depicted in Table I. The clinical diagnosis of arterial injury was often not evident or was obscured at the time of presentation; as many of these patients exhibited delayed manifestations of vascular injury such as arteriovenous fistula and false aneurysms (Table 11). Accompanying remote significant injuries were noted when

A large variety of occlusive materials and delivery systems for vascular occlusive therapy have been developed and previously described [5-141. The materials that we have used fall into three general classes including particulate emboli, mechanical devices, and tissue adhesive. For particulate emboli, we prefer polyvinyl alcohol foam (Ivalon*), gelatin sponge (Gelfoam+), or bariumimpregnated silastic microspheres'. The balloon catheters used have been both fixed and detachable. In early cases, a fixed balloon** was used along with occasional spring coilsit. More recently, we have used a detachable Silastic balloon catheter system [lo]. In several instances we have utilized the tissue adhesive isobutyl 2-cyanoacrylates9 to attain relatively quick permanent vessel occlusion. The specific choice of agent and delivery system varies with the clinical setting and particular lesion, as no single agent is optimal in all circumstances. The distribution of the materials and techniques applied in the series are summarized in Table 111. Patient management

Patients resuscitated in the field and brought to Harbor-UCLA Medical Center or those referred for complications of recent injury were considered as candidates for intravascular occlusive techniques provided the vascular lesion was of a complex nature or was situated in a relatively inaccessible area. In all cases selective arteriography was a prerequisite for either adjunctive or definitive occlusive therapy. The delivery system was placed as close to the site of the abnormality as possible, thereby minimizing tissue loss and the potential for reflux of emboli, and at the same time maximizing TABLE 11.-Manifestations of arterial injury the probability of a successful occlusion. The folHead1 lowing examples illustrate the decision-making of Neck Trunk Extremity the clinician (vascular surgeon) in such cases and Finding (n = 57) (n = 13) (n = 32) demonstrate the utility of intraarterial occlusion. Circulatory deficit 0 0 6 We have formulated a treatment strategy based on Pulse deficit 0 5 3 14 13 6 Active hemorrhage Hypotension Central nervous system deficit Arteriovenous fistula False aneurysm Significant remote injury

0 9

10 0

0 0

39 8 10

2 3 3

19 7 0

"Unipoint, Inc., High Point, North Carolina. tUpjohn, Kalamazoo, Michigan. 'American Heyer-Schulte Corporation, Goleta, California. "*Edwards Labs, Santa Anna, California. ttGianturco "Bucrylate

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TABLE Ill.-Summary

of occlusive techniques ~~

Occlusive theraw Particulate emboli Mechanical device - balloons - sprin coil Tissue a hesive Combination

%

Head/ Neck In = 571 15

25 0 0

17

Trunk In = 131 7

Extremity In = 32)

4 0 0 2

5 3

22

0 2

vessel caliber and type of lesion which has widespread applicability and proven validity in a variety of clinical situations:

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fistula (Fig. la). Silastic detachable balloons were used to occlude the right vertebral artery. Follow-up arteriography two weeks later showed complete occlusion of the right vertebral artery (Fig. lb). The patient was transferred to a chronic care facility and died due to sepsis one year later. This case demonstrates the application of the detachable balloon. Their expansile qualities do not require the use of a large catheter or arteriotomy for delivery. Placement prior to surgery allowed for patient stabilization and minimal blood loss at the time of definitive surgical intervention.

Case 2: Extremity injury

A 29-year-old white man suffered two gunshot wounds to the neck. He was found awake and breathing with field vital signs including a blood pressure of 130/80 and pulse of 100. He was unable to move his extremities. On arrival he became apneic and required emergent cricothyroidotomy. Physical examination was compatible with a C-4 transection. A nonexpanding neck hematoma was identified. Aortic arch study revealed a traumatic left vertebral artery occlusion and a right vertebrojugular arteriovenous

A 23-year-old man sustained a type I1 shotgun blast to both lower extremities and buttocks [15]. Physical exam demonstrated a tense right calf with foot drop. Doppler pressures in the distal extremities included a right dorsalis pedis of 110 mm Hg and left of 150 mm Hg. The patient underwent fasciotomy of the right leg plus wound exploration and debridement. A follow-up bilateral lower extremity arteriogram on postoperative day 2 demonstrated an arteriovenous fistula involving the right profunda artery and a nearby venous channel (Fig. 2a). Occlusion of the arteriovenous fistula using a 5-French catheter to deliver an Ivalon sponge was accomplished. A postembolization arteriogram demonstrated obliteration of the fistula. The fasciotomy was closed 10 days later without complication. Eight month follow-up revealed a

a

b

Case 1 : Head and neck injury

Flg. 1. (a) Arch study demonstrating right vertebrojugular arteriovenous fistula (arrow). (b) Arteriogram demonstrates silastic balloon in place with complete occlusion of arterlovenous fistula.

