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Weir A, Kennedy P, Joyce S, Ryan D, Spence L, McEntee M, Maher M, O'Connor O. Endovascular management of pelvic trauma. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1196. [PMID: 34430637 PMCID: PMC8350659 DOI: 10.21037/atm-20-4591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 12/18/2020] [Indexed: 11/06/2022]
Abstract
Traumatic pelvic injuries are an important group of acquired pathologies given their frequent association with significant vascular compromise. Potentially fatal as a consequence of rapid hemorrhage, achievement of early hemostasis is a priority; endovascular management of traumatic pelvic arterial injuries is an important potential option for treatment. Precipitated by any number of mechanisms of trauma, pelvic vascular injury necessitates timely patient assessment. Variable patterns of arterial injury may result from blunt, penetrating or iatrogenic trauma. Selection of the most appropriate imaging modality is a priority, ensuring streamlined access to treatment. In the case of CT, this is complemented by acquisition of the most appropriate phase of imaging; review of both arterial and delayed phase imaging improves the accuracy of detection of low-flow hemorrhage. In cases where surgical intervention is not deemed appropriate, endovascular treatment provides an alternative means for cessation of hemorrhage associated with pelvic injuries. This may be achieved in a selective or nonselective manner depending on the patient's clinical status and time constraints. Consequently, a detailed understanding of vascular anatomy is essential, including an appreciation of the normal variant anatomy between males and females. Additional consideration must be given to variant anatomy which may co-exist in both sexes. This review article aims to provide a synopsis of endovascular management of pelvic vascular injury. Through case examples, available treatment options will be discussed, including thrombin injection and transcatheter arterial embolization. Furthermore, potential adverse complications of pelvic arterial embolization will be highlighted. Finally, in view of the potential severity of these injuries, a brief overview of initial management of the hemodynamically unstable patient is provided.
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Affiliation(s)
- Arlene Weir
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland.,Department of Radiology, Mercy University Hospital, Grenville Place, Cork, Ireland
| | - Padraic Kennedy
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland.,Department of Radiology, Mercy University Hospital, Grenville Place, Cork, Ireland
| | - Stella Joyce
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland.,Department of Radiology, Mercy University Hospital, Grenville Place, Cork, Ireland.,School of Medicine, University College Cork, Cork, Ireland
| | - David Ryan
- School of Medicine, University College Cork, Cork, Ireland
| | - Liam Spence
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland
| | - Mark McEntee
- School of Medicine, University College Cork, Cork, Ireland
| | - Michael Maher
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland.,Department of Radiology, Mercy University Hospital, Grenville Place, Cork, Ireland.,School of Medicine, University College Cork, Cork, Ireland
| | - Owen O'Connor
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland.,Department of Radiology, Mercy University Hospital, Grenville Place, Cork, Ireland.,School of Medicine, University College Cork, Cork, Ireland
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Hiroshige T, Matsuo M, Ueda K, Nakiri M, Nishihara K, Igawa T. Transarterial embolization for pelvic hematoma following laparoscopic radical prostatectomy: A case report and review of the literature. Oncol Lett 2015; 10:1889-1892. [PMID: 26622770 DOI: 10.3892/ol.2015.3381] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 05/20/2015] [Indexed: 11/06/2022] Open
Abstract
The present study reports a case of hemorrhage from branches of the right obturator artery following laparoscopic radical prostatectomy. On post-operative day 9, the patient complained of lower abdominal pain, and the hemoglobin and hematocrit levels had decreased. Emergency computed tomography angiography showed a large pelvic hematoma suggesting active bleeding. Transarterial embolization (TAE) was performed using microcoils. There were no post-procedure complications. At 3 months post-surgery, using computed tomography, the pelvic hematoma was shown to have been absorbed. To the best of our knowledge, TAE for a hemorrhage from the obturator artery following laparoscopic prostatectomy has not previously been described. TAE is a safe and minimally invasive treatment compared with surgical intervention, and should be considered as a treatment for post-operative arterial hemorrhage.
