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Case 1: Lower GI Bleeding | Emoblization: Bleeding and Trauma
Case 1: Lower GI Bleeding | Emoblization: Bleeding and Trauma
angiogrambleedbleedingbleedsbloodcatheterchaptercoilscolonoscopyembolizationembolizeessentiallygroinimaginglowerLower GI BleedmesentericNonepatientspicturepicturesprepscanseriesvessel
Case 2: Upper GI Bleed | Emoblization: Bleeding and Trauma
Case 2: Upper GI Bleed | Emoblization: Bleeding and Trauma
abnormalangiogramarteryaxisbleedingbleedsbloodcatheterceliacchaptercoilscontrastembolizationembolizeendoscopyesophagusFistulagastroduodenalhemoptysishepaticmalformationsmesentericNoneportalsuperiortipsupperUpper GI Bleedvaricesvenousvesselvesselsvomiting
Case 3a: Splenic Trauma | Emoblization: Bleeding and Trauma
Case 3a: Splenic Trauma | Emoblization: Bleeding and Trauma
angiogramangiographybleedingchaptercoilscontrastembolizationembolizeextravasationgradehemodynamicallyimagelacerationlacerationsmicrocatheterNoneorganpainpatientproximalquadrantscanspleensplenicSplenic Traumatrauma
Case 3b: Splenic Laceration | Emoblization: Bleeding and Trauma
Case 3b: Splenic Laceration | Emoblization: Bleeding and Trauma
angiogramarteriesarterychaptercoilsdelayedembolizationgastrichealhemodynamicallyinjurylacerationNonepictureproximalreconstitutionrupturespleensplenicSplenic Lacerationvessels
Case 4a: Renal Trauma | Emoblization: Bleeding and Trauma
Case 4a: Renal Trauma | Emoblization: Bleeding and Trauma
angioangiogramangiographyarteriovenouscenterschaptercoilscontrastembolizationembolizeembolizedextravasationFistulagradehematomahemodynamicallyimageinjurieskidneyNoneparenchymapatientspenetratingpictureposteriorrenalRenal Traumaretroperitoneumscanspleensurgicallytrauma
Case 4b: Embolization After a Post Biopsy Renal Bleed | Emoblization: Bleeding and Trauma
Case 4b: Embolization After a Post Biopsy Renal Bleed | Emoblization: Bleeding and Trauma
angiogramarteriesbiopsybleedbleedingchaptercoilsembolizationembolizeextravgoalhematomakidneymassNoneorganpatientpatientsPost biopsy bleedrenalretroperitonealscanvascular
Case 5: Liver Trauma | Emoblization: Bleeding and Trauma
Case 5: Liver Trauma | Emoblization: Bleeding and Trauma
activeangiogramarterybleedingbloodchaptercoilsembolizationembolizeextravasationhematomainjuryleakingliverLiver TraumamelenamicrocatheterNonenoticeportalposteriorpseudoaneurysmtraumavenousvessels
Case 6: Pelvic Fracture | Emoblization: Bleeding and Trauma
Case 6: Pelvic Fracture | Emoblization: Bleeding and Trauma
angiogramaortabottomchaptercoilscontrastcontrolembolizationextravasationfracturegoalimageimagesinjuryNoneparticlespatientpatientspelvicPelvic fracturepicturepicturesscanselectivetraumaunstable
Case 7: Retroperitoneal Hematoma | Emoblization: Bleeding and Trauma
Case 7: Retroperitoneal Hematoma | Emoblization: Bleeding and Trauma
angiogramaortaarterybifurcationchaptercoilsdelayedembolizationembolizefillgramhematomaimageinjurylumbarmicrocatheterNonerastretroperitonealRetroperitoneal hematoma due to a transverse process fracturespacespinetransverse
Case 8: Retroperitoneal Hematoma- Cover Stent | Emoblization: Bleeding and Trauma
Case 8: Retroperitoneal Hematoma- Cover Stent | Emoblization: Bleeding and Trauma
angiogramarteryaxialbleedcatheterizationchaptercontrastcoronalCoverage StentembolizationembolizehematomailiaciliacsimageinjuryNoneoptionpatientpseudoaneurysmRetroperitoneal hematomastentstents
Case 9: Embolizing a Pseudoaneurysm Rrising from the Branch of the Inferior Epigastric Artery | Emoblization: Bleeding and Trauma
Case 9: Embolizing a Pseudoaneurysm Rrising from the Branch of the Inferior Epigastric Artery | Emoblization: Bleeding and Trauma
abdominalafibangiogramangiographyanteriorarterybruisingchaptercoilembolizationepigastrichematomainferiormicrocatheterNonepatientpseudoaneurysmPseudoaneurysm arising from the branch of the inferior epigastric arterywall
Case 10: Peritoneal Hematoma | Emoblization: Bleeding and Trauma
Case 10: Peritoneal Hematoma | Emoblization: Bleeding and Trauma
activeaneurysmangiogramanteriorarterycatheterchaptercoilcontrastcoronalctasembolizationembolizeembolizedflowgastroduodenalhematomaimageimagingmesentericmicrocatheterNonepathologypatientperitonealPeritoneal hematomapseudoaneurysmvesselvesselsvisceral
Case 11: Bleeding Tracheostomy Site | Emoblization: Bleeding and Trauma
Case 11: Bleeding Tracheostomy Site | Emoblization: Bleeding and Trauma
aneurysmsangiogramarterybleedingBleeding from the tracheostomy siteblowoutcancercarotidcarotid arterychaptercontrastCoverage StentembolizationimageNonepatientposteriorpseudoaneurysmsagittalscreenstent
Case 11b: Embolizing a Pseudoaneurysm of the Brachiocephalic Artery | Emoblization: Bleeding and Trauma
Case 11b: Embolizing a Pseudoaneurysm of the Brachiocephalic Artery | Emoblization: Bleeding and Trauma
angiogramarterybrachiocephaliccatheterchapterclickcoilcoilsembolizationmicromicrocatheterNonepseudoaneurysmPseudoaneurysm brachiocephalic arterystenttrachea
Q&A- Embolization: Trauma and Bleeding Cases | Emoblization: Bleeding and Trauma
Q&A- Embolization: Trauma and Bleeding Cases | Emoblization: Bleeding and Trauma
abnormalityaccessangiogrambleedbleedingchapterembolizationfoamgelfoamhemorrhagenaturenegativeNoneorganpathologypatientpatientsplacementpostpartumpreserveradialrupturescantpa
Transcript

