Download Multidetector CT of Blunt Traumatic Venous Injuries in the

Multidetector CT of
Blunt Traumatic Venous
Injuries in the Chest,
Abdomen, and Pelvis
A Cilliers
27/01/2012
Introduction
 Rare
 High morbidity and mortality due to
associated injuries
 Primary attention to more common and
obvious injuries
 MDCT protocols designed to evaluate
arterial and solid organ injuries
MDCT trauma protocol
 IV material–enhanced multidetector CT of the
neck, chest, abdomen, and pelvis
 Arterial phase
 90-second delayed imaging through the abdomen
and pelvis (PV phase)
 Delayed phase imaging is not routinely included
 Concern about an injury to the renal collecting system or
 Findings from the initial whole-body CT reveal a renal injury
that is associated with an increased likelihood of a
collecting system injury
Direct signs:
 Diagnostic
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Thrombosis and/or occlusion
Avulsion and/or complete tear/rupture
Active extravasation
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
veins:
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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:
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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 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, mainstem 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:
 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 IVC
A 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 vein
Trace 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
Conclusion
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Rare injuries
Subtle findings
High index of suspicion
High morbidity and mortality
Multiplanar reformats
If in doubt, further imaging needed
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/AtlasofVascularAna
tomy
 Sutton