Transcatheter Treatment of Hemorrhage - SD

Introduction

Hello everybody.
I'm Al Hami, Zari radiologist from Georgia.
I work at Bil State Medical University.
Today we'll have a talk about transcatheter
treatment of hemorrhage.

Definition of Hemorrhage

Hemorrhage. In other words, bleeding is a discharge
of blood from the vascular compartment of the exterior
of the body, or into nonvascular body spaces,
which we call internal bleeding.

Causes of Hemorrhage

It might be caused by trauma, accidental
or the iatrogenic blood vessels, spontaneous
blood vessel wall, spontaneous disintegrity due to aneurysm,
rupture, atherosclerosis, erosion by tumor ulcer infections,
or might be caused by severe hypercoagulation.

Internal Hemorrhage and Hematoma

Internal hemorrhage may lead
to the blood accumulation in pleura, peritoneum,
pericardium soft tissues, parenchymal organs.
This accumulated circumscribed
blood is hematoma.

Treatment of Hemorrhage

Hemorrhage treatment means evacuation
of accumulated blood or hematoma.
You should stop the bleeding source if still exists,
and perform resuscitation or blood transfusion if necessary.
It might be done using surgical approach,
or it might be done
by transcatheter treatment using percutaneous
or endo cavity approach.
This is the treatment option we are talking about today.

Transcatheter Approach: Capabilities and Considerations

What can we do by transcatheter approach?
Of course, we can evacuate the hematoma, but is it enough?
The most important question which arises now is,
is this hematoma stable or not?
Very important is this primary source,
what is the primary source of hematoma.
If it's artery or high pressure system,
it's more likely to have non-stable hematoma.
Unstable hematomas mostly are of arterial origin.
If we are dealing with the hematoma, which is fed by vein
or low pressure system,
we have much more possibility to
have this bleeding spontaneously stopped.

Differentiating Stable vs Unstable Hematoma

Can we differentiate between stable
versus unstable hematoma?
Of course, we take in consideration the history.
Longstanding hematoma tends to be stable.
We have clinical findings.
Symptoms of infections suggest stable hematoma.
Of course, we use imaging ultrasound may reveal the fresh
clots or totally liquefied content.
Incoming jet and doppler detects unstable hematoma.
CT and or MR with contrast can differentiate
between fresh versus old blood.
Contrasting flow detects unstable hematoma.

So can we get reliable information about the
hematoma stability?
The answer is no, because reliable is only positive answer.
Unstable hematoma, the negative answer is not reliable
because the blood inflow might be stopped due
to pressure equilibration
between the hematoma feeding vessel and accumulated blood.

Next Steps for Unstable Hematoma

If so, what should be the next step?
Wait and antibiotics surgery
or low invasive drainage using percutaneous
or endo cavity approach.
This is the treatment option we will
focus on today.

Low Invasive Drainage Procedure

Low invasive drainage, how we do it.
Low invasive means without surgery,
without general anesthesia.
So we need the imaging guidance.
What can we use as a imaging guidance tool?
Of course, ultrasound, combination of ultrasound
and fluoroscopy.
CT or mr.

Let's say a couple
of words about each of them.
Ultrasound can detect the target,
can image the movement
of the needle towards the target.
Helps us to aim the target
and provides the possibility
of imaging of vessels in real time.
Combination of ultrasound
and fluoroscopy is important when you need to
opacify the puncture cavity
to see the guidewire needle
and to monitor the
drainage catheter advancement in real time CT helps
to see any fluid collection very nicely
and to perform the
imaging guided puncture, and finally, the drainage.
But usually it's not
a real time technique,
but we should keep in mind possibility of CT fluoroscopy.
Also, MR provides with very nice possibility of imaging
and is not connected with ionizing radiation,
but it's relatively expensive
and time consuming technique.

Preferred Imaging Guidance: Ultrasound

Which imaging guidance technique is number one?
I suppose ultrasound is the best
because of certain advantages.
It's quick, it's not connected with ionizing radiation.
It's real time, which very critical.
It's including the vessel imaging using doppler.
The needle aiming and guiding
capability is very important advantage.
Possibility of endo cavity approach sometimes is critical
possibility of any plane guidance to have
the guidance procedure in any plane.
And finally, it's cost saving technique.

Equipment for Ultrasound and Combined Guidance

This is where a simple equipment, which is needed to,
to perform the ultrasound
or combined ultrasound fluoroscopy guidance.
This is ultrasound machines c-arm unit
with the operating table, which moves from the area
of ultrasound to the area of fluoroscopy.
You see here the probes,
which we use to reach the target.
This one we use convex we use,
when we perform,
percutaneous procedure.
This is the needle guide,
which accepts the different diameter adapters
for different diameter needle.
This transducer is endo cavity, which we use for transrectal
or transvaginal approach devices.
This is the one step drainage device, which is
inserted assembled.
So we are trying to, using this device, we are trying
to introduce the
drainage catheter into the target
with the very first puncture.
This is the
set which we use
for guidewire technique.
When we access the target using
puncture needle, which accepts the G wire
through which we conduct.
Finally, we introduce finally the
drainage catheter into the target.