I am dr. TBA for the 245 talk and what I what I've kind of decided to do since right now I about an hour and a half off of my flight here and I just sat in the back with some friends eating a full bag of candy is what I'd like to do is just shift gears for those a couple of

minutes we're not going to talk about lean and Six Sigma and cath lab orientation and leadership we're not going to talk about stuff like that we're just going to go over some cases and we're just gonna have a discussion

this is not going to be a lecture my plan is to completely screw up the video guy all right like it's not gonna work out I'm just telling you so what I'd like to do is I'll grab this whatever remote I have here for moving the slides

hopefully I have one great and what I'd like you to do is to wake up cuz I recognize that at 2:30 or two forty five in the afternoon you guys are hitting your post lunch low here and everyone's gonna go to sleep

and my goal is to keep you all awake so what I really like to do is to close the doors to not allow anybody to leave but basically we're gonna show some cases all right and I'm gonna ask you questions and I even have a mic to give

to people if I ask you a question so you can speak and be part of this whole thing for an hour so here's my hint though if I ask you what you want to do for the patient the answer is going to be embolization alright that's the

answer to the question because these are all embolization cases they're all bleeding cases in trauma cases that was the the subject I was asked to speak on today and I thought that rather than go through a boring lecture for an hour

giving you the indications for a procedure in the findings and the embolic agents it'll just be more fun to picture ourselves in the midst of a regular day and I are going over some cases talking about what we do and why

we do it and just involve you because I know in my own lab usually if we're in the middle of a case I'll sit there when we see a finding and I'll say does everyone see what we're looking at does everyone get what we're doing and I

think whether you're attacked or you're a nurse at the very least you should get what we're doing all right so that's the goal the goal here is to just to do that so here we are we've a 65 year old male

patient who presents with rectal

bleeding he's had a transfusion and this is the angiogram so it's gonna be a lot easier people volunteer so who wants to say what they see what do you say what do you say show me tell everyone what you say well there's two

slides the first one you see just a little bit of blood and on the second slide you can see where he's really bleeding all right so these are the same the same patient same angiogram so one thing you guys should realize if you

don't know this already about an angiogram is an angiogram is a series of pictures over time good job by the way so a series of pictures over time so it's not just one image and the analogy I like to give is if I take my kids to

Disney World right I can have that picture of all of us in front of the castle with the Mickey hats and everyone's smiling but like one second before this one kicked that one and one second after this one smacked the other

one in the head and they're all crying but I got that one picture an angiogram is that situation it's a series of pictures over time so while you may look at that first picture on the left and maybe not see so much going on what you

should appreciate on the right is that big blobby thing of contrast over on the right side all right now what that means is that there is blood pouring out of that person's vessel all right this is a mesenteric angiogram it's a superior

mesenteric artery angiogram we put a catheter in by the groin from the groin we went into the SMA and we took some pictures and this is what we're seeing and we're appreciating hopefully that big blobby thing on the right all right

so this is what we'll call a lower GI bleed all right the patient's essentially crapping blood that's a lower GI bleed all right so given that just another hint this kind of implies that we're gonna talk about upper GI

bleeding later all right just so you know so there's lots of different causes for lower GI believes there's diverticular disease there's angiodysplasia switch our small malformations of the blood vessels

there's a ski mcdowell there's patients who maybe had radiation therapy for different cancers can be predisposed to bleeding cancer itself can cause bleeding and different inflammatory diseases like either infections or other

diseases can as lower GI bleeding now how do we work these patients up well usually I would think that most of the time these patients have hit an ir suite they've probably had a colonoscopy first and a

colonoscopy is really the first line used to assess what's going on with a lower GI bleed it's not that easy to do it's difficult to prep those of you who resolve this I am and have had a colonoscopy know that it's better when

you prep before the colonoscopy and if someone comes in with a lower GI believe they haven't been adequately prepped that makes the colonoscopy very difficult the other thing is remember you're going from the bottom up into

colonoscopy and you have blood coming at you in someone who is experiencing a lower GI bleed and that essentially means it's difficult to see so many times the colonoscopy is not really able to tell us what we need to know I would

say the next thing that usually happens is some type of imaging now of a sudden the patients are coming to radiology and what you may have is any one of three different options you might have a nuclear medicine bleeding scan you might

have a CT angiogram you might have a regular old conventional angiogram and for those of you saying who cares what's the difference just take some pictures the big difference is that the amount of bleeding that it takes to see it is

different for each of those exams so the most sensitive exam is the nuclear medicine scan that's going to pick up the lowest rates of bleeding a conventional angiogram is the worst scan we can do for GI bleed or worse imaging

we can do because you need a lot of bleeding to see it so when we saw when my friend here picked up the the blobby thing on the right would that bleed that's a big bleed like we can look at it and say aren't these really pretty

