eMedicine Specialties > Radiology > Vascular/Interventional
Embolization, Hemorrhage
Updated: Sep 16, 2008
Introduction
Embolization is useful in a broad spectrum of clinical situations. Embolization can be particularly effective in hemorrhage, regardless of whether the etiology is trauma, tumor, epistaxis, postoperative hemorrhage, or GI hemorrhage. It can be performed anywhere in the body that a catheter can be placed, including the intracranial vasculature, head and neck, thorax, abdomen, pelvis, and extremities. With the availability of coaxial microcatheters, superselective embolizations can be performed. In most patients, embolization for hemorrhage is preferable to surgical alternatives.
Digital-subtraction angiogram of the right internal maxillary artery in a 73-year-old woman with a 1-day history of epistaxis (same patient in Images 3-5 in Multimedia). This image confirms the area of blush and further demonstrates active extravasation from the sphenopalatine branch of the internal maxillary artery. A coaxial microcatheter was placed in the internal maxillary artery.
Bronchial artery embolization in a 46-year-old man with massive hemoptysis (same patient in Images 7-9 in Multimedia). This arteriogram is an unsubtracted image of Image 8. The straight coils are demonstrated more clearly. The patient's hemoptysis resolved postembolization.
Splenic artery angiogram in a 32-year-old man who was an unrestrained passenger in a head-on motor vehicle accident (same patient in Images 13-15 in Multimedia). There are numerous small areas of contrast accumulation in the splenic parenchyma known as the "starry night" appearance, which is consistent with splenic injury. At the junction of the mid and superior poles, an area of active extravasation is highlighted within the circled area.
For excellent patient education resources, visit eMedicine's Ear, Nose, and Throat Center and Digestive System Center. Also, see eMedicine's patient education articles, Nosebleeds and Gastrointestinal Bleeding.
Technique and Equipment
Identifying hemorrhage
Embolization procedures begin with diagnostic angiography to identify the source of bleeding. For example, in epistaxis, angiography of the external carotid artery with attention to the internal maxillary artery can be helpful.1,2,3 In pelvic fractures, the internal iliac arteries are examined angiographically.4,5
Selective and superselective angiography is more sensitive in finding the source of bleeding than are nonselective studies.2,6,7,8,9 Consequently, clinical suspicion and the results of other imaging studies such as contrast-enhanced computed tomography (CT) scanning and radionuclide scans with technetium-99m (99m Tc)–labeled red blood cells (RBCs) are important in guiding angiographic examination. In intra-abdominal bleeding, such as after complex trauma, CT scanning may identify the site of acute bleeding, because acute bleeding often demonstrates higher density (Hounsfield units [HU]) than older blood; this is termed the "sentinel clot sign."10
Hemorrhage is identified by active extravasation of contrast medium outside of the confines of the vessel lumen. The angiographic appearance depends on the rate and location of bleeding. The extravasating contrast medium may flow toward the dependent part of the viscus; in the bowel, the extravasated contrast may outline the mucosa. When the bleeding site and artery have been identified on the initial angiogram, a catheter, often a 3-French (3F) microcatheter, is placed as selectively as possible into the bleeding artery to confirm the bleeding and to stop it with embolization.
Angiography in the setting of lower gastrointestinal (GI) hemorrhage generally does not demonstrate unique diagnostic findings that explain the cause of bleeding, only the site of active bleeding. Thus, angiographic examinations during the episode of acute, brisk bleeding are required. In cases of recurrent occult GI bleeding, angiography can be performed electively in hopes of identifying a distinct finding such as angiodysplasia, arteriovenous malformations (AVMs), or intestinal varices. Occasionally, provocative protocols that use angiography and infusions of lytic agents or heparin have been administered, although these techniques have provided mixed results. Carbon dioxide angiography may increase the yield of angiography in the acute GI bleeding scenario.
Agents and coils
When a vessel requires embolization, coils are typically the agent of choice (see Image below and Image 1 in Multimedia). Coils are available in a variety of shapes and sizes. Once microcatheter technology (3F or smaller) became available, microcoils were developed to embolize increasingly smaller vessels.7,11 Microcoils assume a deployment diameter as small as 1 mm. In addition, some coils are straight when deployed; thus, the coil has the same diameter as the wire from which it is made (the term "straight coil" is somewhat misleading and definitely an oxymoron). The advantages of coils include their high radiopacity and the fact they can be deployed with high accuracy.
