Figura 1. Abdominal computed tomography. A. Preoperative. Arrows mark the area of liver laceration ...

Figura 2. A. Selective hepatic arteriography. Arrows indicate sites of active bleeding in the right ...

Figura 3. A. Hepatic arteriography. Control. B. Hepatic venography. Late phase. Arrows indicate tiss...

Figura 4. Abdominal computed tomography. A. Venous liver pre-embolization. B. Post-embolization foll...

Introduction

Over the last few years, nonsurgical management of trauma-induced vascular lesions of solid abdominal viscera through angioembolization (AE) has been gaining more ground.1 This is the case of a patient with late bleeding after surgery and transarterial embolization of the liver.

Clinical case

We present the case of a 15-year-old male patient admitted with polytrauma in the traffic accident setting (motorcyclist). The patient presents with close abdominal trauma with grade III liver laceration as seen on the computed tomography (CT) scan.2 (Figure 1A)

He immediately underwent surgery due to his compromised hemodynamic status and the presence of hemoperitoneum. The surgical team performed liver packing with an early good clinical response. The patient progressed into a postoperative low hematocrit associated with clinical and tomographic signs of re-bleeding (Figure 1B).

The abdominal arteriography performed via right femoral access revealed signs of active bleeding in branches of the right hepatic artery (Figure 2A). Superselective embolization with gelatin sponge followed (Spongostan™; Ferrosan Medical Devices A/S, Søborg, Denmark) through a 5-Fr Cobra hydrophilic catheter (Radiofocus™ Glidecath™; Terumo Medical Corporation, Tokyo, Japan), and a 2.8-Fr microcatheter (Progreat™; Terumo Medical Corporation, Tokyo, Japan) with satisfactory results (Figure 2B).

Sometime later (25 days later), the patient shows new signs of anemia and bleeding on the CT scan (Figure 4A). The new arteriography performed reveals no signs of bleeding (Figure 3A). However, the hepatic venography performed via right jugular access reveals signs of minor tissue bleeding coming from the right supra-hepatic vein (Figure 3B). The heart team decided a new percutaneous endovascular strategy.

The right supra-hepatic vein was selectively catheterized via right jugular access with a 5-Fr catheter for visceral angiography (Imager™ II; Boston Scientific Corporation; Massachusetts, United States). Another 10 mm x 40 cm fiber coil was successfully released through the catheter in a controlled way (Interlock™; Boston Scientific Corporation; Massachusetts, United States) with good results (Figure 3C).

The patient’s favorable progression has been confirmed both in-hospital and at the long-term follow-up with a good correlation of clinical signs and imaging modality findings as Figure 4B shows.

Discussion

AE is seen as part of the nonsurgical management of trauma-induced vascular lesions of solid abdominal viscera such as the liver. It is indicated in hemodynamically stable patients without peritoneal signs.³

In the case of unstable patients, as in our clinical case, the early surgical management is advised. However, there is no consensus in the medical literature on how to act when this procedure fails. Much less in situations where both techniques fail.

When indicated, AE has a 93% success rate stopping arterial bleeding, which proves it is an effective approach. The possible complications described in the medical literature are hepatic necrosis, 14.9%; hepatic abscess, 7.5%; bilioma/biliary leak, 15.2%, and vesicular infarction, 7.4%. 

Procedural failure, defined by immediate bleeding (6.9%), is associated with several problems that may lead to incomplete target vessel embolizations such as celiac trunk stenosis, impossible selective catheterization due to numerous anatomical curves, and persisting myocardial blush without an identifiable vessel or due to numerous nonembolizable collateral branches. Also, the presence of severe vascular lesions is associated with procedural failure in such a way that the predictors of failure are intraperitoneal contrast extravasation and hemoperitoneum in multiple abdominal compartments. On the other hand, the predictors of success are low-grade hepatic or intraparenchymal lesions with capsular retraction.

These patients’ survival depends on the degree of tissue lesion, damage to the biliary tract, and additional compromise of other viscera and systems due to polytrauma and complications.

Hepatic event-related mortality in embolized patients is somewhere around 5.6% (range between 0% and 12%) according to different series published to this date.

Also, there are scenarios where failure of the nonsurgical management is reported despite successful arterial AE, as it was our case. This makes us think of juxtahepatic venous injuries whose clinical sign is late bleeding, which is also the leading cause of death.⁴

The presence of clinical factors like abdominal pain, low hematocrit, elevated transaminase levels, peritoneal signs, persistent systemic inflammatory response, and jaundice are all markers of suspected re-bleeding—which although rare (2.8% to 3.5%)—is of vital importance; performing a computed tomography scan here is mandatory.¹

A hybrid approach has been proposed in the medical literature: AE to treat arterial bleeding plus laparotomy with packing to treat juxtahepatic venous injuries.³

However, in our case, our suspect was intrahepatic venous injury and here surgical treatment is limited considering that hepatectomy, although partial, would be adding significant morbidity and mortality.⁵

And this is how the concept of hepatic vein embolization (HVE) was born. However, up until now, there are only two classic indications for this therapy: scheduled pre-hepatectomy to facilitate the formation of interlobar venous collateral branches and combined with portal embolization (sequentially) to increase the volume of the future hepatic remnant. Both indications have been described for the management of liver cancer.⁶

The physiological bases of this technique rest on hepatic hemodynamic changes where two mechanisms of tolerance are produced: retrograde portal venous drainage in an early stage, and the development of intrahepatic venous collateral branches that become established within the first two weeks after the procedure4. 

These means of compensation contribute to tolerate venous occlusion as long as it is segmental and selective.

Conclusions

The HVE is a rare procedure that should be performed in the liver cancer setting only.⁴

This is the first case ever reported in the trauma setting with satisfactory results and no complications, which proves it is a safe and decisive procedure in cases of failed surgeries. 

1. Stassen, et al. Nonoperative management of blunt hepatic injury: An Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012;73:S88-S93.

2. Liver injury scale – The American Association for the Surgery of Trauma. http://www.aast.org/Library/TraumaTools/InjuryScoringScales.aspx#liver.

3. Green C, et al. Outcomes and complications of angioembolization for hepatic trauma: a systematic review of the literature. J Trauma Acute Care Surg 2016;80(3):529-37.

4. Madoff, et al. Venous Embolization of the Liver. 2011. Textbook. Cap. 19;169-75.

5. Coccolini, et al. Liver trauma: WSES 2020 guidelines. World J Emerg Surg 2020;15: 24. https://doi.org/10.1186/s13017-020-00302-7.

6. Shin Hwang, et al. Preoperative Sequential Portal and Hepatic Vein Embolization in Patients with Hepatobiliary Malignancy. World J Surg 2015; DOI 10.1007/s00268-015-3194-2.

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Endovascular therapeutic options for vascular liver lesions. Case report

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