pictures but when we see it and you see that kind of bleed you have to realize that's a lot of bleeding to see it like that so our antenna has to go up and we have to start moving a little bit CTA is kind

of right in the middle and actually a lot of people are turning now to see TAS I'm not personally a huge fan of that because I think it's a waste of time and contrast in my opinion I think a CTA for GI bleeding is a way if I can translate

it is I don't feel like doing that case right now so I'm gonna get a CTA and we'll figure it out later all right that's that's my language for a CTA but in my opinion you know it has some value how do we treat them well if

you can see on colonoscopy then you can potentially treat it with colonoscopy and there's different things that they can do with their scopes obviously if there's more diffuse disease they can remove part of

the bowel that's that's a problem and then of course the answer is embolization exactly so here is the picture from our embolization procedure and what do you see all right I won't pick on anybody yet basically what we

did was you can see over there you can see the shade of our angiographic catheter there's a micro catheter now passing all the way into the actual vessel that's bleeding and now when we do an angiogram you can actually see the

vessel that's bleeding now conventionally in the old days for those of you that have been doing this for a while you probably are used to living in a world where it's not great to embolize lower GI bleeds it's better to embolize

upper GI bleeds and lower GI bleeds and the reason why is because there's less collateral flow so if we block up a blood vessel we essentially kill everything beyond where we blocked it up because there's no alternative routes

for blood to flow all right in this particular case you can actually see that long stringy thing going right to the bleed and here we were able to get into that single vessel and kind of see it right there the long think heading

towards 4 o'clock and when we embolize it you can see we put coils in there and blocked it up so the only thing we embolize there is the blood vessel going to the abnormality the risk of ischemia is low and the clinical efficacy is high

but if you can't make it all the way out there if we embolize let's say right there that entire loop of intestine would be infarct it and that would be bad so we always have to think about that when we're embolizing GI bleeds all

right now here's a different case is a 49 year old male who presented to the emergency department after vomiting a lot of blood vomiting was the key word there it's going the other direction so that's an upper GI bleed all right and

when we talk about upper GI bleeds there's a lot of different causes for upper GI bleeds the most common are ulcers but there's mallory-weiss tears of the esophagus there's just esophagitis or gastritis

there's different cancer vascular malformations fistula is varices which I'm not going to talk about but varices on the venous side in a patient with portal hypertension these are all causes of upper GI bleeding now

once again we might treat them medically we might look at them with endoscopy and potentially cauterize something embolization usually is used when and when endoscopy is not successful all right or certainly surgery but an upper

GI bleeds embolization is a lot more attractive of an option all right so here's another picture what do you think you up for it nope you turned me down all right who wants to who wants to tell me what they see how about you how about

you guys you can team up together what do you think so what do you seeing so let's look at that together so this is a seal EF is an anagram of the celiac axis you want to think it through you want to volunteer you see a filter we don't care

about that yeah all right that's fair so you see the catheter going up right in the middle and it's going right into the celiac axis all right what I want to draw your attention to is right in the middle of the screen a little bit over

to the left is again a blobby thing all right that's extravagant of contrast and the vessel that that's coming off of is the gastroduodenal artery so I want you to see that if you look at the catheter you

can see the shadow of the catheter right up going up from the bottom that's going into the celiac axis and the big vessel going over to the left side of the screen is the proper hepatic artery that the common hepatic artery excuse me and

the first vessel heading south from there is the gastroduodenal artery that blood vessel is supplying the end of the stomach and the beginning of the small intestine and what you see is the extravagant coming off now what it's

very important if you're dealing with bleeding patients whether it's in dusky whether it's hemoptysis or GI bleeding anything like that we're looking for that type of blob appearance which just mean the contrast is no longer

constrained by the artery it's free into space okay usually the way we were built is that the blood vessels the biggest they ever are near the heart as they leave the heart they get progressively smaller until they reach

the tips of your fingers and the tips of your toes if there's any place that you see where it gets big small then big again that's not normal okay that's not normal and now we just got to figure out what's

the abnormal part is it the small part or the big part all right in this particular case it's that big blob that's big it doesn't belong there all right but in the upper GI system there's lots of collateral vessels so we can

just go in and we can put coils right in the gastroduodenal artery and we can embolize that and we can do it safely because we know that there is alternative routes for blood to flow now the one thing we have to do here and

this is an important concept for any abnormal bleeding whether it's trauma or other causes is we always look for the backdoor so in this particular patient we did an angiogram of the superior mesenteric artery there's another vessel

going to the intestines and it's nice cuz we have the coils there you can get a sense that it's possible for blood to flow from a branch of the superior mesenteric artery backwards into the GDA and so we just want to make sure that

that's not happening because we can do the best job ever with an embolization procedure but if we don't get the front door and the back door we're gonna fail patients will come back with recurrent bleeding and at least in my experience

that's a big reason why people do come back so we think we do a great job in two or three days later people come back with abnormal bleeding it's weak because we didn't address both sides of the pathology all right so here's another

case I can make up the ages anyway so it doesn't matter so 43 year old patient on a motorcycle that collided with a deer all right presents with left upper quadrant abdominal pain and now we're looking at a cat scan all right who

wants to look at a cat scan you look like you're up for it what do you think what do you see no no you're not sure so we're looking so the key is the left upper quadrant pain right the patient presented with left-sided pain you

should know that whenever we're looking at a study like this we're looking as if we're talking to the person so the right side is on the left the image the left is on the right side and so if you look on the these are two

images if you look at the right side of the image you can actually see the spleen that's like that beam shape thing towards the back of the patient and what we should see is a homogeneous appearance of the organ but what we're

seeing are some kind of dark grayish lines going through it that's essentially a laceration of the screen that's what we're looking at that's the pathology that will prompt us doing a procedure like this and when we ever we