Embolization coils. Note the variety of shapes and sizes. The white "fuzz" on the coils is Dacron, which promotes a stronger thrombotic reaction.
Coils are made from stainless steel, platinum, or titanium wire. Most are coated with Dacron fibers to elicit greater thrombogenic reactions. A coil is generally packaged in a deployment needle, which is used to load the coil into the catheter. Once inside the catheter, the coil is advanced with a standard angiographic wire. Typically, the stiff end of the guidewire is used to introduce the coil into the catheter and the floppy end to deploy the coil. The tip of the catheter is positioned at the desired point of embolization, and the coil is pushed out the end. As it is deployed, the coil assumes its shape and final diameter. Most often, a "nest" of coils is deployed to occlude the artery fully.
Note: Care must be taken when deploying microcoils, particularly when using "high flow" microcatheters. The coil may attempt to form inside the lumen of the catheter, which can cause occlusion of the delivery catheter, and the embolization may fail.
Particulate embolic agents useful in the setting of acute hemorrhage include polyvinyl alcohol (PVA) and absorbable gelatin sponge (Gelfoam).9,12 Trisacryl microspheres (Embospheres) have become available in a variety of sizes and may be useful in some settings. Particulate agents are mixed with an iodine-contrast agent for fluoroscopic visualization and injected through a catheter or microcatheter. PVA is available in particle sizes ranging from 100-1200 μm (see Image below and Image 2 in Multimedia). An appropriate range of particle size must be chosen based on the size of the vessels to be occluded. The smaller the particles, the more distal the embolization, and the greater the likelihood of tissue necrosis. Extreme care should be taken not to reflux the particle/contrast mixture outside the intended area of embolization. PVA and Embosphere particles are permanent occlusive agents, as are coils, polyvinyl alcohol, collagen spheres, and silk.
Polyvinyl alcohol particles. Note the particle size printed on the bottle labels.
Gelfoam is generally a temporary occlusive agent, although it can incite an inflammatory response, contributing to permanent thrombosis. Once injected, Gelfoam acts as a mechanical occlusive agent, as well as inducing a thrombogenic reaction, occluding the vessel. However, once the vessel is occluded, thrombolytic enzymes degrade the clot and Gelfoam, recanalizing the occluded vessel over a period of days to weeks. Gelfoam can be useful in trauma cases in which a temporary occlusion is desired while either surgical repair of the injury is undertaken or the body's natural healing processes repair the damage. Gelfoam is available as either a sponge, which can be cut into pledgets or from which a slurry can be made, or as powder particles that average approximately 50 μm in diameter.
Until recently, acrylic glue has not routinely been used in the setting of acute hemorrhage. However, one study included a series of 16 patients in whom cyanoacrylate glue was used for embolization in a variety of anatomic sites, including the GI tract, kidney, and liver, among others.13 Embolization was successful in most patients, even in the setting of failed embolization with the use of coils and particles.
Other embolic agents that are not useful in the setting of hemorrhage should be mentioned for comparison. Absolute alcohol, small particles, and surgical gelatin powder (Gelfoam) cause occlusion at the capillary level, leading to tissue necrosis. Because of tissue necrosis, these agents are typically reserved for tumor embolization where cell death is the intended result. These agents should not be used for hemorrhage. Another embolization agent, a detachable balloon, is used in specific circumstances, such as intracranial AVMs.14 Balloons are not routinely used in patients with hemorrhage, and only recently became commercially available again in the United States.
Clinical Applications: The Head and Neck
In the head and neck, embolotherapy is most often performed for epistaxis and traumatic hemorrhage.
Epistaxis
A common indication for embolization in the head and neck is epistaxis. Otorhinolaryngologists differentiate anterior and posterior epistaxis on anatomic and clinical bases; however, this discussion considers anterior and posterior epistaxis the same entity. Epistaxis results from a number of causes, including environmental factors such as temperature and humidity, infection, allergies, trauma, tumors, and chemical irritants (see Images below and Image 3-5 in Multimedia).
