CASE 16480 Published on 30.09.2019

Combined surgical and interventional management of a high grade blunt injury of the liver

Section

Interventional radiology

Case Type

Clinical Cases

Authors

Sergio Savastano, Luca Boi, Jacopo Dall'Acqua, Mario Beghetto, Luca Spigolon, Giuseppe Mansi

Azienda ULSS 8 Berica, Vicenza, Italy

Patient

32 years, male

Categories
Area of Interest Interventional vascular, Liver, Trauma ; Imaging Technique Catheter arteriography, CT
Clinical History

The patient was directly transferred from the scene of a motor vehicle accident into the CT room; he was conscious, with hypotension yet haemodynamically stable during a whole body CT investigation. Just after the examination he suddenly went into hypovolaemic shock in the CT room. Intensive resuscitation and an emergency laparotomy for damage control were promptly accomplished; after stabilisation a hepatic embolisation was performed. Fractures of the right clavicle, scapula and some ribs were also diagnosed.

Imaging Findings

CE-CT demonstrated a grade IV laceration of the right lobe of the liver with extravasation of contrast medium (Fig. 1). Hepatic DSA after perihepatic packing showed active bleeding from the dorsal branch of the right hepatic artery (Fig. 2 a,b), which was successfully treated with coil embolisation (Fig. 2 c-e). A CE-CT confirmed the absence of bleeding the day after (Fig. 3). A one-month CE-CT follow-up showed a large devascularised area corresponding to the lacerated parenchyma, (Fig. 4) which slightly decreased in size on sonographic follow-up three months later (Fig. 5).

Discussion

Primary assessment of haemodynamically stable patients with a polytrauma relies on whole body CT investigation, which allows the shortest time to diagnosis and pivots the treatment towards a prompt intervention in case of life-threating injuries or an active surveillance for minor injuries. Non-operative management of hepatic blunt injuries is the standard treatment, regardless of the injury grade, for patients haemodynamically stable and not demanding laparotomy for concomitant abdominal injuries [1–4]. High quality CT imaging, availability of an interventional team, an advanced intensive care management and damage control are the pillars ruling management of hepatic injuries [2, 3]. Two clinical scenarios can synthetically present in clinical setting [3]. The first scenario accounts for 80% of patients, haemodynamically stable or responding to resuscitation. In this occurrence, liver injury is graded with multiphasic CE-CT and if an active bleeding is detected a prompt embolisation, as superselective as possible, is performed. An active surveillance, intensity of which depends on the trauma grade, is mandatory after the radiologic step (diagnosis/intervention) for a surgical damage control in case of an uncontrolled bleeding, and for early diagnosing all events (like bile peritonitis, intra-abdominal hypertension, abdominal comportment syndrome, biloma, abscess) requiring further radiological interventions or a delayed surgery [3]. The second scenario comprises all patients (20% of cases) haemodynamically unstable (at presentation or after hospitalisation), which should be promptly operated on for damage control with direct haemostasis or hepatic packing [3]. A CE-CT is mandatory immediately after the operation and embolisation attempted in case of an active bleeding [1]; an elective reoperation for hepatic packing removal is thereafter scheduled within few days [3]. Embolisation can be performed with particulate agents (resorbable or non-resorbable) or coils or both; whatever the agent used, the procedure should be as selective as possible to lessen the risk of ischaemia of the non-injured parenchyma or the gallbladder. Embolisation management of hepatic injuries has a successful rate over 90%, technical failures relying of an adverse vascular anatomy preventing catheter negotiation of the target artery; nonetheless complications are common. The higher the injury grade, the more frequent are complications [1, 4, 5]. In a systematic review of the literature a mean mortality rate accounts for approximately 10% of cases, with liver-related mortality of 5%, but without procedural-related mortality [4]. Unfavorable sequelae include hepatic necrosis (15%) abscess (7.5%), bile leaks, gallbladder infarction and cause prolonged hospitalisation, a higher number of blood product transfusions, further radiologic interventions and reoperations [1, 4, 5]. Hepatic necrosis is secondary to devascularisation due to trauma or embolisation or combination of the two; despite the dual blood liver supply, the hypovolaemic shock impairs not only the arterial supply but also the portal flow, and makes the liver highly susceptible to ischaemia [5]. For this reason, hepatic necrosis usually affects patients with high-grade injury of the liver; nevertheless this complication is independent from the embolic materials whereas the extension of embolised parenchyma seems to be more relevant [5]. Written informed patient consent for publication has been obtained.

Differential Diagnosis List
Surgical and interventional treatment of hepatic grade IV bleeding injury
Grade IV laceration injury of the liver with active bleeding
Grade IV laceration injury of the liver without active bleeding
Ruptured hepatocellular carcinoma
Spontaneous hepatic rupture
Final Diagnosis
Surgical and interventional treatment of hepatic grade IV bleeding injury
Case information
URL: https://www.eurorad.org/case/16480
ISSN: 1563-4086

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