see a patient with splenic trauma we try and grade the trauma so one thing you're going to hear about is it's a patient with a grey 2 laceration or a great 4 laceration or something like that and that basically just describes the extent

of the laceration through the spleen the further through the spleen it goes the higher the number is the worse it is for the patient okay we tend to get involved with patients who who essentially have grade 3 or higher lacerations and are

hemodynamically stable so in this particular patient this was thought to be a grade 3 splenic laceration but there was not a whole lot of blood around the spleen so we thought this patient had some time to come to

angiography and embolization so here's the angiogram lo and behold what we see is again a blobby thing which is the theme of this lecture remember this is bleeding so we're looking for blobby things and all the way on the right side

of that image you can see that cloud of contrasts that black contrast that's extravasated of contrast that's not normal all the way to the right you guys see it are you good so going all the way to the right that's

what we're trying to do now when we do splenic embolization there's two ways we think about this do we want to go all the way to where the bleeding is all the way out into the screen and embolize one little branch that's injured or do we

want to do something called the proximal splenic embolization we would just put like some coils or plugs right at the origin of the splenic artery with the goal of being to slow down the flow and allow the spleen to heal a lot of it is

just what's possible maybe what time it is how tired we are things like that all factors that weigh into it but here's a little bit of a better view you can see the area of extravasation now here's another picture now we put

our microcatheter out there now you're getting a bit more of a sense of what's going on there you can see the extravagance II the vessel that it's coming from and then we put our catheter all the way out there and now we're

right at the source of the bleeding so our philosophy is if we see bleeding we want to go as far as we can towards the source of the bleeding keeping in mind that whenever we don't get as close to the bleeding as possible we're

sacrificing normal parts of the organ that we're treating and that's the philosophical leap that we make during these procedures so we were able to get out there and then we embolize leaving a lot of flow through the rest of the

spleen and the patient was able to survive like we never did anything alright that's our goal now here's a

different patient this is an unrestrained passenger in a motor vehicle accident now that you are all

experts in looking at this CT you can see on the right side of both of those images is the spleen you can see that darker grey areas within the spleen that's bad it should look more like the the the lighter parts

and actually all the grey are on the outside is all blood or fluid in the abdomen so this is a bad laceration probably at least a grade four splenic laceration but again this was a hemodynamically stable patient all right

and here's what we saw this is the angiogram you can see the splenic artery and you can see they're kind of diffuse abnormality of the spleen it just doesn't look right under normal circumstances it just look like branches

on a tree and what we're seeing here is just kind of splotchy looking splenic ranked them up so that's not normal we just want to give it a chance to heal this is the scenario we might do a proximal splenic embolization where

we'll go in and we'll basically put a plug or some coils right at the origin of the splenic artery and I love this picture because what it shows is why we do this philosophically what I want you to notice is on the image to the left

you can see the coil right there right if you see the abrupt stopping of the splenic artery and then what you see are all those vessels going up towards the top of the picture those are arteries that are supplying

the stomach it's the left gastric artery some other vessels that then go through vessels we call the short gastric arteries and what you get is is the reconstitution of the splenic artery so on the image to the right all the way on

the right side of the picture those branches that you see are within the spleen so even though we plugged up the splenic artery right at its start the spleen is able to get blood flow through those collateral vessels all right so

that's our goal that's what a proximal splenic embolization is trying to do we just want the spleen to heal a little bit and reality what we want to do is these patients are usually fine we just don't want them to go home and have a

delayed rupture of their spleen because that's something many of us probably don't appreciate if someone has a splenic artery injury or splenic injury and they're doing fine and then we send them home there is an incidence of

delayed rupture of the spleen and what we know through lots of good papers is doing these proximal embolization procedures helps to reduce that risk of delayed splenic rupture so that's what we're trying to do there all right so

let's move on here is another patient who took a fall skiing we see a lot of these patients up in upstate New York and they presented with severe left-sided abdominal pain and here's the cat scan

all right who's up for it what do you think what looks bad you look like you're into it what do you think yeah the right the bottom right-hand side of the picture should be spleen and it just looks like a big pool of blood that's

pretty good you did pretty good spleens a little higher so we're gonna presume spleen is there Graham this is just one image one slice through the picture through the body so we're just not at the level of the spleen but that's the

kidney that's exactly right that white thing on the right side of the image of the patient's left side is the kidney and the one thing I'd like everyone who appreciates that doesn't look at all like the other side all right so when

you look at a cat-scan like this you want to look for symmetry that's really important all right that's the cool thing is we're kind of meant to be similar looking on both sides of our body and in this particular

case you can see that the left kidney has been pushed way forward in the body compared to the right side and there is a kind of a hematoma sitting in the retroperitoneum posterior behind the kidney that's bad

the other thing you should notice is if you look at that left kidney you notice that white squiggly line that doesn't belong there okay that's contrast that's not really constrained inside an artery that's extravagant of

contrast that's bad all right we don't want to see that all right again there's a grading system for renal trauma and you're gonna hear people talk about grade 1 2 3 4 injuries all right obviously as the number gets higher the

extents of the injury gets more significant all right so again here's that picture think you can appreciate that it's at least a grade 4 laceration of the kidney so we went in and we did an angiogram now we can watch these

patients we can surgically manage them by taking out their kidney in some ways that's the easy part excuse me it's a lot more elegant to try and embolize these patients if they're hemodynamically stable and can take you

know getting to angio and doing the case now in general we do embolization for patients with lower grade injuries and usually penetrating injuries a penetrating trauma that's seen on CT I think this is something that's changing