Digital-subtraction angiogram of the right external carotid artery (EC) in a 73-year-old woman with a 1-day history of epistaxis (same patient in Images 3-5 in Multimedia). This image demonstrates a suspicious blush of contrast off one branch of the internal maxillary artery (IM) within the highlighted area. Hemorrhage continued despite anterior and posterior nasal packing.
Digital-subtraction angiogram of the right internal maxillary artery in a 73-year-old woman with a 1-day history of epistaxis (same patient in Images 3-5 in Multimedia). This image confirms the area of blush and further demonstrates active extravasation from the sphenopalatine branch of the internal maxillary artery. A coaxial microcatheter was placed in the internal maxillary artery.
Postembolization digital-subtraction angiogram in a 73-year-old woman with a 1-day history of epistaxis (same patient in Images 3-5 in Multimedia). This image demonstrates cessation of flow past the mid portion of the internal maxillary artery. The internal maxillary artery was embolized using polyvinyl alcohol. No further evidence of extravasation is seen.
Treatment of epistaxis is placed in 3 categories, as follows:
- First aid measures include digital compression and cotton plugs.
- Acute management includes chemical or electrocautery and nasal packing.
- If the above measures fail, surgery and endovascular therapies are next. Surgical ligation of the internal maxillary artery has been the more common treatment, compared with embolization. As interventional services become more widely available, the use of embolization will, no doubt, increase in frequency.
An advantage of embolization over surgical ligation is the more selective blockade of smaller branches. By embolizing just the bleeding branch, normal blood flow to the remainder of the internal maxillary distribution is retained. Complications of embolization may include the reflux of embolization material outside the intended area of embolization, which, in the worst case, may result in stroke or blindness. Embolization has been proven to be more effective than arterial ligation. Although embolization has a higher rate of minor complications, no difference in the rate of major complications was found.
Trauma
For traumatic hemorrhage, the technique of embolization is the same as for epistaxis. Because of the size of the arteries in the head and neck, microcatheters are often required. Endovascular treatment of ruptured cerebral aneurysms is controversial and is mentioned for the sake of completeness. Interested readers are encouraged to refer to the Bibliography.14,15,16,17
Clinical Applications: The Thorax
In the thorax, the 2 indications for embolization in relation to hemorrhage are (1) pulmonary AVMs (PAVMs), and (2) hemoptysis.
Pulmonary arteriovenous malformations
PAVMs usually are congenital lesions, although they may occur after surgery or trauma. The congenital form is highly associated with hereditary hemorrhagic telangiectasia, also termed Osler-Weber-Rendu Syndrome. There is a genetic predisposition to this condition. It is also associated with liver AVMs; however, preemptive treatment of the latter is presently unwarranted. Screening head CT scans or magnetic resonance images (MRIs) are important to exclude intracranial AVMs. PAVMs can be single or multiple, and if large enough, can result in a physiologic right-to-left cardiac shunt. Clinical manifestations of the shunt include cyanosis and polycythemia. Stroke and brain abscesses can result from paradoxical embolism through the PAVM. PAVMs may also hemorrhage, which results in hemoptysis.
Treatment options for PAVMs include surgery and transcatheter therapy. The treatment objective is to relieve the symptoms of dyspnea and fatigue that are associated with the right-to-left shunt. In addition, if the patient suffers from paradoxical embolism, treatment prevents further episodes. As a result of the less invasive nature of the procedure and excellent technical success rate, embolization is currently considered the treatment of choice for PAVM, whether single or multiple.
Transcatheter embolization of PAVMs is performed with coils of appropriate size or detachable balloons. Potential complications of the procedure include pulmonary infarction, pleurisy, and loss of coils into the systemic circulation. Correct sizing of the coils is paramount, as is fastidious technique to be certain no clots or air are injected during the embolization procedure, as this can result in embolization to the systemic circulation. Embolotherapy is the clear treatment of choice for PAVMs. Patients (and asymptomatic siblings) should be periodically screened for new PAVMs with the use of chest radiography or perhaps thin-section CT scanning. Generally PAVMs larger than 3 mm in diameter are embolized.
