Emergency IR · IR Playbook

Endovascular Management of Solid-Organ Trauma (TAE)

Endovascular management of solid-organ trauma uses angiography and transarterial embolization to control splenic, hepatic or renal arterial hemorrhage while preserving viable parenchyma. It is primarily used in hemodynamically stable or stabilized patients with active extravasation, pseudoaneurysm, arteriovenous fistula or ongoing hemorrhage during nonoperative management. Persistent instability requiring immediate laparotomy must not be delayed for angiography, although postoperative or hybrid-room embolization may complement damage-control surgery.

Learning objectives

• Select trauma patients who benefit from embolization rather than observation or immediate surgery.
• Recognize active extravasation, pseudoaneurysm, arteriovenous fistula, arterial truncation and organ devascularization on multiphase CT.
• Choose proximal or distal splenic embolization according to injury distribution and physiology.
• Perform superselective hepatic and renal embolization while minimizing parenchymal loss.
• Recognize rebleeding, infarction, abscess, hepatic necrosis, biloma and renal dysfunction after embolization.

Indications

• Hemodynamically stable or stabilized adult with splenic, hepatic or renal arterial extravasation, pseudoaneurysm or arteriovenous fistula on multiphase CT.
• Splenic arterial blush in a stable adult, irrespective of parenchymal injury grade.
• Stable adult with AAST grade IV–V splenic injury, even without CT blush, when experienced embolization services are rapidly available.
• Hepatic arterial hemorrhage during nonoperative management or persistent arterial bleeding after damage-control packing or operative hemostasis.
• Renal arterial extravasation, pseudoaneurysm, AVF or non-self-limiting gross hematuria in a stable or stabilized patient.
• Delayed hemorrhage or post-traumatic splenic, hepatic or renal pseudoaneurysm.
• Ongoing transfusion requirement or falling hemoglobin attributed to an arterial solid-organ injury without another indication for laparotomy.

Relative contraindications

• Severe coagulopathy or trauma-induced coagulopathy that cannot be corrected concurrently with hemorrhage control.
• Severe iodinated-contrast hypersensitivity when alternative management is immediately available.
• Advanced renal dysfunction, particularly when treating the only functioning kidney; life-threatening hemorrhage generally outweighs contrast risk.
• Severely diseased, injured or inaccessible arterial access routes.
• Pregnancy, requiring individualized radiation and contrast-risk minimization.
• Pediatric splenic blush without continuing hemorrhage; CT blush alone is not an absolute indication for embolization in children.

Equipment

• Ultrasound machine, sterile probe cover and 21G micropuncture access set
• 4–6 Fr introducer sheaths; 5 Fr is routine
• 0.035-inch hydrophilic angled guidewire and 0.035-inch supportive exchange wire
• 4–5 Fr flush catheter for aortography when the bleeding source is uncertain
• 5 Fr Cobra, Simmons, SOS, renal double-curve or reverse-curve diagnostic catheters
• 2.0–2.8 Fr microcatheter with 0.014-inch or 0.016-inch microwire
• 0.018-inch and 0.035-inch pushable or detachable coils in multiple diameters and lengths
• Vascular plugs sized to the target splenic or other proximal artery
• Gelatin-sponge sheet for 1–2 mm pledgets, torpedoes or slurry; avoid gelatin-sponge powder
• Calibrated particles generally larger than 300 µm for selected low-flow lesions without AVF
• NBCA with iodized oil, D5W and a compatible microcatheter for selected severe coagulopathy or rapid permanent occlusion
• Nonionic iodinated contrast, power injector and hemodynamic monitoring equipment
• Femoral closure device or manual-compression equipment selected according to access anatomy and coagulopathy