I if any of you work at high-volume trauma centers the reality is that we're doing more and more renal angiography for trauma than we used to because it's just becoming a more accepted thing for us to

be doing that all right so here's the angiogram and again I think you can notice it really correlates very well to what we saw on the CT scan you see that first image on the left and on the delayed image you see that that kind of

poorly constrained contrast going out into space now we were never really quite sure what this was if it was extravasation or if it was potentially an arteriovenous fistula with early filling of a renal vein regardless of

which it's not normal all right so what we did was we went in and we embolized and I only included this picture because I'm a big drawer during cases so when I'm working with a resident or a fellow I like to really

lay out our plan on a piece of paper and try and stick to the plan and this particular picture look really good so I included on the lecture but basically you can see that the coils the goal here for any embolization procedure

when it comes to trauma is to preserve as much of the normal organ as we can and to simply get you know to the source of the bleeding and to get it to stop and that's what we did there so what you can appreciate on this is kind of the

renal parenchyma or the tissue of the kidney is largely maintained you can see the dark black kind of blush within the kidney and all that really stands for properly working kidney all right and yet we embolize the pathology so that's

our goal here's a similar patient not

similar but similar story an older patient who presented for a biopsy of a right renal mass now sometimes it's a skiing accident sometimes it's a car accident sometimes it's us that causes

these problems so here's a patient who came in for a biopsy of a renal mass here's the CT scan hopefully you can appreciate that the patient is face down or prone on this scan this by the spine is on the top side you can see our

biopsy needle going into a mass in the left kidney excuse me the right kidney and now this is the she comes back later because of some pain and now in a manner that's similar to what you said earlier on that first CT scan you can now see

the right kidney is pushed forward by a very large retroperitoneal hematoma so this is probably a post biopsy bleed this doesn't happen very often in fact as someone who does kidney biopsies once or twice every day I'm shocked that this

doesn't happen more often we're sticking big needles into vascular organs or vascular masses it's amazing that we don't have more patients come back for this it only happens about 2% of the time and usually people who have these

types of risk factors are at risk for this type of bleeding after a biopsy but we can do is we can go in do an angiogram and again I want you to just appreciate look at the picture I think everyone hopefully can see on the bottom

of the picture there's this active extrav enough contrast from the lower pol renal arteries all right lo pol renal artery and that's bad if it's great in a lecture because it's very easy for everyone to see but the reality

is it really signifies very significant bleeding and that's what everyone here should appreciate if you're managing the trauma patient or the bleeding patient if you see if this Cleary this clearly means everyone's got to move a little

faster to address it because this is a bad bleed but the great news is that we have the technology now to go all the way into the renal arteries or frankly the arteries of any organ get very far distant land just embolize it and so

look how far we got here for this patient we took care of it this patients kidney function didn't pump an inch because the reality is there was very little impact on the normal parts of the kidney so that's the goal if you guys

work with people who say oh we don't have to get that far out just throw some coils you know near the origin it's fine it'll accomplish the same goal but at the same time they will have killed half of the patients kidney so it is always

worth making some effort to get as far as you can into the organ that you're treating but at the same time you don't want to take an hour to do that because the patient's bleeding pretty heavily and you have to address it so that's our

goal during these procedures next case

24 year old patient after a car accident has lower abdominal pain and melena so blood coming out of the rectum here's the CT scan anyone want to take a stab but you can just shout it out

so this time we're looking at the liver right so the liver is the big thing on the right side of the screen and what you can see is the dark hematoma posterior to the liver but you should also notice that big white dots sitting

right in the hematoma all right that's important because that's active bleeding that's the report when you guys when you guys get called in for these cases and someone says oh this you know liver trauma with active

bleeding this is the picture that is spurring that announcement okay this is what active bleeding and the liver looks like again there's a bleeding scale there's an injury scale for a liver trauma we don't need to go into that

slides are available if you want them alright here is the angiogram now again my rule works all right if you see vessels get smaller and then big again something's abnormal so in this particular picture I want you to notice

the catheter sitting in the right hepatic artery the blood is going up into the right lobe of the liver and right near the top of the pictures that big circular kind of blobby thing now this is by definition extravasation

sometimes we use the term pseudoaneurysm to describe this I just want you to appreciate what a pseudoaneurysm means it means that there's a hole in the artery that contrasts or blood is leaking out of that hole and the body is

essentially constraining the bleeding it's not going all over the place it's being constrained that's what we call a pseudoaneurysm all right that's just one way to look at it and geographically so this is an injury to the artery blood is

leaking out of the artery but maybe one layer of a three-layered blood vessel or even just the surrounding tissue is constraining that bleeding alright so what do we want to do for this exactly exactly you're getting it all right so

here we can get our microcatheter all the way out there the closer we get to it the better now in end organs like the liver or the kidney we don't actually have to get all the way out there getting close to it's going to be good

enough but the closer we get to it the better for stopping the bleeding and preserving the function of that organ all right so look how close we literally got right into the injury and then we're able to embolize it that's the goal all

right now the liver is a nice place the treat because as you know there's two sets of blood vessels going to the liver there's the portal veins in the apat ik artery so if we just embolize a little a patek artery the

liver is not going to notice that at all because it still has the portal venous flow bringing blood to that liver but our goal is to get in there preserve as much of the liver that we can and address that injury okay here's another

patient 40s year-old patient again car accident lower abdominal pain and bruising so it sounds like you guys can appreciate that's an injury alright so we'll move past that so here's a CT scan these are four separate images from the

same patient CT scan and it is a bit more subtle I'm not suggesting it's easy to see you know we can appreciate the injury but one thing that you should be able to notice again is that concept of symmetry so when our residence or even

myself or anybody reads a cat scan we always want to kind of appreciate all the differences in the symmetry that we're seeing and so what you can see here is especially on that upper left hand side you can see the penis coming

