Introduction

Embolization is an important weapon in the armamentarium of the interventional radiologist, particularly those who practice in a Trauma center. In a perfect world, an embolization agent would offer ease of deliverability in terms of system trackability and preparation, precise placement, stability, avoidance of non-target embolization, and cost-effectiveness. While the “pushable” coil has historically offered many of these assets, its lack of retrievability, poor packing density, and potential for nontarget embolization have limited its use. Until recently, “detachable” coil systems have been limited to the Neurointerventional world. However, focused developments of 0.018-inch and 0.035-inch fibered detachable coil systems such as the Interlock™ Fibered IDC™ Occlusion System have been approved for use in the peripheral vasculature. As a result, many cases that could not have been performed without detachable coils are now approachable.

The following cases demonstrate the application of detachable coils in trauma patients with uncontrollable bleeding.

CASE 1: POST-CARDIAC CATHETER HEMORRHAGE

Overview

A 67-year-old woman was catheterized 2 days prior to admittance into the OR. Upon arrival, the patient was hypotensive, had a hemoglobin of 7 gm/dL, and was sent for a CT of her pelvis.

Figure 1 shows a CT of a large right thigh hematoma with active extravasation from the common femoral artery region. The patient was immediately sent to Angio and catheterized through the left common femoral artery.

An angiogram of the right external iliac showed acute extravasation from the right proximal profunda, just proximal to the common femoral artery trifurcation (Figure 2).

Procedure Description

With a 5-F, 0.038-inch diagnostic catheter in place within the common femoral artery, an angled Renegade® STC Catheter was coaxially directed into the extravasation.

Once the catheter was put in place, three Interlock™ Coils were placed in the location of the extravasation, and special care was taken to pack the coils in a manner that did not disrupt the blood flow within the trifurcation (Figure 3). Figure 4 demonstrates this occlusion and the uncompromised adjacent branches.

Discussion

In a case such as this, a variety of different options may be deemed valid. However, all are accompanied by some degree of risk. Although the use of an indicated stent would have been simple, the placement of such a stent would have occurred across a joint and would have compromised a major branch. A second option for this patient was surgery. The final option, which was ultimately selected, was embolization. The obvious downside of this approach was the potential for nontarget embolization, as the landing zone for the coil nest was very small, and there was minimal margin for placement error. As discussed previously, the use of detachable Interlock coils allowed for rapid and precise coil placement, which minimized the risk of nontarget embolization.

CASE 2: SPLENIC ARTERY ANEURYSM

Overview

An elderly patient on Coumadin was admitted to the ER after a fall at home. Upon admission, the patient was in shock and had a systolic blood pressure of approximately 70 mm Hg and a hemoglobin of 8 gm/dL. The patient was consulted by trauma surgeons for preoperative splenic artery embolization to allow for resuscitation prior to attempted laparoscopic splenectomy.

A CT showed a massive perisplenic hematoma with acute intraparenchemal bleed (Figure 5). The superior mesenteric artery (SMA) angiogram showed an occluded celiac origin and a splenic blood supply from the SMA, via the pancreatic duodenal collaterals (Figure 6).

Procedure Description

A 5-F, 0.038-inch Cobra-shaped diagnostic catheter was used to gain access into the proximal superior mesenteric artery. A Renegade® STC Catheter was introduced through the diagnostic catheter and into the proximal splenic artery (Figure 7).

Multiple Interlock™ Coils were used for the embolization of the proximal splenic artery (Figure 8).

Discussion

The patient was stabilized and resuscitated with fluids and blood. The patient's coagulopathy was corrected, and an uneventful laparoscopic splenectomy was performed the next morning. In this case, detachable coils allowed for precise placement through very tortuous anatomy.

As a result of the interlocking connection between the coil and the pusher wire, we experienced no coil loss, which, in this case, would have been very difficult to retrieve. In addition, the long lengths of the coil allowed for fewer coils than would have been required with short, pushable coils.

CASE 3: SUPERIOR MESENTERIC ARTERY ANEURYSM

Case 3 is a 40-year-old man with a prior history of HIV. The patient developed a new large mesenteric mass, which was detected on CT. After imaging, the patient was sent for a core biopsy procedure with the working diagnosis of lymphoma. Pulsatile blood came from a 17-gauge needle guide, and the patient was sent immediately to angiography for possible embolization (Figure 9).

Procedure Description

A 5-F, 0.038-inch Cobra 2–shaped catheter and a hydrophilic guidewire were used to gain access into the SMA. A 6-F guide sheath was then placed. A 5-F, 0.038- inch Bern-shaped catheter was used to access the aneurysm. The aneurysm was then framed with multiple 20-mm X 40-cm Interlock™ – 35 Coils. After numerous 20-mm X 40-cm coils, smaller-diameter coils were used to begin filling the framed portion of the aneurysm (Figure 10).

Upon filling the aneurysm, a 14-mm Amplatzer™ Vascular Plug was utilized in an attempt to embolize the proximal portion of the IMA. However, the rapid blood flow quickly moved the device toward the base of the nest of coils (Figures 11 and 12).

The case was finished by packing multiple additional Interlock™ – 35 Coils in the neck of the inferior mesenteric artery. In total, thirty-six 40-cm-long coils were utilized to attain complete stasis (Figure 13).

Discussion

This patient had a difficult situation, and removal of the guide would have resulted in massive hemorrhage. The precise, safe, and quick embolization of the IMA saved his life. As was demonstrated by the migration of the Amplatzer™ Vascular Plug, the blood flow was quite rapid, and the detachable nature of the Interlock™ – 35 Coils allowed confidence when addressing this embolization procedure. In addition, the extremely long coil lengths offered by the Interlock™– 35 Coil allowed for a total of more than 1,500 cm of coil to be delivered very efficiently in this case.

Dana Tomalty, MD, is an Interventional Radiologist at Huntsville Hospital in Huntsville, Alabama.