Lumbar arterial injury after trauma is a rare cause of significant retroperitoneal haemorrhage. Early diagnosis followed by endovascular transcatheter embolization is a very effective treatment to control bleeding in patients who do not respond to conservative management. We present a case of post traumatic avulsion of left fourth lumbar artery which was successfully treated with percutaneous transcatheter arterial embolization with glue

Azeemuddin, Muhammad

Chishti, Ishtiaq

Hamid, Rana Shoaib

ul, Haq Tanveer ul

eCommons@AKU

eCommons@AKUDepartment of Radiology Medical College, PakistanJune 2010Post traumatic avulsion of lumbar artery: a rarecause of retroperitoneal haemorrhage treated byglue embolizationRana Shoaib HamidHaq Tanveer ul ulIshtiaq ChishtiMuhammad AzeemuddinFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_radiolPart of the Radiology CommonsRecommended CitationHamid, R., ul, H., Chishti, I., Azeemuddin, M. (2010). Post traumatic avulsion of lumbar artery: a rare cause of retroperitonealhaemorrhage treated by glue embolization. Journal of the Pakistan Medical Association, 60(6), 487-9.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_radiol/32Vol. 60, No. 6, June 2010 487Case ReportPost traumatic avulsion of lumbar artery: A rare cause of retroperitonealhaemorrhage treated by glue embolizationRana Shoaib Hamid, Tanveer ul Haq, Ishtiaq Chishti, Muhammad AzeemuddinDepartment of Radiology, Aga Khan University Hospital, Karachi, Pakistan.AbstractLumbar arterial injury after trauma is a rare cause ofsignificant retroperitoneal haemorrhage. Early diagnosisfollowed by endovascular transcatheter embolization is avery effective treatment to control bleeding in patients whodo not respond to conservative management. We present acase of post traumatic avulsion of left fourth lumbar arterywhich was successfully treated with percutaneoustranscatheter arterial embolization with glue.IntroductionPelvic and spinal fractures caused by blunt abdominaltrauma are associated with significant mortality andmorbidity.1 Pelvic retropenitoneal haemorrhage remains amajor cause of death despite improvements in prehospitalcare resuscitation and increased therapeutic options.2 Upto60% of such patients die due to significant haemorrhagesecondary to vascular injury.1 Early CT scan followed byarteriography with selective embolization is recommendedfor the management. Embolization is a safe and effectivemethod for immediate control of active extravasation, as wellas to prevent future haemorrhage.3Lumbar artery rupture is a rare and often overlookedcause of haemorrhage after pelvic and spinal trauma. We presenta case of retroperitoneal haemorrhage due to rupture of lumbarartery successfully treated by endovascular embolization.Case ReportA 31 year old patient was brought to the emergencydepartment after sustaining abdominal trauma from aheavy steel door which fell on him. He was conscious butirritable, unable to sit or stand and had haemodynamicinstability due to shock. His blood pressure was 90/60 mmHg with a pulse rate of 110/min. Lower abdomen was softbut distended. His left leg was rotated and shortened. HisHaemoglobin level was 5.3 G/dl. An ultrasound (FAST)was positive for minimal free fluid in peritoneal cavity. 3-D CT scan of pelvis showed diastasis of pubis withfractured pubic rami on right side. Fractures were alsoinvolving left sacral ala, bilateral transverse processes oflower lumbar vertebrae and neck of left femur. Contrastenhanced helical CT scan of abdomen and pelvis revealeda large retroperitoneal haematoma on left side extendingfrom lumbar region into pelvis and also involving leftpsoas and ileus muscles.Patient was resuscitated with blood transfusions,intravenous fluids, plasma expanders and fresh frozenplasma but his lower abdominal distension continued toincrease and haemodynamic status worsened despiteconservative management. Digital substractionangiography was planned to look for and embolize site ofretroperitoneal haemorrhage. The angiogram of aorta(performed on Seimens Axiom Artis machine, throughright femoral artery approach by 5Fr RDC catheter) waspositive for active extravasation from ruptured left 4thlumbar artery from its origin (Figure-1). Completeembolization was performed with histoacryl (n-butyl-2-cyanoacrylate) glue (Figure-2). After the procedure, patient was closelymonitored and managed in intensive and special careunits. His haemodynamic status and clinical conditiongradually improved over couple of days. Theretroperitoneal haematoma was drained percutaneouslyby catheter placement. The patient then underwentinternal fixation for his femoral fracture and was laterdischarged from hospital.Discussion Continuous retroperitoneal bleeding from the injuredpelvic or paraspinal arteries particularly lumbar arteries couldbe a major source of haemorrhage in patients with pelvicfractures.4 Sheering forces from sudden rotation or violentflexion extension injuries may be the cause