out of the patient almost coming out of the patient and if you just draw a line straight back from there you should notice that there's a bit more tissue on the left side of the patient than the right side of the patient but that's

what we're looking at and if you go to the image over to the right the top right image right at that same area there's a little bit of a white blush which just shows that there is some bleeding going on there and if you look

at the third image which is the one on the bottom left right below one of the bones or there's another area of a white contrast collection or bleeding all right you can maybe see that again on the fourth image so that's what we're

looking for on the CT that asymmetry or the thickening of the tissue and we're looking for an escape of some contrast from where we should expect it to be all right so many of these patients will be

unstable those are the patients that probably need to go right to the or but for the patients who are really you know doing okay we have a chance to intervene on them and the reason why that's important is the more unstable they are

the higher the chance of mortality especially with the pelvic fracture so pelvic fractures are a big deal if you have a hemodynamically unstable patient with a pelvic fracture that's something to take very seriously

all right many of these patients will get CTS or C if we see extravasation they often come to us for angiography so here's the angiogram again a great example if you only look at one picture or two pictures

you're not going to see the problem all right so if you look at the first two pictures you really don't see anything I would I would argue it looks normal but as you get to that third picture you see that kind of collection of contrast

on the bottom right-hand side of the picture all right that's why you need to look at all the pictures of the and reom not just one picture you watch them it's like watching a

little movie now you just stand there and watch it over and over again I get a sense of what it looks like at the beginning middle and end of the angiographic run or set of images the other thing is it's very hard to see

extravasation of contrast when you're in the aorta so many times we do an aorta gram we take some pictures and we may or may not see anything but if we know there's a pelvic fraction we know it's more on the left side we'll go into the

left internal iliac artery and do a more selective angiogram and here's a picture of that selective angiogram and now you can see the extrapolation even more clearly hopefully you can all see it the bottom kind of leftish part of the image

all right here's a more selective now we say okay we definitely see something now we're going to get a little bit further into the system here's a picture now it's very clear you can go if you don't see it all right so you should see it on

the bottom all right and now our goal is to just get as close as we can and so we got all the way down then we put some coils there and again our goal is to make sure that we get just into the vessel that we treat and embolize it now

people will say what agent should we use do we use gel foam do we use particles do we use coils do we use glue or onyx the truth is you can you can really use anything but the thing with the most control so for trauma we tend to use

coils for trauma alright because our goal is to deposit an embolic agent right at the site of the injury that's our goal if we use particles we don't have as much control or a liquid we don't have

as much control they could go somewhere we don't want it to go all right here you're dealing with the blood supply of the penis the rectum the bladder other things which you know most of us would prefer not be injured during an

angiogram all right so we don't want to do something that we don't have complete control over and coils give us that type of control

all right another patient 52 year old patient ATV accident we get a lot of

lunatics on ATVs in our area and they presented with severe back pain here's the cat scan you see that white thing kind of in the back on the right side it almost looks exactly like that liver one I showed you two patients ago the

difference is that that's not conscious that's a part of the patient's bone that's the spine that fractured off and is now sitting in the middle of a big hematoma so that's why my kids don't have ATVs all right so basically that's

a big retroperitoneal hematoma due to a transverse process fracture all right in light of an ATV injury here's the angiogram now look at the picture on the left first that's an aorta gram you see the renal

artery at the top you see the bifurcation of the aorta kind of in the middle going down to each side and maybe just on that first image you see a hint of maybe some cloudy extravasated on the left side of the spine excuse me the

right side of the spine the left side of the image now remember I just I know I keep hammering this point home but you need the delayed image to make the diagnosis that's normally going to tell you if there's a real problem and on

that image on the right which is a bit more delayed you can see the extravagant Rast next to where the spine was that's an injury that's a lumbar artery injury and as we get closer all right we put a micro catheter in that lumbar artery now

you see the extraction and the question always comes up how much of that space do we need to fill that's an abnormal space that's just receiving all the blood that's leaking out of the artery and basically we don't have to fill all

of it we try we try to but it takes a lot to fill that up so we'll go in there you can see we put a lot of coils in this space and then we started packing coils back into the artery that was injured and I know it looks really big

on that image but if you go back into a finally orna gram you can appreciate that we were in a very small artery there but the technology that we have now allows us to get very far into very small arteries and that I think is

what's changed over the 20 years that I've been doing this at the very beginning of my career we wouldn't think about doing any of these things since we didn't have the tools to get that far out we had to

embolize these vessels very close to their origin and that led to a failure rate and an adverse injury rate that we don't see now that we can get this far out keypoint another case we have an older

patient who experienced the heart attack who had right little quadrant pain after a cardiac catheterization all you like oh so here's the cat scan and what you should appreciate there is in the front of that first image which is the axial

image all right you can see the hematoma that's brewing kind of in the front you notice how all these pictures kind of look the same that's the good part about giving a lecture on bleeding and trauma because they all kind of look the same

so that's the hematoma on the front part of the pelvis and on the on the right image which is more of a coronal like looking at the patient image you can see it right near the right groin you can see that hematoma all right so our next

step was to do an angiogram and this is what the angiogram looks like who wants to volunteer what do they say all right I saw someone raise his hand over here some walk over here what do you think yeah well yes so it is a retro hematoma

would you say describe the angiogram for everybody right where it's at the external iliac down the common femoral looks like there's contrast going up to the left and down to the right probably close to where they accessed yeah

probably but so yeah probably probably too high but the other thing is that's probably a pseudoaneurysm that probably is the evidence that there was a bleed there we're not seeing Frank extrapolation of contrast in a literally

contrast pouring out but we are seeing the effects of an injury to the artery and the constraining of the the remaining normal tissue to hold on to that bleed so the question is what do we want to do no that was very good because