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b

Flg. 2. (a) Right profundaarteriovenousfistula visualized during arterial phase following shotgun blast to both lower extremities and buttocks. (b) Obliteration of arteriovenous fistula using lvalon sponge.

resolving right peroneal nerve palsy, equal distal doppler pressures, and no evidence of a bruit. Ivalon sponge is a nonabsorbable agent which is suitable for the rapid and permanent occlusion of small vessels. Unlike Gelfoam, there is no danger of recanalization. Both Ivalon sponge and Gelfoam allow delivery of a large embolus through a small catheter since these agents expand after leaving the catheter. Ivalon sponge was chosen in this case because of its nonabsorbable character, the size of the fistula, and the fact that the delivery system could be manipulated close to the fistula.

pressure decreased from 160/100 to 120/80. A renal scan one week later demonstrated decreased flow to the left upper pole. At follow-up four months later no recurrent pain, bruit or hematuria was found. The patient remained nonnotensive. Balloons made of silicon are available in sizes ranging from 5.0 mm maximum inflated diameter to 13.0 mm inflated diameter. Smaller vessels may be occluded by detaching the balloon in a partially inflated state. Metrizimide in a concentration slightly hypertonic to blood is used to fill the balloon in order to avoid shrinkage and to allow radiographic localization. To avoid the possibility of early deflation, two or more balloons are often placed sequentially at the site of the embolization.

Case 3: Truncal injury

A 23-ye=-old man presented with hematuria, left flank pain with bruit and hypertension one month after suffering multiple stab wounds. Arteriography demonstrated an arteriovenous fistula in the left kidney. Exploratory laparotomy was undertaken and intrarenal surgical ligation of the fistula was attempted. Because of a persistent bruit, arteriography was repeated five days postoperatively (Fig. 3a). After the man was transferred to our facility, the fistula was found to be patent and two balloons were placed in the renal arteriovenous fistula, resulting in occlusion (Fig. 3b). The patient had immediate relief of pain. He remained afebrile and blood

Case 4: Truncal-lower extremlty injury

A 30-year-old man sustained a gunshot to the right lower quadrant five years prior to admission. Exploratory laparotomy at that time disclosed only a small bowel injury. In the intervening five years, his right leg had slowly enlarged in size and numerous venous varicosities had appeared. Physical exam revealed a harsh thrill in the right groin and an audible bruit in the same location. Rectal examination disclosed a palpable pulsatile mass. Noninvasive arterial studies were normal. An arteriogram

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b

Fig. 3. (a) Arterial phase of arteriogram demonstrating left renal arteriovenous fistula. Multiple clips from previous attempt at surgical control. (b) Closure of fistula after placement of detachable silastic balloons (arrow).

of the right iliac artery showed an enormous false aneurysm in the pelvis which displaced the bladder. It originated from an enlarged right internal iliac artery and communicated primarily with the common iliac vein

(Fig. 4a). Fistula closure was attempted surgically but had to be abandoned because of an inability to control the multiple enlarged arterial and venous channels. On postoperative day 3 the patient underwent occlusion of the

a

b

Fig. 4. (a) Gigantic pelvic pseudoaneurysm involving enlarged right internal iliac artery and emptying primarily into right common iliac vein. Bladder filled with contrast and displaced laterally. (b) Pelvic arteriogram demonstrated complete occlusion of right hypogastric arteriovenous fistula following removal of Fogarty catheter and placement of detachable balloons and 2-cyanoacrylate.