Hemoptysis
Bronchial artery embolization is performed in patients with massive hemoptysis, defined as 500 mL of hemoptysis within a 24-hour period. Etiologies vary and include bronchiectasis, cystic fibrosis, neoplasm, sarcoidosis, tuberculosis, and other infections. Rarely, Rasmussen aneurysms (pulmonary artery aneurysms from tuberculosis) can cause massive hemoptysis and should be considered when bronchial artery angiography proves negative. Untreated, massive hemoptysis carries a high mortality rate. Death most often results from asphyxiation rather than exsanguination. Bronchoscopy is performed first, both to treat any intrabronchial source of bleeding with cauterization and to localize the source of the bleeding. Radiographic studies, including chest radiographs and CT scans, localize the responsible lesion.
Medical and surgical treatments for massive hemoptysis are usually ineffective, with mortality rates ranging from 35-100%. Embolization has an initial success rate of 95%, with less morbidity and mortality than surgical resection. Consequently, transcatheter embolization has become the therapy of choice for massive hemoptysis, with surgical resection reserved for failed embolization or for recurrent massive hemoptysis following multiple previous embolizations.
The embolization technique involves catheterization and angiography of the descending thoracic aorta. A 5F reverse-curve catheter (eg, a Mikaelsson catheter or Shetty catheter) or a double-curve catheter (eg, a cobra-shaped catheter or "headhunter" catheter) is used to cannulate the origins of the bronchial arteries, which typically arise at the level of the T3-T7 thoracic vertebrae. A Mikaelsson catheter has a characteristic hook on the end, which is particularly useful for cannulating branch arteries coming off at right angles to the aorta, such as the bronchial arteries (see Image below and Image 6 in Multimedia). Often, conventional 4F hydrophilic cobra catheters are useful, particularly in concert with coaxial microcatheters.
Mikaelsson catheter. Note the characteristic hook, which makes cannulation of branch arteries arising at right angles from the aorta (bronchials, intercostals, lumbars) much easier.
The number and distribution of the bronchial arteries vary widely. In the most common situation, 1 artery supplies the right lung and 2 arteries supply the left; however, as many as 4 arteries may supply each side. In as many as 40% of patients, the arteries to both the right and left arise as a common trunk with one of the intercostal arteries. Care must be taken to avoid embolization of common-origin intercostal arteries, which may result in infarction of the musculature supplied by the intercostal branches.
Most importantly, spinal arteries must be identified during angiography. Spinal arteries can have common origins with intercostal branches and are identified by a characteristic "hairpin" loop overlying the vertebral column. The presence of spinal arteries may be a contraindication to embolization, although using a microcatheter to deliver the embolic agent beyond the origin of the spinal artery typically renders this issue moot. Permanent embolic agents (eg, PVA) are typically used. One strong disadvantage of coils is a more proximal occlusion, which prevents or hinders repeat embolization in the same arterial distribution (see Images below and Images 7-9 in Multimedia).
Bronchial artery embolization digital-subtraction angiogram of the right bronchial artery in a 46-year-old man with massive hemoptysis (same patient in Images 7-9 in Multimedia). Chest computed tomography scanning showed a consolidation of unknown etiology in the right upper lobe. Bronchoscopy confirmed the right upper lobe as the source of bleeding. The angiogram was performed with a Mikaelsson catheter in the descending thoracic aorta. The tip of the catheter is in the ostia to the right bronchial artery. The angiogram demonstrates an abnormally intense blush in the right upper lobe.
Bronchial artery postembolization digital-subtraction arteriogram in a 46-year-old man with massive hemoptysis (same patient in Images 7-9 in Multimedia). Four 1-cm straight coils were used to embolize the main trunk of the right bronchial artery. The arteriogram demonstrates complete embolization of the artery. The proximal trunk of the main artery is opacified.
Bronchial artery embolization in a 46-year-old man with massive hemoptysis (same patient in Images 7-9 in Multimedia). This arteriogram is an unsubtracted image of Image 8. The straight coils are demonstrated more clearly. The patient's hemoptysis resolved postembolization.