I fooled you it's not always embolization so sorry I lied so in today's world a lot of times when we see this type of pathology we have again relatively new technology available to us again we

could go into that pseudoaneurysm and embolize it and that would be a legitimate treatment but my friend here is right you know this is a great case for a covered stent so we could go in and put a stent right across that area

of injury and stent it so these days looking at coverage stands as an option for patients with arterial injury is a very legitimate option you just have to be able to deliver it has to be the right artery you have to be able to get

the stent where it needs to go we all work with vascular surgeons who are great and they can put these stents and iliacs and aortas but they can't make those turns into livers and kidneys and spleens it's got to be the right artery

this is this is the right artery okay we saw this patient and we said well we could kind of get a micro catheter into that area of injury and embolize it or we could just put a cover sent across it and all go home to have dinner with our

kids so that was option B is what we chose here so this is a great cover stent case okay here's another patient

60s year old patient with afib who fell and presented with abdominal pain and bruising in their anterior abdominal

wall for whatever reason we see a lot of these patients who come in with kind of bruising after they fall on their abdomen here you can see why hopefully you can see the big hematoma and the anterior abdominal wall so you can

imagine what this patient look like they have this kind of you know ball sized thing under their abdominal wall all right here's our angiogram in this particular case we went into the inferior epigastric artery which kind of

runs up from the pelvis up along the anterior abdominal wall you can see how small it is we were able to get a micro catheter in there and just in the middle just to the left of the middle of the picture you can see that kind of black

your circle that's again a pseudoaneurysm arising from the branch of the inferior epigastric artery and boom we can go in and coil it all right so that's what that looks like so now all of you kind of maybe I used to

sitting in the background we'll know when you're getting called in for these patients this is the type of pathology that we're looking at on CT and on angiography all right another patient 68 year old

patient female patient who has the sudden onset of upper abdominal pain here's the CT we did all these cases in one day it was crazy it was terrible so so here's a big hematoma a big peritoneal hematoma you

can see it anterior to the right kidney you can see the white blob of contrast right in the middle of the hematoma that's a pseudoaneurysm or even active extravagance um less experienced people would probably say it's active

extravagant I think most of us would prefer that it be called kind of a pseudoaneurysm this active extrapolation would be much more cloudy and spread out this is more constrained and you can see on the

coronal image you get a sense that there's that hematoma same type of problem all right is there more imaging that we can do to figure out the next step again I said earlier earlier in this lecture

that sometimes we use CTA now sometimes a CTA is worthwhile I do find that for a lot of these patients I think we're getting smarter and we're doing CTAs right at the beginning of this whole thing you know when a trauma

patient comes in we're getting CTAs so we can max out the amount of information that we get on the initial diagnostic imaging here's what we're seeing on the CTA and in this particular case I think it's pretty clear that you can see the

pseudoaneurysm arising from what looks like a branch of the superior mesenteric artery so this is just an odd visceral and Jake visceral aneurysm which looks like it probably ruptured I don't have an explanation for it led to a big

hematoma here's what that is and now we're gonna do an angiogram the neat thing is it just perfectly correlated with a conventional angiogram so here's our super mesenteric angiogram all right the supreme mesenteric artery

on the first image to the left is that vessel going downward towards the right side of the screen all those vessels coming off are really just collateral vessels going up to the liver through the gastroduodenal artery again that

left one looks pretty good it's not until you see the delayed image on the right that you see that area of contrast all right so that's the finding that correlates with the CT scan all right here we're able to get in there you put

a micro catheter in that vessel alright the key next step for this patient as I mentioned earlier is the whole concept of front door and back door so here we're technically in the front door the next thing that we do is we put the

catheter past the area of injury and now we embolize right across the injury because remember once you embolize one thing flow is gonna change we screw it up body the body wants to preserve its flow if we block flow

somewhere the body's gonna reroute blood to get to where we blocked it so we want to think ahead and we want to say okay we're blocking this vessel how's the body going to react and let's let's get in the way of that happening that's what

we did here so we saw the pathology we went past it we embolized all across the pathology and boom now we don't have anymore bleeding and the likelihood of recurrence is gonna be very low for that patient because we went all the way

across the abnormality and I think from

my last case here you have a 54 year old patient recent case who had head and neck cancer who presents with severe bleeding from a tracheostomy alright for some bizarre reason we had two of these

in like a week all right kind of crazy so here's the CT scan you can see the asymmetry of the soft tissue this is a patient who had had a neck cancer was irradiated and hopefully what you can notice on the

right side of the screen is the the large white circles of contrast which really don't belong there they were considered to be pseudo aneurysms arising from the carotid artery all right that's evidence of a bleed he was

bleeding out of his tracheostomy site so here's a CTA I think the better image is the image on the right side of the screen the sagittal image and you can see the carotid artery coming up from the bottom and you can see that round

circle coming off of the carotid artery you guys see that so here's the angiogram all that stuff that is to the right to the you know kind of posterior to the right of the screen there it doesn't belong there that's just

contrast that's exiting the carotid artery this is a carotid blowout we'll call it okay just that word sounds bad all right so that's bad so another question right what do you want to do here