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arteriovenous fistula with a #4 Fogarty balloon catheter, TABLE IV.-Results of intravascular occlusive therapy: head and neck at which time an arteriogram revealed 90% obliteration of the arteriovenous shunting. Subsequent clinical and raSuccessful diographic evaluations showed no migration of the balNo. of Hemostasis/ bon and complete closure of the fistula. Ten days later, Reason for occlusion cases Control the Fogarty balloon was deflated and arteriography demInternal carotid-cavernous 35 35 onstrated persistent occlusion of arteriovenous fistula. sinus fistula Four silicone detachable radiopaque balloons were then Internal carotid-jugular fistula 1 1 placed in the right hypogastric artery both proximal and Internal carotid transection/ 4 4 distal to the site of the previous fistula. Subsequent pelvic laceration arteriography showed complete occlusion of the hypogas- External carotid-cavernous 2 2 tric arteriovenous fistula and a significant decrease in the fistula size of the large pelvic venous pseudoaneurysm (Fig. 4b). External carotid-jugular fistula 2 2 5 5 One week later, the aneurysm was sealed with 2-cy- External carotid-branch transection anoacrylate cement which was placed proximally to the 5 5 balloons which were then punctured percutaneously un- Meningeal arteriovenous fistula 3 3 der fluoroscopy. Arteriography showed complete and Vertebral arteriovenous fistula persistent occlusion of the arteriovenous fistula. Eight months later, the patient’s right leg was no longer swollen, the varicose veins had regressed, and no bruit or Overall follow-up vaned from four weeks to three thrill was present in the groin area. years with a mean of 10 months. Although several The size and complexity of this arteriovenous fistula required the use of three sequential techniques for its extremity intraarterial occlusions were not definitive permanent occlusion: Fogarty balloon catheter to control and required subsequent operative procedures, no inthe fistula and a detachable Silastic balloon with 2- stance of remote recurrence of the initial lesion has cyanoacrylate to seal it. occurred.

RESULTS

DISCUSSION

There were no deaths in this series. Complications were rare and included four cases (4%) in which particulate emboli migrated and produced two strokes, both of which the patients fully recovered from. Additionally, there were two asymptomatic pulmonary emboli. Three minor catheterization hematomas were noted and resolved. In our experience with 102 patients in whom adjunctive or definitive intravascular occlusive techniques were applied, the procedure was “successful” in 95 cases (93%). Success is gauged by cessation of hemorrhage in patients who present with bleeding and obliteration o r facilitation of surgical management in lesions such as arteriovenous fistulae and false aneurysm. In the head and neck region (Table IV), the majority of cases were complex and surgically inaccessible arteriovenous fistulae. All 57 cases of this region were successfully treated. In the cases of posttraumatic hemorrhage, false aneurysm and arteriovenous fistulae occurring in the trunk (Table V) and extremities (Table VI), 38 out of 45 cases were treated successfully (84%). Of the four cases of pelvic posttraumatic hemorrhage requiring greater than six units of blood, all were managed definitively. One very large pelvic false aneurysm required application of a tissue adhesive for complete control (Case 4). Occlusive therapy in the extremities resulted in several instances of dislodgement of the occlusive agent and had the most frequent requirement for a secondary surgical procedure to successfully control the lesion.

Endovascular occlusive therapy is a recognized modality for control of hemorrhage and management of other vascular entities. Management of such lesions may be on either a temporary or permanent basis, and can be applied as the definitive therapy or as an adjunct to surgical intervention. The procedures are relatively simple but necessarily require supraselective meticulous arterial catheterization techniques to avoid the

TABLE V.-Results of intravascular occlusive therapy: trunk

Reason for occlusion Vascular laceration or transection Pelvic fracture requiring greater than six units transfusion Pseudoaneurysm Arteriovenous fistula

No. of cases 5

Hemostasisl Control 4

4

4

2 2

2 2

TABLE V1.-Results of intravascular occlusive therapy: extremities

Reason for occlusion Vascular laceration of transection Pseudoaneurysm Arteriovenous fistula

No. of cases 6

Hemostasisl Control 4

7 19

6 16

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inherent risk of misplaced occluding agents. Occlusive therapy for traumatic vascular lesions has a number of advantages in contrast to traditional surgical management. It can be performed in conjunction with the initial arteriographicevaluation, thus obviating surgical intervention in patients with other remote injuries. Additionally, it can be applied to manage lesions whose inaccessible anatomic location makes them a difficult target for the vascular surgeon. The choice of occlusive agents used in this series is based on vessel caliber and type of lesion under consideration. Our strategy has been that small vessel interruptions and fistulas at a distance from the catheter tip are treated initially with Silastic spheres of 1 to 1.5 mm in diameter. If this does not effect closure of the injured vessel or fistula, larger pieces of polyvinyl alcohol foam (Ivalon sponge) are injected. This material has the property of expanding greatly in size once in contact with blood, hence it usually becomes lodged more proximally in arteries than Silastic spheres. Therefore, when the catheter can be placed in juxtaposition to the injury site, polyvinyl alcohol foam may be used as the initial agent. Gelatin sponge (Gelfoam) alone is used only in those instances where temporary occlusion is acceptable, as there is evidence that recanalization may occur soon after its placement [lo]. For the large vessel arterial injuries, most commonly situated in the head and neck region, we have used detachable Silastic balloon catheters [9]. In cases of arteriovenous fistula the balloons are preferably placed in the fistula without compromise of the arterial lumen. When this is not possible, the fistula is trapped by placing a balloon distally and then proximally on the arterial side (Case 1). If the safety of arterial occlusion is questioned, the involved artery may be temporarily occluded with the balloon before detachment and the patient observed for ischemic symptoms. The maneuverabllity of balloon catheters offers the best opportunity for precise occlusion placement when larger vessels are involved. This is especially true in the management of arteriovenous fistulas. The clinical presentation of patients with vascular trauma requiring intraarterial occlusive therapy is variable. Acute hemorrhage is a frequent indication for occlusive therapy, especially when the origin is relatively inaccessible or surgery has proven unsuccessful (Case 3). However, hemorrhage alone has not been the sole indication for endovascular occlusive therapy. Arteriovenous fistulas frequently are not detected at the time of the initial trauma and gradually develop increasing symptoms (Case 4). Such large lesions, necessarily involving many vascular channels, often prove treacherous for even the most experienced surgeon. Elective endovascu-

