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 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 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 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: 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 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/AtlasofVascularAnatomy Sutton