Clinical Applications: The Abdomen and Pelvis
Many indications for embolization in the abdomen and pelvis exist. For embolization of hemorrhage, the most common indication is acute GI hemorrhage.7,8,9 GI hemorrhage is usually categorized as upper GI (UGI) or lower GI (LGI) hemorrhage, because the etiologies and treatments differ considerably. UGI bleeding is defined as bleeding from the esophagus to the ligament of Treitz, whereas LGI bleeding is defined as occurring distal to the ligament of Treitz, usually in the colon or rectum.
Bleeding in the small bowel is rare; the most notable exception is a Meckel diverticulum in the pediatric population. Solid organ injury, usually to the liver and spleen, can be readily treated with embolization. Other indications exist, such as gynecologic/obstetric -related hemorrhage and pelvic ring fractures.4,5,6,12,18,19,20,21
Etiologies of GI hemorrhage
UGI bleeding has many etiologies, including peptic ulcer disease, hemorrhagic gastritis, esophagitis, gastroesophageal varices, neoplasm, and Mallory-Weiss tear. UGI endoscopy is initially performed to localize the source of bleeding and possibly to treat the cause of the bleeding. However, endoscopy fails to find the source of bleeding in 10% of patients. Endoscopic treatment failures can also occur. With endoscopic diagnostic or treatment failure, angiographic evaluation and embolization are the next step. The results of endoscopy are important to the radiologist performing angiography, because the angiographic evaluation can be guided to a particular arterial distribution.
The 2 most common causes of LGI bleeding are diverticular disease and angiodysplasia. Less common causes include inflammatory bowel disease, neoplasia, and bowel ischemia. Endoscopy in the LGI tract is more problematic than in the UGI tract. When the colon is filled with blood and stool, the source of bleeding can be difficult to identify. As much as 40% of the colonoscopy is nondiagnostic regarding the source of bleeding. When endoscopy fails to identify the source of bleeding, a nuclear medicine study can help. Frequently, a nuclear medicine study can localize the source of bleeding to a particular arterial distribution, thus guiding the angiographic evaluation. The radionuclide scan can also help in determining the rate of bleeding, as arteriography is not helpful if bleeding has stopped.
Treatment of GI hemorrhage
Once the source of bleeding is identified, an appropriate embolization procedure can be planned. The technique for embolization is different for UGI bleeding and LGI bleeding. The vascular supply in the UGI tract is so richly collateralized that relatively nonselective embolizations can be performed without risk of infarcting the underlying organs. Conversely, the LGI tract has less collateral supply, which necessitates more selective embolizations, often with microcatheters and microcoils.
Before microcatheter technology was available, vasopressin infusions were the initial treatment of choice in LGI hemorrhage. Vasopressin is a locally active vasoconstrictor that effectively controls LGI bleeding in most patients when delivered via a catheter. However, vasopressin is relatively contraindicated in patients with coronary insufficiency. For these patients, concomitant administration of nitroglycerine by infusion or patch is required. Unfortunately, bleeding treated with this procedure tends to recur, necessitating either an embolization procedure or colonic resection.
Before the advent of microcatheter technology, embolizations for LGI bleeding could not be performed as distally in the artery as is possible with a microcatheter. Consequently, proximal embolizations might have resulted in intestinal ischemia or infarction, which might have then mandated subsequent colonic resection.
Microcatheter technology has led to substantial improvement in the effectiveness of embolization. Several series have reported using both coils and particulate embolization with good results. Because of high success and low complication rates, superselective embolization is currently considered the treatment of choice for LGI bleeding.
Solid organ hemorrhage
Outside the GI tract, there are organ-specific considerations when performing embolizations in the abdomen. For instance, the liver has a dual blood supply, with 75% of the total supply arising from the portal vein and 25% from the hepatic artery. The hepatic artery is often responsible for hemorrhage resulting from trauma due to its higher blood pressure compared with the portal vein. Therefore, all embolizations in the liver are performed in the hepatic artery and not in the portal vein. Because of the dual blood supply, occlusion of large branches of the hepatic artery can be performed without risk of necrosis. The exception to this rule is the biliary tree, which derives its vascular supply from the hepatic artery. Embolization of the hepatic artery, therefore, may cause ischemia to the biliary tree.
