Multidetector CT of Blunt Multidetector CT of Blunt Traumatic Venous Injuries Traumatic Venous Injuries in the Chest, Abdomen, in the Chest, Abdomen, and Pelvisand Pelvis

A CilliersA Cilliers27/01/201227/01/2012

IntroductionIntroduction RareRare High morbidity and mortality due to High morbidity and mortality due to

associated injuriesassociated injuries Primary attention to more common and Primary attention to more common and

obvious injuriesobvious injuries MDCT protocols designed to evaluate MDCT protocols designed to evaluate

arterial and solid organ injuries arterial and solid organ injuries

MDCT trauma protocolMDCT trauma protocol IV material–enhanced multidetector CT of the IV material–enhanced multidetector CT of the

neck, chest, abdomen, and pelvisneck, chest, abdomen, and pelvis Arterial phaseArterial phase 90-second delayed imaging through the abdomen 90-second delayed imaging through the abdomen

and pelvis (PV phase)and pelvis (PV phase) Delayed phase imaging is not routinely includedDelayed phase imaging is not routinely included

Concern about an injury to the renal collecting system or Concern about an injury to the renal collecting system or Findings from the initial whole-body CT reveal a renal Findings from the initial whole-body CT reveal a renal

injury that is associated with an increased likelihood of a injury that is associated with an increased likelihood of a collecting system injurycollecting system injury

Direct signs:Direct signs: Diagnostic

1. Thrombosis and/or occlusion 2. Avulsion and/or complete tear/rupture 3. Active extravasation 4. Pseudoaneurysm

Indirect signs 1. Perivascular hematoma 2. Fat stranding 3. Vessel wall irregularity

These indirect signs can often be seen in association with other adjacent injuries

Discussion of specific Discussion of specific veins:veins:

Brachiocephalic Vein Azygos Vein Superior Vena Cava Pulmonary Vein Inferior Vena Cava Main Portal Vein Hepatic Veins Mesenteric Veins Splenic Vein Renal Vein Iliac Vein

Brachiocephalic Vein Rare Most commonly in iatrogenic penetrating

trauma Posterior dislocation of the clavicular

head

Posterior sternoclavicular dislocation in a 43-year-old woman after blunt trauma. Evaluation of the right subclavian and brachiocephalic veins was limited because of contrast material injection from the left side.

Venographic image depicts occlusion (solid arrow) of the right subclavian vein secondary to the posteriorly dislocated clavicle. The occlusion causes dilation of the collateral veins (open arrows)

Azygos Vein Mediastinal hematomas:

Aorta or aortic arch vessel Venous injuries Small vessel injuries Fractures of the sternum Azygos vein injuries

Rare Adjacent spinal fractures

Evaluation in multiple planes is often helpful for localizing a focus of active bleeding or a pseudoaneurysm

Mediastinal hematoma and azygos vein injury in a 34-year-old man after blunt trauma. Pseudoaneurysm present.

Superior vena cavaSuperior vena cava Extremely rare:

Die because of SVC injuries and other associated injuries

Most commonly in the setting of penetrating trauma

Blunt injuries: Near its insertion into the right atrium, where it is

enveloped by the pericardium Coexisting injury to the right atrium is common

Superior vena cava injury: Mediastinal hemorrhage (closed arrows) and a linear defect in the superior vena cava with an adjacent pseudoaneurysm (open arrow)

Superior vena cavogram: pseudo-aneurysm (arrows) along the lateral wall of the superior vena cava

Pulmonary Vein Strongly associated with severe comorbid

injuries (injuries to the atria, ventricles, main-stem bronchi, pericardium, and aorta)

Patients present with hypotension, hypovolemia, and massive hemothorax

Intrapericardial or extrapericardial Intrapericardial:

Hemopericardium with or without cardiac tamponade Extrapericardial:

Hemothorax

Inferior Vena Cava High morbidity and mortality Any subtle abnormality should prompt

(a) further evaluation with oblique nonstandard multiplanar reformatted images or

(b) additional imaging Imaging options:

Conventional venography CT venography

Few to no data exist to compare conventional venography to CT venography of the IVC in the setting of trauma

Each case should be considered individually: patient’s clinical presentation renal function likelihood of intervention needed

IVC injuries:IVC injuries: Associated with severe hepatic injuries and other

adjacent injuries Retrohepatic IVC injuries:

Special case - complicated surgical approach including both a laparotomy and thoracotomy

Identifying the location of the IVC injury aid in surgical planning Imaging pitfall:

Mixing of unenhanced blood with contrast material Simulate a thrombosis or vessel injury