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Affiliation(s)
- Tasuku Hiroshige
- Department of Urology, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan
| | - Mitsunori Matsuo
- Department of Urology, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan
| | - Kosuke Ueda
- Department of Urology, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan
| | - Makoto Nakiri
- Department of Urology, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan
| | - Kiyoaki Nishihara
- Department of Urology, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan
| | - Tsukasa Igawa
- Department of Urology, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan
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Govindarajan A, Sai PMV, Anupama C, Joseph SS. Post-traumatic Cavernosal Artery Pseudoaneurysm Presenting as Right Hip Pain: An Imaging Evaluation. J Clin Imaging Sci 2012; 2:15. [PMID: 22530186 PMCID: PMC3328978 DOI: 10.4103/2156-7514.94232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Accepted: 02/14/2012] [Indexed: 11/04/2022] Open
Abstract
Pseudoaneurysm of the cavernosal artery is quite rare. Herein, we describe color Doppler findings of post-traumatic pseudoaneurysm of the right cavernosal artery in a 19-year-old adolescent boy who presented with right hip pain. Doppler showed turbulence of flow with arterial inflow and outflow from the aneurysm. Selective transarterial catheterization of the internal iliac and internal pudental artery with microcatheter and embolization of pseudoaneurysm using histocryl resulted in alleviation of symptoms.
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Affiliation(s)
- Aarthi Govindarajan
- Department of Radiology and Imaging Sciences, Sri Ramachandra University, Porur, Chennai, Tamilnadu, India
| | - P. M. Venkata Sai
- Department of Radiology and Imaging Sciences, Sri Ramachandra University, Porur, Chennai, Tamilnadu, India
| | - C. Anupama
- Department of Radiology and Imaging Sciences, Sri Ramachandra University, Porur, Chennai, Tamilnadu, India
| | - S. Santosh Joseph
- Department of Radiology and Imaging Sciences, Sri Ramachandra University, Porur, Chennai, Tamilnadu, India
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Cantasdemir M, Gulsen F, Solak S, Numan F. Posttraumatic high-flow priapism in children treated with autologous blood clot embolization: long-term results and review of the literature. Pediatr Radiol 2011; 41:627-32. [PMID: 21127852 DOI: 10.1007/s00247-010-1912-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Revised: 10/18/2010] [Accepted: 10/23/2010] [Indexed: 11/24/2022]
Abstract
BACKGROUND Usually high-flow priapism is caused by perineal or penile blunt trauma with direct cavernosal artery injury and formation of an arterial-lacunar fistula. Rarely, cavernosal artery injury may result from penetrating trauma. Treatment of high-flow priapism is not considered an emergency because patients are at low risk for permanent complications. For this type of priapism there are several options for treatment including embolization or surgical ligation. OBJECTIVE To describe the technique of superselective transcatheter embolization with the use of autologous blood clot and to discuss the long-term results. MATERIALS AND METHODS Seven children with a mean age of 10 years suffering from high-flow priapism were treated with superselective transcatheter embolization with autologous blood clot. In all cases, colour Doppler US was performed to demonstrate increased cavernous blood flow with definitive diagnosis established by superselective arteriography. After the angiographic diagnosis, superselective transcatheter embolization of the fistula with autologous blood clot was performed during the same session. The children were followed up on a monthly basis up to 1 year with clinical findings and penile colour Doppler US examinations. After 1 year, they were followed up annually with clinical assessment only. The mean follow-up period was 6.0 years. RESULTS Following embolization complete detumescence was achieved in all but one child, who was treated with a second embolization 3 d after the initial session. In addition, for one child a second session of embolization was performed due to the recurrence of partial erection during the 1 week period after the initital embolization. In both cases, complete detumescence was achieved after the second embolization, and no recurrence of priapism was observed in the follow-up period. CONCLUSION Selective arterial embolization with autologous clot achieved treatment for high-flow priapism in this study with 100% occlusion rate with a maximum of two sessions and no signs of erectile dysfunction were observed in any of the children during long-term follow-up.
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Affiliation(s)
- Murat Cantasdemir
- Department of Interventional Radiology-Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
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Post-traumatic high-flow priapism treated by endovascular embolization using N-butyl-cyanoacrylate. Radiol Oncol 2010; 44:103-6. [PMID: 22933899 PMCID: PMC3423678 DOI: 10.2478/v10019-010-0024-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Accepted: 11/25/2010] [Indexed: 11/20/2022] Open
Abstract
Background Priapism, persistent erection without arousal, can be classified into low-flow (venous or ischemic) and high-flow (arterial or non-ischemic). The diagnosis of high-flow priapism can be confirmed by colour Doppler and arteriography and it is usually treated by the endovascular embolization. Case report We present a case of a 20-year-old man with a post-traumatic high-flow priapism as a result of the previous perineal trauma. After a period of watchful waiting and an unsuccessful attempt at endovascular embolization using the resorptive gelatinous foam he was successfully treated by the endovascular embolization using N-butyl-cyanoacrylate. Conclusions High-flow priapism can be successfully treated by the endovascular embolization, but the optimal choice of the embolization agent and a careful technique is essential.