In patients with normal livers (ie, no hepatic dysfunction), occlusion of the entire proper hepatic artery results in hepatic necrosis in >10% of patients. The remainder experiences a transient rise in their liver enzymes, which normalize after a few days. However, embolizations should be performed as distally as possible to minimize the risk of necrosis. An angiographic study of a patient in whom embolization of the liver was performed for trauma-induced hemorrhage is seen below and in Images 10-12 in Multimedia.
Hepatic artery embolization digital-subtraction arteriogram of the common hepatic artery (CHA) in a 21-year-old male who was brought to the emergency department with a gunshot wound to the abdomen (same patient in Images 10-12 in Multimedia). Emergent exploratory laparotomy revealed that the bullet traversed the liver. Surgical measures to control the bleeding were unsuccessful. The abdomen was packed with surgical sponges and the patient brought to the angiography suite. This image shows that at the bifurcation of the proper hepatic artery (PHA), a large amount of extravasation is seen from where the bullet lacerated the artery. GDA = gastroduodenal artery.
Hepatic artery embolization digital-subtraction arteriogram of the proper hepatic artery in a 21-year-old male with a gunshot wound to the abdomen (same patient in Images 10-12 in Multimedia). A more selective injection with the tip of the catheter in the proper hepatic artery shows a large amount of extravasation from the lacerated artery. Note the subtraction artifact from the radiopaque markers on the surgical sponges. The artery was injured within the hepatic parenchyma, making surgical control difficult, if not impossible.
Hepatic artery postembolization arteriogram in a 21-year-old male with a gunshot wound to the abdomen (same patient in Images 10-12 in Multimedia). Three 4-mm coils were placed in the mid portion of the proper hepatic artery. Complete embolization of the artery was accomplished. The patient experienced a transient rise in his liver function enzymes, which eventually normalized. The patient was released after a 1-month hospitalization without further sequelae.
In contrast, embolizations of the spleen may be performed either proximally or distally. Proximal occlusion may be performed by placing coils in the main splenic artery. In the best of circumstances, embolization of the main splenic artery is performed just distal to the origin of the dorsal pancreatic artery. Proximal embolization simply decreases the pressure head in the main splenic artery; collateral flow via pancreatic and gastric branches supplies the spleen, decreasing the risk of infarction. Distal embolization is performed as it is in other organ systems, with a microcatheter being placed as close to the bleeding source as possible. Antibiotic prophylaxis is required both before and after the embolization (see Images below and Images 13-15 in Multimedia).
Splenic artery embolization in a 32-year-old man who was an unrestrained passenger in a head-on motor vehicle accident (same patient in Images 13-15 in Multimedia). This computed tomography scan of the abdomen revealed a splenic laceration. The patient was hemodynamically stable with a falling hematocrit.
Splenic artery angiogram in a 32-year-old man who was an unrestrained passenger in a head-on motor vehicle accident (same patient in Images 13-15 in Multimedia). There are numerous small areas of contrast accumulation in the splenic parenchyma known as the "starry night" appearance, which is consistent with splenic injury. At the junction of the mid and superior poles, an area of active extravasation is highlighted within the circled area.
Splenic artery postembolization arteriogram in a 32-year-old man who was an unrestrained passenger in a head-on motor vehicle accident (same patient in Images 13-15 in Multimedia). A microcatheter was used to select the segmental branch supplying the area of extravasation. Three 1-cm straight coils were placed. Repeat arteriogram showed no further evidence of extravasation. Note the wedge-shaped lack of perfusion to the mid spleen. The patient's bleeding was controlled, and he subsequently recovered well.
Other types of hemorrhage
Further indications for hemorrhage embolization in the abdomen and pelvis include postpartum, postcesarean, and postoperative bleeding. The differential diagnosis for postpartum bleeding includes laceration of the vaginal wall, abnormal placentation, retained products of conception, and uterine rupture. Conservative measures for treating postpartum bleeding include vaginal packing, dilatation and curettage to remove retained products, intravenous and intramuscular medications (eg, oxytocin, prostaglandins), and uterine massage.
