European Conference on Embolotherapy

June 21-24 | Valencia, Spain

June 21-24 | Valencia, Spain

June 21-24 | Valencia, Spain

June 21-24 | Valencia, Spain

June 21-24 | Valencia, Spain

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ProgrammeTrauma and emergencies: Acute thoracic bleeding

Trauma and emergencies: Acute thoracic bleeding

Dr. Deborah Low

Speaker bio

Thoracic injury is common in polytrauma patients and can be life-threatening, especially if not promptly identified and treated during the primary survey. Injury to the thorax directly accounts for approximately 25% of trauma related mortality and contributes (usually due to lung injury) to another 25%. Blunt injury to the chest is often associated with abdominal, pelvic and head injury and is more common than penetrating trauma.

IR may get involved slightly later in management compared to other aspects of trauma, as lifesaving interventions such as airway management and chest tube insertion for pneumo/haemothorax are vital early interventions.

In a major trauma centre, causes of acute thoracic bleeding, in which IRs are often involved, are aortic transection and vascular injury related to stab (penetrating) wounds or rib fractures. The former is usually managed with stent grafting and therefore not for an embolotherapy conference!

Massive haemothorax is defined as greater than 1500mls of blood in an adult. In blunt trauma, it is most commonly due to multiple rib fractures with associated lacerated intercostal arteries. However, bleeding can also be due to lung parenchymal lacerations and hilar vascular injuries. It is the ‘massive’ haemothorax that is an indicator for ‘operative’/surgical intervention, although if intercostal artery injury is identified, IR and transarterial embolisation (TAE) should be considered primarily or in addition to this. Indeed, significant haemothorax from intercostal artery injury can be a delayed presentation.

 

Therefore, the most common injury requiring embolisation is haemothorax due to intercostal vessel injury, owing to their location in the neurovascular bundle beneath the inferior rib edge. However, they also arise as branches from the subclavian artery. There is also the internal mammary artery – all may be in the trajectory of injury and result in significant blood loss. Therefore, knowledge of the anatomy of the chest wall vasculature and associated pathways is important.

In my experience, all patients who undergo IR for thoracic trauma will have been imaged with CT. There is then the challenge of identifying the level or levels of injury in relation to the site of contrast extravasation on CT. This is often not obvious or easy, and an open mind and thorough interrogation of possible sources needs to be the approach.

In addition to trauma, there is also iatrogenic injury from the ‘innocent chest drain insertion’ that has gone awry!

 

We will discuss:

WHEN to intervene – thoracic haemorrhage may not seem significant on initial CT. Concern is raised with a change in haemodynamics or volume of blood loss from a chest drain. A haemothorax does not necessarily mean intercostal/arterial injury, and often draining the haemothorax, re-expansion of the lung and resuscitation will result in cessation of bleeding. 80% of pneumothorax/haemothorax injuries can be definitively managed with thoracostomy. Identifying the cause of the haemothorax, if possible, and communicating with the trauma team is paramount in the management of these patients – situations can change quickly.

HOW – access to the small intercostal vessels and anatomical considerations. Be prepared to change from your usual ‘go to catheter’; the importance of selective distal angiography of MULTIPLE vessels – don’t fall for the ‘satisfaction of search’ once a bleeding point is found. There is often more than one contributor!

WHAT – embolic agents for this purpose – most have been used, where you need to place them, how much to embolise, important anatomy (collaterals, the spinal artery – Artery of Adamkiewicz) and thus awareness of potential consequences.

WHEN – to consider an operative/surgical approach. There are ATLS guidelines and indications for urgent thoracotomy in the context of trauma and in my experience, they are acted upon swiftly without requiring IR involvement. However, when we can help, communication with the trauma team or thoracic team is key in the management of these patients, as the nature of an additional injury to the thorax and/or other injuries will dictate the nature and timing of IR and/or surgical intervention.

It may be obvious from imaging (Fig. 4) that a surgical approach is required!

Fig. 1 Evidence of active extravasation (arrow) on a second CT into a relatively small but persistently bleeding haemothorax.
Fig. 2 Selective arteriography of intercostal vessels demonstrates delayed blush of contrast (arrow) – with several supplying vessels.
Fig. 3 Embolisation across the supply. Final arteriography also demonstrates the anterior spinal artery at this level (arrow) – something to beware of.
Fig. 4 Chest drain inserted into huge left atrium rather than suspected haemothorax – requires surgical repair!

 

Deborah Low

 

Barts Health NHS Trust, London/UK

 

Dr. Deborah Low is a Consultant Interventional Radiologist at the Royal London Hospital and St. Barts Hospital, London, and has been so for 15 years. Prior to this, she trained in interventional radiology and clinical radiology in Toronto, Canada and Nottingham, UK.

The Royal London Hospital is one of London’s major trauma centres, in addition to being a tertiary referral centre for many specialties. Dr. Low is also the Training Programme Director for Barts Health Clinical Radiology training programme encouraging radiology trainees to become the future generation of interventional radiologists!

 

References

  1. Stewart RM, Rotondo MF, Henry S. (2018) Advanced Trauma Life Support Student Manual, 10th American College of Surgeons:62-81.
  2. O’Connor JV, Adamski J. The diagnosis and treatment of non-cardiac thoracic trauma. J R Army Med Corps. 2010 Mar;156(1):5-14.
  3. Edgecombe L, Sigmon DF, Galuska MA, et al. Thoracic Trauma. [Updated 2021 Jul]. In: StatPearls [Internet]. StatPearls Publishing; 2022 Jan.
  4. Ludwig C, Koryllos A. Management of chest trauma. J Thorac Dis 2017;9(Suppl 3):S172-S177
  5. Lohan R, Leow KS, Ong MW, et al. Role of Intercostal Artery Embolization in Management of Traumatic Hemothorax. J Emerg Trauma Shock. 2021;14(2):111-116.
  6. Moore C, Kwayisi G, Esiobu P, et al. Successful treatment of massive hemothorax with class IV shock using aortography with transcatheter embolization of actively bleeding posterior left intercostal arteries after penetrating left chest trauma: A case for the hybrid OR. Int J Surg Case Rep. 2018;48:109-112.
  7. Chemelli AP, Thauerer M, Wiedermann F et al. Transcatheter arterial embolization for the management of iatrogenic and blunt traumatic intercostal artery injuries. J Vasc Surg. 2009 Jun;49(6):1505-13.