Hemopericardium Rare manifestation of an IVC injury Differential diagnosis

IVC injuries in a 38-year-old woman after blunt trauma - subtle contour irregularity (arrow) of the IVC

Multiplanar reformatted image shows a small intimal flap (arrow)Follow-up cavogram helps confirm an abnormality (arrow) of the IVC, a finding consistent with a small intimal tear and formation of a small pseudoaneurysm

IVC injuries in a 27-year-old man after blunt trauma: hematoma (arrow) around the IVCA more inferior axial CT image from the same study shows a laceration through the IVC just proximal to the bifurcation, with associated intimal flaps and intraluminal thrombi (arrow)

Large hemopericardium and IVC injury in a 63-year-old woman after severe blunt chest and abdominal trauma.

(a) Axial contrast-enhanced CT image obtained in the arterial phase shows a small focus of hyperattenuation (arrow) in the right inferior pericardial space. (b) Axial contrast-enhanced CT image obtained in the portal venous phase shows enlargement of the focus of hyperattenuation (arrow).

Main Portal Vein Associated injuries:

Liver Pancreatic duct Bile duct

Require aggressive surgical treatment Injury to the intrahepatic portal veins:

Traumatic arteriovenous fistula Manifest with early filling of the portal veins with

contrast Arteriography indicated to determine diagnostic and

therapeutic options

Main portal vein injuries in a 63-year-old woman after blunt abdominal trauma:Contour abnormality and an intimal flap (black arrow) in the portal veinTrace surrounding fat stranding (white arrows) indicates a hematoma

Main portal vein dissection in a 30-year-old man after blunt abdominal trauma: Periportal and perihepatic hematoma (arrowheads)Intimal flap (arrow) is depicted in the main portal vein

Hepatic Veins Small hepatic venous injuries are relatively common in

the setting of liver parenchymal injuries, and bleeding typically stops spontaneously

Bleeding from hepatic venous injuries closer to the liver hilum or from one of the major hepatic veins is less likely to be controlled without intervention

Early filling of hepatic veins should raise concern for an associated arteriovenous fistula

Additional signs: Hepatic laceration extending into or through a hepatic or portal

vein Vessel irregularity Abrupt cutoff

Mesenteric Veins Unusual but are associated with considerable

morbidity and mortality (60%) Frequently associated with bowel injuries Clinical signs and symptoms of mesenteric or

bowel injury are nonspecific Difficult or impossible to differentiate whether

the source is arterial or venous

Mesenteric vein injury in a 53-year-old man after blunt trauma from a motor vehicle collision. (a, b) Axial (a) and coronal (b) contrast-enhanced CT images obtained in the portal venous phase show a large mesenteric hematoma (arrowheads).An abnormal focus of high-attenuation contrast material (arrow in a) is depicted within the hematoma

Splenic Vein Exceedingly rare Usually a result of penetrating trauma Injury to the small intrasplenic veins occurs in

the setting of a blunt traumatic injury to the spleen

As in intrahepatic injuries, early filling of the splenic vein with contrast material should prompt further evaluation with arteriography

Renal Vein Injuries to the pedicle are more likely to occur

in association with renal parenchymal injuries Isolated renal vein injuries are a rare Careful evaluation of the delayed phase

images for expanding hematoma is essential because this finding indicates a vascular injury with continued active bleeding

Axial contrast-enhanced CT image obtained in the late arterial phase shows decreased perfusion of the left kidney (arrow) and a large perirenal hematoma (arrowheads)

Axial contrast-enhanced CT image obtained in the delayed phase depicts accumulation of high-attenuation material (arrows) within the perirenal tissues, a finding that is consistent with active venous extravasation into the surrounding tissues

Iliac Vein Pelvic fractures are typically associated with

considerable blunt force trauma, and associated vascular injuries are identified frequently

Arterial injuries are more common Pelvic CT angiography (arterial, portal venous,

and delayed phases) - arterial and venous extravasation can be distinguish

ConclusionConclusion Rare injuriesRare injuries Subtle findingsSubtle findings High index of suspicionHigh index of suspicion High morbidity and mortalityHigh morbidity and mortality Multiplanar reformatsMultiplanar reformats If in doubt, further imaging neededIf in doubt, further imaging needed

References:References:

Brian P. Holly, Scott D. Steenburg: Multidetector CT of Blunt Traumatic Venous Injuries in the Chest, Abdomen, and Pelvis. RadioGraphics 2011; 31:1415–1424.

http://www.musc.edu/intrad/AtlasofVascularAnhttp://www.musc.edu/intrad/AtlasofVascularAnatomyatomy

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