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Lopes RI, Mitre AI, Rocha FT, Piovesan AC, da Costa OF, Karakhanian W. Case report: late recurrent hematuria following laparoscopic radical prostatectomy may predict internal pudendal artery pseudoaneurysm and arteriovenous fistula. J Endourol 2009; 23:297-9. [PMID: 19196067 DOI: 10.1089/end.2008.0494] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We report two cases of a pseudoaneurysm of the internal pudendal artery with arteriovenous fistula after extraperitoneal laparoscopic radical prostatectomy. The clinical presentation was delayed recurrent hematuria and urinary retention that necessitated bladder clot evacuation. Subsequent arteriography detected the vascular abnormality and a superselective embolization was performed. Hematuria was no longer observed, and the quality of penile erection remains unchanged in both patients.
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Sandler G, Chennapragada SM, Soundappan SSV, Cass D. Pediatric high-flow priapism and super-selective angiography--an Australian perspective. J Pediatr Surg 2008; 43:1898-901. [PMID: 18926228 DOI: 10.1016/j.jpedsurg.2008.05.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2008] [Revised: 05/06/2008] [Accepted: 05/10/2008] [Indexed: 11/30/2022]
Abstract
High-flow priapism is an uncommon entity in the pediatric and adolescent population. It is usually caused by perineal trauma. Here we describe the experience of our institution in this condition over the past 10 years, the various treatment options available, and the successful application of super-selective angiographic embolization as our treatment modality of choice. Included here is the case of a 4-year-old boy (case 3) who, to our knowledge, is the youngest patient described with this condition in the literature.
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Affiliation(s)
- Gideon Sandler
- Department of Academic Surgery, The Children's Hospital at Westmead, Westmead, New South Wales 2145, Australia.
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Lloret F, Martínez-Cuesta A, Domínguez P, Noguera JJ, Bilbao JI. [Arterial microcoil embolization in high flow priapism]. RADIOLOGIA 2008; 50:163-7. [PMID: 18367068 DOI: 10.1016/s0033-8338(08)71951-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
High flow priapism occurs mainly as a result of a posttraumatic arteriocavernous fistula. Treatment aims to seal the fistula without damaging erectile function. Of all the available treatments, supraselective embolization of the lacerated artery achieves optimal sealing of the fistula with minimal damage to the surrounding tissues. There is no consensus regarding the best materials to be used. Although reabsorbable materials have traditionally been the most commonly used, it is also possible to achieve adequate resolution of the priapism with adequate conservation of erectile function using non-reabsorbable materials, especially microcoils. We describe two cases of patients with high flow priapism caused by bilateral arteriocavernous fistulas treated using microcoil embolization.
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Affiliation(s)
- F Lloret
- Hospital General Universitario Morales Meseguer, Murcia, España
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Towbin R, Hurh P, Baskin K, Cahill AM, Carr M, Canning D, Snyder H, Kaye R. Priapism in children: treatment with embolotherapy. Pediatr Radiol 2007; 37:483-7. [PMID: 17415602 DOI: 10.1007/s00247-007-0441-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2006] [Revised: 02/15/2007] [Accepted: 02/19/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Priapism is defined as involuntary, prolonged penile erection caused by factors other than sexual arousal, and is classified as either low-flow or high-flow. Embolotherapy is an accepted form of therapy in adults with high-flow priapism. Because the differences in etiology, management and outcome are significant, accurate and timely diagnosis is imperative. OBJECTIVE The purpose of this report is to present our experience with embolotherapy for treatment of high-flow priapism in three children. PATIENTS AND METHODS This was a retrospective study. During an 18-month period, three boys ranging in age from 6 to 15 years presented with priapism. All three children were treated with embolotherapy. RESULTS All three children were successfully treated with angiography and embolotherapy. One boy had a presentation that initially raised the possibility of low-flow priapism. No complications occurred, and to date all children are able to maintain normal erections. CONCLUSION Subselective transcatheter embolization is the procedure of choice for high-flow priapism. In cases where priapism persists despite adequate therapy, angiography might be useful to exclude high-flow disease. In children with high-flow priapism, selective occlusion of the penile arteriovenous fistula led to detumescence and normal erectile function.
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Affiliation(s)
- Richard Towbin
- Children's Hospital of Philadelphia, Philadelphia, PA 19103, USA.
