Embolization Therapy: Principles and Clinical Applications, 1 Ed.

Spine and Bone Trauma

Pierre E. Bize • Yann Lachenal • Alban Denys

Transcatheter arterial embolization (TAE) has proven to be useful in the treatment of hemodynamically stable polytrauma patients.1,2 It has also proven to be useful in selected hemodynamically unstable patients who responded at least transiently to fluid resuscitation.3,4 However, the place of TAE in the treatment algorithm of polytrauma patients remains to be defined.512 TAE has several advantages in selected trauma patients. It can control several sources of bleeding from one single vascular puncture, avoiding unnecessary surgical exposure in those fragile patients, thus avoiding hypothermia, which is often a problem in this setting. It can be performed in the angiography suite while other resuscitation maneuvers are carried on. It can be performed without major risks in patients with impaired coagulation, which is also quite frequent in polytranfused patients. As opposed to solid organ or pelvic bone fractures, there is little information on the role of TAE in the treatment of paraspinal bleeding associated with spine trauma or with fractures of other bones such as in the limbs.1321

DEVICE AND MATERIALS

Bleeding associated with spine or bone fractures is usually of osseous or venous origin and is self-limited. However, some cases of bleeding from an arterial injury can be associated with significant blood loss. Arterial bleeding in the paraspinal space and in the limbs may have originated from muscular branches and thus can be embolized with gelatin sponge or even glue. Particulate agents such as Bead Blocks (Biocompatible, Farnham UK) are not usually recommended because they might cause ischemia and rhabdomyolysis. Coils are convenient when there is a single well-identified vessel that can be selectively catheterized, such as the intercostal or the lumbar arteries. However, when using coils, one should use the “front door/back door” embolization technique to prevent further bleeding from retrograde flow. This technique consists of placing the coil beyond and before the vascular lesion. However, glue and gelatin sponge are perfectly suitable in this particular situation, with the advantage of being able to control the bleeding from both the antegrade and retrograde flow more quickly and at a lower cost.

TECHNIQUE

The target vessel should be identified from the computed tomography (CT) with contrast as it might be difficult to identify bleeding vessels by digital subtraction angiography (DSA) in hypotensive patients. Arterial access is gained usually from one of the common femoral arteries. When bleeding from a lower limb is present and other vessels need to be embolized, it is best to choose the contralateral common femoral artery and to catheterize the bleeding side by crossover. Antegrade puncture of the common femoral artery on the bleeding side is not convenient as it will render catheterization of other bleeding vessels uneasy if not impossible. In case of nonpalpable pulse, ultrasound guidance should be used promptly. The Seldinger technique is used to gain vascular access, and a 5-Fr or 6-Fr introducer sheath is inserted in the common femoral artery. The choice of catheter curvature will depend on the vessel to be embolized. A Cobra C2 (Glidecath, Terumo Europe, Leuven Belgium) catheter usually allows catheterization of the lumbar arteries and also allows crossover to the contralateral iliac and femoral arteries. Vascular anomalies such as irregular vessel walls, dissection, pseudoaneurysm, or active bleeding should be looked for by selective catheterization using a 4-Fr or 5-Fr catheter. If no abnormality and no active bleeding is seen in the suspected vascular territory, a forceful hand injection can reveal the bleeding from an injured vessel, which was occluded by spasm, dissection, or clot. In case of superselective catheterization, a microcatheter allowing the use of 0.018-in coils should be used. In case of embolization of a lumbar artery with coils, care should be taken to embolize the lumbar arteries above and below the bleeding level to avoid retrograde filling of the embolized artery by collateral flow from the upper and lower levels.

In the paraspinal space, always look for spinal arteries, especially in the dorsolumbar region. The anterior and posterior spinal arteries supply the spinal cord. The anterior spinal artery receives blood from a large segmental vessel originating from one of the last intercostal arteries known as the Adamkiewicz artery (typically located between the vertebral bodies T8–L2 segment). The posterior spinal artery receives many segmental feeders known as the radiculospinal arteries, which can be recognized by their “hairpin” shape on angiography (Fig. 25.1). When present, embolization should take place from beyond the origin of the radiculospinal artery. Coils or large gelatin sponge torpedoes are best used in this situation. If particulate agents are to be used, they should be greater than 350 µm in size.22

CLINICAL APPLICATIONS

TAE of arterial bleeding associated with spine or peripheral bone fracture can be convenient in patients with other bleeding sites that also need to be treated by embolization or in patients with altered coagulation status. One typical scenario is a patient with a ruptured spleen associated with rib and lumbar transverse apophysis fractures. Another scenario would be a patient with a fractured bone and an impaired coagulation status. TAE could resolve the hemorrhage quickly while the coagulation status is restored before reparative surgery.

Bleeding in the Paraspinal Space

In trauma patients, bleeding in the paraspinal space is usually associated with vertebral fractures. Paraspinal bleeding originates mostly from the broken bone itself or from the azygos and hemiazygos veins and perispinal venous plexuses. These bleeding sources are not amenable to embolization, but they are usually self-limiting.19 However, bleeding in the paraspinal space when associated with bleeding in other territories can lead to significant blood loss.21,23 Care should be taken to look for an arterial bleeding source when interpreting a CT scan in a polytrauma patient with a significant hematoma in the paraspinal space. In the absence of other sources of bleeding such as the renal or the internal iliac arteries and their branches, the most frequently involved arteries in this setting are the intercostal and lumbar arteries.21,23,24 If the bleeding vessel can be identified from multislice CT imaging, TAE can be used to control bleeding in the paraspinal space. TAE is particularly useful in patients with other bleeding sites. As it is the case for abdominal organ lesions, a good CT with arterial enhancement and multiplanar reconstruction will guide the embolization procedure and make it quicker and easier, avoiding the time-consuming catheterization of all lumbar and pelvic arteries. Figure 25.2 displays the case of a woman on anticoagulants with a vertebral fracture and paraspinal hematoma with active bleeding treated by TAE. Another interesting use of TAE is the treatment of bleeding from penetrating wounds such as stab wounds or gunshot wounds.1,18,25 When surgery is not absolutely mandatory, such as in case of hollow viscus perforation, TAE can avoid surgery and quickly control bleeding from the injured vessels. Figure 25.3 displays the case of a patient who sustained a stab wound in the paraspinal region and was treated by TAE only.