When conservative methods fail to manage hemorrhage, surgical methods to control hemorrhage are used, including ligation of the internal iliac arteries and hysterectomy. With the availability of transcatheter embolization, surgical risks are avoided. Several series in the literature compare iliac-artery ligation to transcatheter embolization. The studies conclude that embolization is a safe and effective procedure for controlling pelvic hemorrhage, avoids surgical risks, preserves fertility, and shortens hospital stays. In addition, embolization is advocated when conservative methods fail. Surgery is typically reserved for patients in whom embolization fails.
Finally, embolization of the internal iliac arteries is valuable in patients with hemodynamically unstable pelvic fractures5 ; enough collateral flow exists in the pelvis to safely embolize both internal iliac arteries, although complications have been reported. Protocols for trauma include treatment of associated soft-tissue injury first, followed by stabilization of the pelvic ring. Patients with persistent hemodynamic instability are candidates for embolization. As in other clinical settings, angiography is used to identify the source of hemorrhage, and a selective embolization is performed.
Multimedia
 | Media file 1: Embolization coils. Note the variety of shapes and sizes. The white "fuzz" on the coils is Dacron, which promotes a stronger thrombotic reaction. |
 | Media file 2: Polyvinyl alcohol particles. Note the particle size printed on the bottle labels. |
 | Media file 3: Digital-subtraction angiogram of the right external carotid artery (EC) in a 73-year-old woman with a 1-day history of epistaxis (same patient in Images 3-5 in Multimedia). This image demonstrates a suspicious blush of contrast off one branch of the internal maxillary artery (IM) within the highlighted area. Hemorrhage continued despite anterior and posterior nasal packing. |
 | Media file 4: Digital-subtraction angiogram of the right internal maxillary artery in a 73-year-old woman with a 1-day history of epistaxis (same patient in Images 3-5 in Multimedia). This image confirms the area of blush and further demonstrates active extravasation from the sphenopalatine branch of the internal maxillary artery. A coaxial microcatheter was placed in the internal maxillary artery. |
 | Media file 5: Postembolization digital-subtraction angiogram in a 73-year-old woman with a 1-day history of epistaxis (same patient in Images 3-5 in Multimedia). This image demonstrates cessation of flow past the mid portion of the internal maxillary artery. The internal maxillary artery was embolized using polyvinyl alcohol. No further evidence of extravasation is seen. |
 | Media file 6: Mikaelsson catheter. Note the characteristic hook, which makes cannulation of branch arteries arising at right angles from the aorta (bronchials, intercostals, lumbars) much easier. |
 | Media file 7: Bronchial artery embolization digital-subtraction angiogram of the right bronchial artery in a 46-year-old man with massive hemoptysis (same patient in Images 7-9 in Multimedia). Chest computed tomography scanning showed a consolidation of unknown etiology in the right upper lobe. Bronchoscopy confirmed the right upper lobe as the source of bleeding. The angiogram was performed with a Mikaelsson catheter in the descending thoracic aorta. The tip of the catheter is in the ostia to the right bronchial artery. The angiogram demonstrates an abnormally intense blush in the right upper lobe. |
 | Media file 8: Bronchial artery postembolization digital-subtraction arteriogram in a 46-year-old man with massive hemoptysis (same patient in Images 7-9 in Multimedia). Four 1-cm straight coils were used to embolize the main trunk of the right bronchial artery. The arteriogram demonstrates complete embolization of the artery. The proximal trunk of the main artery is opacified. |
 | Media file 9: Bronchial artery embolization in a 46-year-old man with massive hemoptysis (same patient in Images 7-9 in Multimedia). This arteriogram is an unsubtracted image of Image 8. The straight coils are demonstrated more clearly. The patient's hemoptysis resolved postembolization. |
 | Media file 10: Hepatic artery embolization digital-subtraction arteriogram of the common hepatic artery (CHA) in a 21-year-old male who was brought to the emergency department with a gunshot wound to the abdomen (same patient in Images 10-12 in Multimedia). Emergent exploratory laparotomy revealed that the bullet traversed the liver. Surgical measures to control the bleeding were unsuccessful. The abdomen was packed with surgical sponges and the patient brought to the angiography suite. This image shows that at the bifurcation of the proper hepatic artery (PHA), a large amount of extravasation is seen from where the bullet lacerated the artery. GDA = gastroduodenal artery. |