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Porta RMP, Poggetti RS, Pereira O, Chammas C, Fontes B, Fratezi A, Birolini D. An Experimental Model for the Treatment of Lethal Bleeding Injury to the Juxtahepatic Vena Cava With Stent Graft. ACTA ACUST UNITED AC 2006; 60:1211-20. [PMID: 16766963 DOI: 10.1097/01.ta.0000221350.64301.6e] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Juxtahepatic vein injuries present a high mortality rate. Our objectives were to develop an experimental model of endovascular lethal injury of the juxtahepatic inferior vena cava (JHIVC) and to evaluate its hemodynamic alterations; to treat the lesion with volume replacement, and a stent graft (SG); and to follow the animals after treatment. METHODS Twenty dogs were anesthetized and monitored [heart rate (HR), mean arterial pressure (MAP), vesical and peritoneal pressures], and submitted to a JHIVC endovascular injury. After volume replacement the dogs were divided into two groups: control (GI) and experimental (GII). GI was observed until death. GII was treated with SG and followed by Doppler ultrasound (DUS) and cavography for 4 (GIIA), and 8 weeks (GIIB), and then sacrificed and IVC and SG were analyzed. RESULTS GI presented increased abdominal pressures, arterial hypotension, and death after 80 minutes. GII had a 100% survival rate till sacrifice, without clinical repercussions. At DUS and cavography all SG were patent, with monophasic pulsatile flow. On US, SG diameters after 2, 4, and 8 weeks did not show differences. On cavography IVC diameters presented no difference between groups GIIA and GIIB throughout the experiment. These data analyzed for the GII as a whole, showed statistically significant differences. Average lumen diameter reduction of SG was 27.43+/-20,00%. Pressure values in the IVC cranially, caudally to the SG, and inside the SG, did not show differences. In the IVC with the SG we observed a thicker neointima layer, and the injury in the media layer was covered with fibroconnective tissue. CONCLUSIONS We developed an experimental dog model of endovascular lethal injury of the JHIVC with significant increase in abdominal pressures, and a mortality rate of 100%. The treatment of this lesion with SG resulted in a thickened neointima layer, and a 27% reduction in the JHIVC lumen diameter, without clinical repercussion, and with a 100% survival rate.
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Affiliation(s)
- Rina Maria Pereira Porta
- Radiology Service, , Discipline of Trauma Surgery, Hospital das Clínicas of the University of São Paulo School of Medicine, São Paulo, SP, Brazil.
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Abstract
Priapism is a relatively uncommon condition that may present as a medical emergency associated with significant pain and anxiety in the veno-occlusive or low-flow variant. Pharmacologic advances and, specifically, the availability of intracavemosal alpha-agonist therapy have dramatically improved the prospects of resolution for patients with low-flow priapism presenting within the first few hours of the acute episode. High-flow priapism is not considered an emergency and treatment measures are typically conservative aimed at preservation of potency. Urologists, radiologists, and other health care personnel caring for the patient with priapism must be familiar with various etiologic factors implicated in low-flow and high-flow priapism to formulate a logical step-care approach. Differentiation of the low-flow from the high-flow state is perhaps the most critical initial diagnostic challenge that determines the sequence of further interventions including surgical shunts in low-flow priapism refractory to medical therapy.
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Affiliation(s)
- Hossein Sadeghi-Nejad
- Division of Ultrasound, Department of Radiology, Case Western Reserve University, University Hospitals, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
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Hiraki T, Mimura H, Kanazawa S, Yasui K, Dendo S, Yoshimura K, Okumura Y, Hiraki Y. Transcatheter embolization of an aortobronchial fistula with N-butyl cyanoacrylate. J Vasc Interv Radiol 2002; 13:743-6. [PMID: 12119336 DOI: 10.1016/s1051-0443(07)61855-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Aortobronchial fistula is a fatal complication after thoracic aortic surgery. So far, treatment options for aortobronchial fistula have included surgical and endovascular stent-graft methods. Herein, a case of an aortobronchial fistula with life-threatening hemoptysis managed with transcatheter embolization of the fistula with N-butyl cyanoacrylate is reported. For the patient with an aortobronchial fistula who cannot be treated by surgical or endovascular stent-graft methods, transcatheter embolization of the fistula may be the only available life-saving method.
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Affiliation(s)
- Takao Hiraki
- Department of Radiology, Graduate School of Medicine and Dentistry, Okayama University, Okayama, Japan.
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