of such vascularinjuries. Fracture of a transverse process may be responsiblefor direct laceration and avulsion of a lumbar artery or rarelyformation of a pseudo-aneurysm may be the cause.5Prompt diagnosis and urgent intervention is thecornerstone of haemostasis in haemodynamically unstablepatients. Computed tomography is imperative in diagnosisand management. It should be used to determine presence andextent of retroperitoneal haematoma, to localize the pelvicbleeding site and any associated extrapelvic visceral orarterial injury.6Since mid 1950s angiography is being frequently usedas diagnostic modality for evaluation of visceral or vasculartrauma. Overall, angiography confirms posttraumatic arterialbleeding in approximately 80-90% of cases.7 After havinglocalized one or several sources of retroperitonealhaemorrhage, haemostasis is achieved by catheterembolization. The aim of embolization is to achieve immediatevascular occlusion (often temporarily) by decreasing pressureupstream from the leak; this facilitates physiologicalhaemostasis, thrombus formation and healing of the dissectedvessels.6 This technique is proving to be the treatment ofchoice for securing haemostasis. When compared to surgery,it is a relatively simple, safe, prompt and effective method ofcontrolling the haemorrhage.8,9Various authors have reported high technical successrates for selective transcatheter embolization of lumbararterial injury.3-5,10 Embolic agents described in literature forlumbar artery embolization include coils and microparticles,gelfoam and rarely glue.3,10 We used glue instead of otherembolization material since the artery was avulsed from itsorigin and no segment was found to place the coil or particles.Possible complications of the procedure includeretroperitoneal infarction and abscess formation. Anotherimportant concern in embolizing lumbar arteries is that thearteria radicularis magna (also called the artery ofAdamkievicz) should be identified in order to avoid potentialembolization, which can result in severe neurologicaldamage. ConclusionOur case illustrates the potential value of earlyimaging particularly arteriography and transcatheterembolization in cases of pelvic and spinal trauma leading to488 J Pak Med AssocFigure-1: Digital subtraction angiogram of aorta & pelvic vessels showingextravasation of contrast from avulsed left 4th lumbar artery (large arrow), andcomplete cut off in internal iliac artery (small arrow), most likely due to trauma andthrombosis.Figure-2: Post embolization angiogram: note cessation of contrast extravasation.Plain nonsubtracted image showing radio-opaque glue (arrow). Tip of catheter is indistal aorta.retroperitoneal haemorrhage with particular reference tolumbar arterial injury as the cause. References1. Brown JJ, Greene FL, McMillin RD.Vascular injuries associated with pelvicfractures. Am Surg 1984; 50: 150-4. 2. Sclafani SJ, Florence LO, Phillips TF, Scalea TM, Glanz S, Goldstein AS, et al.Lumbar arterial injury: radiologic diagnosis and management. Radiology 1987;165: 709-14.3. Sofocleous CT, Hinrichs CR, Hubbi B, Doddakashi S, Bahramipour P, SchubertJ. Embolization of isolated lumbar artery injuries in trauma patients. CardiovascIntervent Radiol 2005; 28: 730-5.4. Hori A, Nagata Y, Hanashiro Y, Ohshiro K, Shimabukuro K, Mekaru T, et al.Embolization of the lumbar artery for pelvic fracture. Rinsho Hoshasen 1989;34: 1047-50.5. Domenicucci M, Ramieri A, Lenzi J, Fontana E, Martini S. Pseudo-aneurysmof a lumbar artery after flexion-distraction injury of the thoraco-lumbar spineand surgical realignment: rupture treated by endovascular embolization. Spine(Phila Pa 1976) 2008; 33: E81-4.6. Geeraerts T, Chhor V, Cheisson G, Martin L, Bessoud B, Ozanne A, et al.Clinical review: initial management of blunt pelvic trauma patients withhaemodynamic instability. Crit Care 2007; 11: 204.7. Dondelinger RF, Trotteur G, Ghaye B, Szapiro D. Traumatic injuries:radiological hemostatic intervention at admission. Eur Radiol 2002; 12: 979-93.8. Gordon RL, Fast A, Aner H, Shifrin E, Siew FP, Floman Y. Control of massiveretroperitoneal bleeding associated with pelvic fractures by angiographicembolization. Isr J Med Sci 1983; 19: 185-8.9. Akpinar E, Peynircioglu B, Turkbey B, Cil BE, Balkanci F. Endovascularmanagement of life-threatening retroperitoneal bleeding. ANZ J Surg 2008; 78:683-7.10. Geldof K, Maleux G, Heye S, Van Cleynenbreugel B, Oyen R. Transcatheterembolization of an isolated lumbar arterial bleeding complicating radicalnephrectomy for renal infarction with infected perirenal haematoma. JBR-BTR2008; 91: 203-5.Vol. 60, No. 6, June 2010 489

Post traumatic avulsion of lumbar artery: a rare cause of retroperitoneal haemorrhage treated by glue embolization

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Post traumatic avulsion of lumbar artery: a rare cause of retroperitoneal haemorrhage treated by glue embolization

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