Bleeding Associated with Trauma of the Limbs

Most bleeding associated with bone fracture are from osseous or venous origin and is self-limited. However, in case of a penetrating injury, fractures, and joint dislocation, arterial lesions can occur and should be searched for. Angiography is considered to be excellent in revealing vascular lesions in the extremities. These lesions consist of occlusion, extravasation, pseudoaneurysm, and arteriovenous fistula. Intraluminal filling defects such as thrombi and intimal flaps can also be visualized.1

The bleeding in limb trauma can fall in two categories: (1) major vessel injuries, such as the superficial femoral artery or the brachial artery, with immediate threat for the involved limb; and (2) bleeding from secondary muscular branches. The first category is definitely not to be treated by any kind of endovascular procedure but necessitates immediate surgical vascular repair. If surgery is not immediately available or feasible, a tourniquet should be used to control the bleeding. In the second category, muscular bleeding is usually self-limited by tamponade effect from the muscular fascia and might not necessitate TAE. TAE might become necessary if there is evidence of growing hematoma, compartment syndrome, or impaired coagulation status. However, even in these cases, surgery has the advantage of addressing the compartment syndrome that often results from accumulation of large quantities of blood in the fascia by performing fasciotomies. When the fascia is ruptured, such as in an open trauma, TAE can be an option if direct surgical control of the bleeding cannot be performed immediately.

Upper Extremity

The brachial artery should not be embolized as it supplies blood to the hand and the collateral supply at this level is usually not sufficient to preserve viability of the hand territory. Segments of the ulnar and radial arteries can be embolized with coils after angiographic confirmation that the palmar arch is patent. Glue, gelatin sponge, and particulate agents should definitely not be used in the upper limbs because they will cause irreversible ischemia in the hands.22 Muscular branches in the upper extremity can be embolized without risk due to extensive collateralization.

Lower Extremity

The common and superficial femoral arteries should not be embolized as they supply the lower extremity and their occlusion could result in irreversible ischemic damage. The deep femoral artery should be preserved whenever possible as it also contributes in an important way to the perfusion of the lower extremity. Superselective embolization of muscular branches, leaving the main trunk patent, is the preferred way to perform TAE in this territory. In case of cataclysmic bleeding from the deep femoral artery, a transient embolic agent such as gelatin foam should be used. Below the knee, one vessel of the trifurcation is considered sufficient to maintain sufficient perfusion in the foot. Surgical repair of these vessels is considered difficult and surgical treatment often consists of ligation of the injured vessel. Hence, embolization is an alternative as long as one vessel is patent. In case of disruption, the front door/back door technique should be used to prevent continuous bleeding from retrograde flow.

POTENTIAL COMPLICATIONS

The most common complication after embolization of a muscular arterial territory is ischemia and rhabdomyolysis, often accompanied by pain and inflammatory syndrome. Paresis or even paralysis of the treated limb can occur due to nerve ischemia from TAE.26

In the paraspinal space, the most dreadful complication is paraplegia from inadvertent embolization of a spinal artery.19 To avoid the risk of spinal cord ischemia, spinal branches from the segmental arteries should be sought for and embolization should be performed as distally as possible.

TIPS AND TRICKS

Paraspinal Space

 

• Bleeding in the paraspinal space originates mostly from broken bone and veins. These bleeding sources are not amenable to embolization but usually self-limited. Embolize only when there’s a good reason.

• Anticoagulation therapy

• Multiple bleeding sites

• Bleeding vessel clearly identified on CT

• Use coaxial microcatheter technique to navigate through potentially small and tortuous arteries

• Special attention should be paid to the T8–L2 level where the Adamkiewicz artery may be. Embolization of this artery may lead to paraplegia due to ischemia of the spinal cord.

• Perform superselective and precise embolization as close as possible to the target lesion.

• The posterior spinal artery feeders can have a hairpin shape on DSA (Fig. 25.3).

• Preferably use coils for precise embolization, which should take place from beyond the origin of the radiculospinal artery.

Limbs

 

• Bleeding associated with bone fracture are from osseous or venous origin and self-limited.

• In case of a penetrating injury, fractures, and joint dislocation, look for arterial lesions.

• Major vessel injuries with immediate threat for the involved limb

• Immediate surgical vascular repair

• If surgery is not an option, a tourniquet should be used to control the bleeding.

• Bleeding from secondary muscular branches is usually self-limited; embolize when with the following:

• Growing hematoma

• Altered coagulation status

• Multiple bleeding sites

• Surgery is the best choice in case of compartment syndrome.

• Do not occlude the brachial and common and superficial femoral arteries.

• Always check collaterals and assess blood supply to the extremity of the limb.

CONCLUSION

The use of TAE in trauma patients with bleeding in the paraspinal space or in the limbs is marginal. However, in certain situations such as in those patients with multiple bleeding sites or those under anticoagulation treatment, TAE could be an efficient way to limit blood loss. Special care should be taken in the paraspinal space to not embolize any spinal artery and in the limbs to not cause ischemia distally.

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