I think embolization is reasonable but probably not the thing we can do the fastest to present a patient to treat a patient is bleeding out of the tracheostomy site so in this particular case this is a great covered stent case

alright and here's what it looked like after so we can go right up and just literally a cover sent right across the origin of that pseudoaneurysm and address the patient's bleeding alright

here's another patient 62 year old male

patient just a similar case who had head in that cancer again after radiation therapy who experienced some bright red blood while coughing all right here's the CT scan and what I want to draw your attention to a little tough to see I

think I'll let me go up up here point it out with a mouse well I don't have a mouse so I guess not is basically you can see right in the middle of the two lungs kind of right in front of the trachea which is the black

circle alright just go right in front of that up to the top you can see the round white circle which is the brachiocephalic artery and just projecting off the back of that is another little kind of outpouching of

contrast a little nipple coming off of of the brachiocephalic artery that doesn't belong there all right here's the angiogram and it's a little difficult to see but there is a see if I can describe it better to you alright I

think this is actually a video so I'm sorry I don't know the ability to run it unless you can click on it can you guys click on the back up so if you want to look at it again you see the angiogram kind of running and just at the origin

of the brachiocephalic artery which is the first branch of the aortic arch you can see that outpouching of contrasts coming right to the right of that vessel that's a pseudoaneurysm and again we went through the same thought process we

said you know I want to put a covered stent across that but my problem was that we didn't just have the right size that would not block one of the carotid arteries and not extend too far into the aorta so we had no choice but to

consider embolization in this particular case so here's what we did here we actually put a micro catheter if you can just click I think that's a video to the left no I guess not you know what it's okay

what we did for this particular case was we went in from the arm and we put a micro catheter directly into that pseudoaneurysm because we couldn't feel we didn't feel we could put a stent across it so we put the micro catheter

in there we started to put some coils and it actually went further than we thought outside of the artery and here's the post image so you can see our final image you can see the coils that are sitting just adjacent to the

brachiocephalic artery and we preserved good flow there to end this basically

the take-home point is this that most of the time when we see a bleeding patient we're thinking of embolization we're thinking of going in looking for an

arterial abnormality going as far into the organ that we can embolizing that organ and trying to preserve as much flow to the normal parts of the tissue that we can to preserve the function of the organ today in the back of our minds

we're always thinking about putting covered stents across this but in some ways you realize that's a band-aid right with just you know the arteries that we put those covered sense and we're severely injured and there's always a

chance that flow can work around there so they could be leaks around covered sense so I still think embolization is a bit more definitive than cover stent placement but I find it when a growing number of patients cover sent placement

is definitely an option for these patients so I am here for ask any questions but I can also appreciate that you have a break it's been a long day so I will not get offended if none of you have questions all right perfect

yeah yeah no that's it's the nature so what what he asked here is is that GI bleed cases tends to be unsatisfying because you hear about them and then by the time you get them down to the NGO suite and you

do an angiogram they're negative and it does happen a lot you should know it's the nature of the pathology so what ends up happening is let's be honest I mean a lot of people who work in AI are just like to push things off sometimes so

they get a call for a GI bleed or they say oh let's get a bleeding scanner let's get a CTA by the time you see them at 6 or 7 hours later and they're negative because they've stopped bleeding and that's the nature of the

pathology so my personal philosophy is to get at these patients as quickly as I can I think it's just a better way to go if someone thinks they're bleeding the faster you get at them the greater the likelihood is that you're going to see

some some abnormality there and I think that's been true I think as we start to do these faster we're seeing more positive cases it might be nice to have a CT angiogram or a bleeding scan but I think by the time you see them after

that you know they're negative it's not anything you're doing wrong it's the nature of the pathology it's intermittent bleeding and that's what happens some people feel like they can give TPA to some of those patients like

they'll go into the SMA they'll give some TPA which let's be honest right all of us are saying what the hell that seems like a horrible idea and I agree with that I mean if the body has stopped the bleeding on its own why in the world

would I give a drug to dissolve the clot to start them from bleeding again so I don't like that idea but there are people that will do a bleeding you know kind of a challenge with TPA to see if they can open up something to identify

the bleeding to then go back in and embolize it I think my bias is coming through and how I answered that I don't know we don't used to out for that anything else yeah I think gelfoam has its place I think

gelfoam has its place for things like postpartum hemorrhage or you know some maybe some trauma and a younger patient but gelfoam in general is something that you're giving over a much larger area of territory so I think if you can identify

a bleed and just coil that particular bleed you're doing a better service for the patient but all these are obviously good hey let's see it in a lecture case in real life you may or may not see something so obvious and I think if you

have a patient that had some bleeding on a CT scan a bad pelvic fracture and you just didn't see it in geographically but you know something's wrong giving gelfoam is a legitimate thing to do all of us equate gel foam with a

temporary embolization effect the truth is we're not we're second guessing that a little bit and a lot of people who use gel foam feel that the extent of the inflammation that we get when we use gel foam is probably so great that even

though the embolic agent itself may go away the occlusion that we caused with the gel foam probably stays around longer than we think so I'm not so sure it's a it's a great temporary agent but I would say which we mostly limited to

postpartum hemorrhage patients yeah what's the cause of it usually it's a uterine rupture it's a vessel rupture I've gone three more questions than the leadership guy which is great anyone else yeah

well there's no doubt about it I think that IR is moving towards radial access I think 10 years from now the vast majority cases are going to be radial access it's the one area of our practice that I think I'm starting to feel my age

in I mean you know I think and you probably may see this at your own centers I think people that have been doing ephemeral access for a long time we're just more comfortable with that one of the issues that we're facing with

radial access as we begin to think about doing more radial access at our place is that we may be comfortable with it but places like the ER and the ICUs and the other areas that we're sending our patients back to are not yet skilled

enough as to how they manage those patients so our nurses are very frequently the ones to say I don't know if they're ready for us to send a radial access patient to whichever floor we're talking about so we have some work to do

to in service those the nurses on those floors as to how to take care of those patients first and until we do that I think we're going to be limited more to outpatient work with our radial access all right guys enjoy the rest of the

meeting [Applause]

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