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lar control frequently proves definitive or makes operation much less hazardous. Most complications of intravascular occlusive therapy arise from the inadvertent passage of occlusive material into other than target vessels (including pulmonary emboli), usually as a consequence of technical fadure, inexperience, or poor catheter placement. Four such instances occurred in this series, each without serious or permanent sequelae. Other reported complications relate to ischemia and infarction with subsequent infection in the occluded arterial bed [7,8]. Traumatic vascular injuries occasionally result in complex abnormalities that challenge the ingenuity and perseverance of the vascular surgeon. Management of such problems must include an orderly sequence of diagnostic and therapeutic modalities into which endovascular occlusion should be placed. It can safely preserve organ or limb function and minimize morbidity.

REFERENCES 1. RICH NM, SPENCER FC. Vascular trauma. Philadelphia:

W.B. Saunders Company, Inc., 1978. 2. ROSCH J , DOTTER CT, BROWN MJ. Selective arterial embolization. Radiology 1972;102:303-306. 3. KATZEN BT, ROSS1 P, PASSARIELLO R, et al. Transcatheter therapeutic embolization. Rudio(ogy 1976;120:523-531. 4. MATALON TSA, ATHANASOULIS CA, MARGOLIES MN, et al. Hemorrhage with pelvic fractures: efficacy of transcatheter embolization. Am J Roentgen01 1979:133:859-864. 5 . MEHRINGER CM, HIESHIMA GB, GRINNELL VS, et al. Therapeutic embolization for vascular trauma of the head and neck. Am J Neuroradiol 19839:137-142. 6. ATHANASOULIS CA. Therapeutic applications of angiogrdphy. Part 1. N Engl J Med 1980;302: 11 17-1 125. 7. WAGNER WH, LUNDELL CJ, DONOVAN AJ. Percutaneous angiographic embolization for hepatic arterial hemorrhage. Arch Surg 1985;120: 1241-1249. 8. ATHANASOULIS CA. Therapeutic applications of angiography. Part 2. N Engl J Med 1980;302:1174-1 179. 9. BERENSTEIN A , KRICHEFF 11. Catheter and material selection for transarterial embolization: technical considerations. Radiology 1979;132:631-639. 10. HEISHIMA GB, GRINNELL VS, MEHRINGER CM. A detachable balloon for therapeutic transcatheter occlusions. Radiology 1981;138:227-228. 11. VLAHOS L, BENAKIS V, DIMAKAKOS P, et al. A comparative study of degree of arterial recanalization in the kidney of dogs following transcatheter embolization with eight different materials. Eur Urol 1980;6: 180-185. 12. LAYNE TA, FINCK EJ, BOSWELL WD. Transcatheter occlusion of the arterial supply to arteriovenous fistula with Gianturco coils. A m J Roentgeno( 1978;131:1027-1031. 13. THOMPSON WM, JOHNSRUDE IS, JACKSON DC, et al. Vessel occlusion with transcatheter electrocoagulation: initial clinical experience. Radiology 1979;133:335-340. 14. WHOLEY MH. The technology of balloon catheters in interventional angiography. Radiology 1977;125:671-676. 15. SHERMAN RT, PARRISH RA. Management of shotgun injuries: a review of 152 cases. J Trauma 163;3:7&86. 16. DOTTER CT, GOLDMAN ML, ROSCH J. Instant selective arterial occlusion with isobutyl 2-cyanoacrylate. Radiology 1975;I 14~227-230.

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