Procedure steps

1. Confirm the treatment decision with trauma surgery, anesthesia and critical care. Continue blood-product resuscitation, warming and correction of trauma-induced coagulopathy throughout the procedure.Pearl: Embolization is part of damage-control resuscitation, not a reason to pause it.
2. Correlate the organ injury, arterial-phase lesion and delayed-phase behavior with the expected vascular territory. Identify variant arteries, portal-vein patency, collecting-system injury and competing operative lesions.Pearl: Active extravasation enlarges or increases in attenuation on later phases, whereas a contained vascular injury typically follows arterial blood-pool attenuation.
3. Puncture the common femoral artery under ultrasound guidance and place a 5 Fr sheath. Use radial access selectively when femoral access is unsuitable and the operator is experienced.Pearl: In profound hypotension, promptly remove an occlusive femoral sheath after treatment to reduce iliofemoral thrombosis.
4. Perform selective organ angiography guided by CT. Use a flush aortogram only when the source is uncertain, multiple territories are suspected or the patient reached angiography without adequate cross-sectional imaging.Pearl: Hypotension-related vasospasm can conceal bleeding; selective injections and delayed images are more sensitive than a single flush run.
5. Advance a 2.0–2.8 Fr microcatheter toward the abnormal artery and obtain orthogonal or oblique angiograms. Confirm extravasation, pseudoaneurysm, AVF, truncation and collateral inflow before embolization.Pearl: Advance beyond critical side branches and, when feasible, beyond the lesion before using a sandwich technique.
6. For a focal distal lesion, selectively embolize the injured segmental branch. For multifocal injury, high-grade injury or angiographically occult bleeding, perform proximal splenic artery embolization, preferably between the dorsal pancreatic and pancreatica magna origins; combine distal and proximal treatment only when necessary.Pearl: Current WSES consensus conditionally prefers proximal SAE when splenic embolization is required.
7. Interrogate the celiac axis and the SMA when variant hepatic supply is possible. Embolize the involved segmental or subsegmental hepatic branch using coils, gelatin sponge or NBCA according to lesion morphology, flow and coagulation status.Pearl: Use distal and proximal coil occlusion for a pseudoaneurysm or transected artery when collateral backfilling is possible.
8. Select the main and accessory renal arteries and catheterize the injured segmental branch as distally as possible. Use coils for focal arterial disruption or pseudoaneurysm and gelatin sponge selectively for diffuse low-flow bleeding; reserve main renal artery embolization for uncontrollable destruction, nonviable kidney or planned nephrectomy.Pearl: Repeat superselective embolization can preserve the kidney after initial treatment failure.
9. Use coils or plugs for focal large-vessel occlusion, gelatin-sponge pledgets or slurry for rapid temporary distal control and NBCA for rapid permanent occlusion when conventional thrombosis may be unreliable. Match coils to the measured vessel rather than estimating from a vasoconstricted shock-state angiogram.Pearl: Gelatin sponge can reinforce coils in coagulopathy, whereas NBCA is less dependent on the patient's coagulation system.
10. Perform a test injection to confirm catheter stability and exclude hazardous reflux. Inject particulate or gelatin-sponge material in small aliquots under continuous fluoroscopy to partial stasis; densely pack coils or deploy the plug without covering essential branches.Pearl: Flush particulate material from the catheter before withdrawal so retained particles are not released into a nontarget artery.
11. Repeat selective angiography after allowing vasospasm to relax. If bleeding persists, examine variant hepatic arteries, short gastric and pancreatic pathways, accessory renal arteries, inferior phrenic, intercostal or other arteries suggested by the injury location.Pearl: Persistent hemorrhage after apparently successful embolization often represents an untreated collateral or a second injury rather than failure of the embolic.
12. Obtain completion angiography demonstrating exclusion of extravasation, pseudoaneurysm or AVF and preservation of uninvolved organ perfusion. Secure or remove the sheath according to physiology, coagulopathy and likelihood of repeat angiography, then provide a structured handover.Pearl: Record the embolized artery, embolic type, expected infarct territory and any residual lesion requiring surveillance.

Complications

• Post-embolization pain and fever
• Limited segmental splenic or renal infarction
• Access-site hematoma, pseudoaneurysm or arterial thrombosis
• Persistent or recurrent hemorrhage
• Nontarget embolization
• Extensive splenic infarction or splenic abscess
• Hepatic necrosis, abscess, biloma or bile leak
• Renal dysfunction or post-traumatic renovascular hypertension
• Contrast-associated acute kidney injury or severe hypersensitivity

Exam pearls

• Physiology overrides injury grade: a hemodynamically unstable nonresponder generally requires surgery, while stable high-grade injuries may undergo nonoperative management with embolization.
• The current grading reference is the 2018 AAST OIS for spleen and liver, but the kidney scale was updated separately in 2025.
• WSES conditionally favors proximal rather than distal SAE when splenic embolization is required.
• Hepatic embolization should be as selective as physiology permits, and portal-vein patency must be checked before sacrificing a large hepatic arterial territory.
• Renal segmental arteries are end arteries; superselective embolization directly determines how much functioning parenchyma is preserved.
• Coils depend partly on thrombosis, whereas NBCA can provide rapid permanent occlusion in severe coagulopathy but demands liquid-embolic expertise.
• A negative angiogram can reflect vasospasm, hypotension or intermittent tamponade; it does not automatically invalidate a well-localized CT lesion.
• Vaccination is not routinely required after every SAE; individualize it when approximately 50% or more of splenic mass is lost or functional asplenia is suspected.

Viva questions

Which trauma patient is suitable for solid-organ angioembolization?

The ideal patient is hemodynamically stable or stabilized, has no competing indication for immediate laparotomy and has CT or angiographic evidence of arterial bleeding, pseudoaneurysm or AVF. Selected transient responders may undergo embolization only where continuous resuscitation, surgery and rapid escalation are immediately available.

When should a stable splenic injury be embolized?

SAE is first-line for an adult with arterial blush, irrespective of grade. WSES also suggests angiography and possible SAE for stable AAST grade IV–V injuries even without blush, while routine embolization of grade III injury without vascular abnormality remains individualized.

How do proximal and distal splenic embolization differ?

Proximal embolization lowers splenic perfusion pressure while collateral pathways maintain viability and is favored for multifocal or high-grade injury. Distal embolization treats a focal branch injury but causes segmental infarction and has more minor infarction-related complications.

Where should proximal splenic artery embolization be performed?

The usual target is the main splenic artery after the dorsal pancreatic origin and before the pancreatica magna origin. This preserves pancreatic and collateral splenic pathways while reducing splenic arterial pressure.

Why must portal-vein patency be assessed before hepatic embolization?

The liver depends on dual inflow. Extensive hepatic arterial embolization in the presence of impaired portal flow substantially increases hepatic necrosis, biliary ischemia and abscess risk.

Why is renal embolization performed superselectively?

Renal segmental arteries are end arteries, so every embolized branch produces parenchymal infarction. Superselective treatment controls hemorrhage while preserving the maximum functioning kidney.

Which embolic should be avoided in a traumatic AVF?

Particles and uncontrolled liquid embolics should generally be avoided because they can pass through the fistula into the pulmonary or systemic circulation. Detachable coils or a vascular plug provide more controlled occlusion.

What should you do if CT shows renal extravasation but angiography is negative?

Perform careful selective angiography of the main and accessory renal arteries and account for vasospasm or intermittent bleeding. If no active lesion is demonstrated in a patient with two kidneys, blind renal embolization is not recommended; continue monitored management and repeat imaging or angiography if bleeding recurs.

References