Case Examples of Hematoma Drainage

Case 1: Post-Surgical Infected Hematoma in Liver

You see here example of the
hematoma drainage.
This patient underwent the surgery surgical hepa,
and after this surgical period,
patient became symptomatic.
Imaging revealed the complex mass in the liver,
which was suggested to be the infected hematoma.
You see the 18 gauge diameter needle inserted into the
infected hematoma.
You can monitor in real time
how the G wire is inserted into the target.
And finally, according the guidewire, the pigtail
catheter has been advanced into the hematoma.
In this particular case,
the hematoma turned out to be stable.

Case 2: Unstable Hematoma in Liver

Unlike this one, this scenario, it was the,
actually the same I'm measuring now, the volume of this
mass, which is something around three point 0.5,
a hundred ccs.
Patient became symptomatic.
We suggested the infected hematoma.
So drainage procedure is performed,
has been performed to him.
You see here the drainage catheter
and the process of content aspiration.
And when we got 200,
2.5 hundred ccs, it was okay.
But when we got 400 ccs
and we saw the fresh blood in content,
we understood immediately that we are dealing with
unstable hematoma.
So we had to close the drainage catheter.
And in few minutes after the,
after we closed the catheter, we saw the same size
mass in the liver.
So hematoma was unstable.
Finally, hematoma turned out to be unstable.

Management of Unstable Hematoma: Embolization

What is the next step?
First of all, we have to close the drainage catheter,
and then we should
identify the bleeding source, the bleeding vessel.
So CTA for this is preferable.
If it's venous, we can wait,
use antibiotics, resuscitation, blood transfusion,
and coagulopathy treatment, if any.
But if the bleeding source, if artery, we should switch
to trans arterial embolization.
You see here the DSA images of this patient.
The, you see guiding catheter in a common hepatic.
This is GDA, left right hepatic artery.
You see here our drainage catheter.
And shortly you notice the
contrast into the drained cavity,
which is, which reaches the
this hematoma via the fifth segment artery.
So we decided to perform the embolization immediately.
You see here the microcatheter placed in the fifth
segment artery.
And finally, we embolize this branch by glue.
And you see here the follow up post procedure arteriography.
And you see there is no contrast in drained cavity.
So hematoma was
converted to stable.
What is the next step?
Just use the drainage catheter, open it
and rinse the hematoma.

Case 3: Post-Laparoscopic Cholecystectomy with Pseudoaneurysm

This patient was referred to
interventional radiology department
after laparoscopic cholecystectomy with preliminary,
with preliminary diagnosis of destructive pancreatitis.
You see here on CT images,
you see here the fluid collection, which was supposed
to be pancreatic.
But we can note here that this
mass was very nicely demarcated from
probably normal pancreas.
When we do the ultrasound in the liver hilum, we saw the
cystic mass adjacent to the surgical clips, which has,
which has prominent jet blood jet flow,
in it, which was of arterial origin.
We did CTA, we saw this SDO aneurysm here adjacent to the
surgical clips, we performed drainage
of this hematoma, which we suggested that it was unstable.
What we performed drainage to have possibility
to keep the pressure to control the
pressure in this hematoma,
and patient immediately was switched to embolization.
This is CTA with 3D reconstruction.
You see here the three surgical clips and adjacent
pseudo aneurysm.
DSA, you see the drainage catheter,
guiding catheter in the right hepatic artery.
You note that the distal portion of
right hepatic artery is not seen at all, is interrupted.
So the problem is the iatrogenic.
And you see here this SDO aneurysm, which is connected with
small neck with the
other arterial blood circulation of the right lobe.
You can nicely see here that the residual flow of the right
lobe is maintained.
Via the eight segment artery collateral flow from eight segment artery only.
As you see here, the it was very technically very
tough to get the pseudo aneurysm itself
to perform the coiling procedure.
So we decided to use the glue in this case also.
You see the microcatheter in eight segment artery,
and this is the image performed after the glue injection into
into the eight segment artery.
In this video, you see
the glue in the eight segment artery,
and the contrast injection revealed no.
And the contrast injection revealed no
flow, no inflow in pseudo aneurysm.

Importance of CTA in Planning

We could say couple words about the importance of state
of art CTA.
When you perform such procedures,
if you compare the CTA images, which DSA images, you can
note that almost all the architecture of anatomy
of this arterial vessels are depicted on the CTA.
Only the right segment branch is not delineated nicely
on CT image.
And of course, it's much better seen on DSA image.
But anyway, CT angiography helps to
plan DSA guided embolization procedure in detail.

Summary of Transcatheter Treatment Process

Transcatheter treatment of hemorrhage, how we do it,
first of all, we have to detect the hematoma,
then we perform low invasive drainage of it.
If hematoma is stable, that's it.
No further intervention is needed
if we don't mention the catheter withdrawal.
And then when everything finishes,
so if hematoma is unstable, what happens?
We have to lock the drainage catheter,
and then we have to identify the bleeding source
by CT angiography.
And the next step is stabilization of the hematoma.
It might be performed conservatively when
we are dealing with venous source
or patient may require the
transarterial embolization when we are dealing
with arterial source.
And finally, everything finishes with transcatheter rinsing
of drained hematoma.

Thank you very much for your attention.