 | Media file 11: Hepatic artery embolization digital-subtraction arteriogram of the proper hepatic artery in a 21-year-old male with a gunshot wound to the abdomen (same patient in Images 10-12 in Multimedia). A more selective injection with the tip of the catheter in the proper hepatic artery shows a large amount of extravasation from the lacerated artery. Note the subtraction artifact from the radiopaque markers on the surgical sponges. The artery was injured within the hepatic parenchyma, making surgical control difficult, if not impossible. |
 | Media file 12: Hepatic artery postembolization arteriogram in a 21-year-old male with a gunshot wound to the abdomen (same patient in Images 10-12 in Multimedia). Three 4-mm coils were placed in the mid portion of the proper hepatic artery. Complete embolization of the artery was accomplished. The patient experienced a transient rise in his liver function enzymes, which eventually normalized. The patient was released after a 1-month hospitalization without further sequelae. |
 | Media file 13: Splenic artery embolization in a 32-year-old man who was an unrestrained passenger in a head-on motor vehicle accident (same patient in Images 13-15 in Multimedia). This computed tomography scan of the abdomen revealed a splenic laceration. The patient was hemodynamically stable with a falling hematocrit. |
 | Media file 14: Splenic artery angiogram in a 32-year-old man who was an unrestrained passenger in a head-on motor vehicle accident (same patient in Images 13-15 in Multimedia). There are numerous small areas of contrast accumulation in the splenic parenchyma known as the "starry night" appearance, which is consistent with splenic injury. At the junction of the mid and superior poles, an area of active extravasation is highlighted within the circled area. |
 | Media file 15: Splenic artery postembolization arteriogram in a 32-year-old man who was an unrestrained passenger in a head-on motor vehicle accident (same patient in Images 13-15 in Multimedia). A microcatheter was used to select the segmental branch supplying the area of extravasation. Three 1-cm straight coils were placed. Repeat arteriogram showed no further evidence of extravasation. Note the wedge-shaped lack of perfusion to the mid spleen. The patient's bleeding was controlled, and he subsequently recovered well. |
 | Media file 16: Mesenteric angiogram in a 27-year-old woman with a history of Crohn disease. Note the active extravasation from the terminal arterial branches supplying a loop of ileum. Subselective embolization with polyvinyl alcohol was performed, which effectively controlled the localized hemorrhage in the small bowel. |
 | Media file 17: Hepatic angiogram in a 27-year-old man who was the unrestrained driver in a motor vehicle accident. Note the 2 areas of extravasation from the right hepatic lobe. The patient was treated with embolization of the segmental hepatic arteries using Gelfoam slurry, which stopped the active hemorrhage. |
Keywords
embolization, hemorrhage; hemorrhage; embolization; hemorrhages; embolotherapy; uterine embolization; artery embolization; embolization, therapeutic; therapeutic embolization; transcatheter embolization; bleeding; trauma; pseudoaneurysm; Gelfoam; polyvinyl alcohol; PVA; coil embolization; trisacryl microspheres; Embospheres; selective embolization; superselective embolization; cyanoacrylate embolization
The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor Dr Charles Ray to the development and writing of this article.
More on Embolization, Hemorrhage |
| References |
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References
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Further Reading
Related eMedicine topics
Chemoembolization, Hepatic
Embolization, Vascular Lesions
Epistaxis
Pregnancy, Postpartum Hemorrhage
Uterine Fibroid Embolization
Clinical guidelines
Patient care and uterine artery embolization for leiomyomata. Society of Interventional Radiology. 2004 Feb. 6 pages. NGC:003697
Practice management guidelines for the management of genitourinary trauma.
Eastern Association for the Surgery of Trauma - Professional Association. 2004. 101 pages. NGC:003799
Keywords
embolization, hemorrhage; hemorrhage; embolization; hemorrhages; embolotherapy; uterine embolization; artery embolization; embolization, therapeutic; therapeutic embolization; transcatheter embolization; bleeding; trauma; pseudoaneurysm; Gelfoam; polyvinyl alcohol; PVA; coil embolization; trisacryl microspheres; Embospheres; selective embolization; superselective embolization; cyanoacrylate embolization
