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Indications & Contraindications
Patient selection, AAST grading, when to go to angio vs OR
Indications
- Blunt or penetrating hepatic injury with contrast blush, pseudoaneurysm, or arteriovenous/arterioportal fistula on CTA
- AAST grade III–V injuries with arterial injury on imaging — almost 83% success rate for grade III–IV
- Hemodynamically stable or stabilizing patient (responding to resuscitation)
- Post-surgical hepatic bleeding — adjunct to damage control laparotomy
- Failure of nonoperative management (NOM) with hemodynamic instability and high suspicion for hepatic arterial bleed
- Decreasing serial hematocrit measurements suggesting ongoing arterial hemorrhage
Contraindications
- Hemodynamic instability requiring OR — damage control surgery takes priority; “lethal triad” of coagulopathy, acidosis, hypothermia = emergent laparotomy
- Hepatic vein / IVC injury — not amenable to arterial embolization; requires surgical repair
- Juxtahepatic venous injuries (grade V) — retrohepatic vena cava or central major hepatic veins = surgical
- Concurrent peritoneal irritation requiring laparotomy (missed bowel injury)
AAST Hepatic Injury Grading (2018 Update)
| Grade | Injury Type | Description |
|---|---|---|
| I | Hematoma / Laceration | Subcapsular <10% surface area; capsular tear <1 cm depth |
| II | Hematoma / Laceration | Subcapsular 10–50%; intraparenchymal <10 cm; laceration 1–3 cm depth, <10 cm length |
| III | Hematoma / Laceration / Vascular | Subcapsular >50% or expanding; >3 cm depth; active bleeding contained within parenchyma |
| IV | Laceration / Vascular | 25–75% lobar disruption; 1–3 Couinaud segments; active bleeding beyond parenchyma into peritoneum |
| V | Laceration / Vascular | >75% lobar disruption; >3 Couinaud segments; juxtahepatic venous injuries (IVC/central hepatic veins) |
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Pre-Procedure Planning
Imaging review, resuscitation, trauma team communication
Imaging & Labs
- CTA abdomen/pelvis with arterial AND portal venous phases — identify contrast blush, pseudoaneurysm, AV fistula, and extent of parenchymal injury
- AAST grading based on CT findings — grade III–IV stable injuries typically warrant angiographic evaluation
- FAST exam in trauma bay — assess for free fluid; does not accurately estimate degree of injury
- Labs: CBC, CMP, coagulation parameters (PT/INR, fibrinogen), lactate, type & crossmatch
- Abnormal liver function may not manifest for hours to days post-injury
- Evaluate for concurrent injuries: spleen, kidney, bowel, diaphragm
Resuscitation & Coordination
- Massive transfusion protocol if needed — 1:1:1 ratio (pRBC : FFP : platelets)
- Assess for hepatic vein injury (retrohepatic IVC, major hepatic veins) — NOT amenable to embolization, requires surgical approach
- Direct communication with trauma surgery — establish plan: embolization first vs OR first vs adjunct post-surgical embo
- Interventional radiology team on standby in trauma bay for rapid transfer to angio suite
- Ensure angio suite is pre-set with microcatheter systems and embolic agents ready
CTA reviewed. Arterial and portal venous phases evaluated. Active extravasation, pseudoaneurysm, or AV fistula identified. AAST grade assigned.
Vascular anatomy assessed. Check for replaced/accessory hepatic artery anatomy on CTA. Note replaced RHA from SMA if present.
Hepatic vein injury excluded. Retrohepatic IVC and central hepatic veins intact — no surgical indication from venous injury.
Hemodynamic status confirmed. Patient hemodynamically stable or stabilizing with resuscitation. Not in lethal triad.
Trauma surgery communication. Plan discussed: embolization vs OR vs adjunct. Surgical team aware and available if needed.
Blood products available. Type & crossmatch sent. MTP activated or on standby. Blood in angio suite.
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Relevant Anatomy
Hepatic arterial supply, variant anatomy, dual blood supply
Standard Hepatic Arterial Anatomy
- Celiac trunk → common hepatic artery → proper hepatic artery (after GDA takeoff)
- Proper hepatic artery bifurcates into right and left hepatic arteries
- Right hepatic artery (RHA) — supplies segments V–VIII; typically posterior to common bile duct
- Left hepatic artery (LHA) — supplies segments II–IV
- Middle hepatic artery (branch of LHA) — supplies segment IV
- Cystic artery typically arises from RHA
Variant Anatomy (Critical to Identify)
- Replaced RHA from SMA — occurs in 15–20% of patients; MUST inject SMA to evaluate for hepatic arterial injury in these patients
- Replaced LHA from left gastric artery — occurs in ~10% of patients
- Accessory hepatic arteries — supplemental supply in addition to standard anatomy
- Complete replaced common hepatic artery from SMA — rare (~2.5%)
- Always review CTA pre-procedure for aberrant anatomy; if not available, perform aortography or SMA injection during angiography
Dual Blood Supply — Key Concept
The liver receives dual blood supply: the hepatic artery provides ~25% of hepatic blood flow and the portal vein provides ~75%. This dual supply means the liver tolerates arterial embolization significantly better than other solid organs (spleen, kidney). However, in trauma patients with concurrent portal vein injury, shock liver, or post-surgical hepatic ischemia, the protective effect of dual supply is diminished — exercise greater caution with proximal embolization in these scenarios. Hepatic artery ligation/embolization carries increased necrosis risk when portal venous flow is compromised.
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Technique
Access, catheterization, embolic selection, embolization approach
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Arterial Access
Common femoral artery (CFA) access — standard right CFA unless contraindicated. 5F arterial sheath. In unstable trauma patients, rapid access is critical — ultrasound-guided if available. Left CFA or radial access as alternative.
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Celiac Trunk Catheterization
5F Cobra C2 or SOS Omni catheter to celiac trunk. Perform celiac arteriogram to map hepatic arterial anatomy and identify active extravasation, pseudoaneurysm, or AV fistula. Note proper hepatic artery, GDA, splenic artery origins.
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Selective Hepatic Arteriogram
Advance into proper hepatic artery or common hepatic artery. Perform selective hepatic arteriogram. Identify injured arterial branch, active extravasation site, pseudoaneurysm, or fistula. Evaluate right and left hepatic artery territories separately if needed.
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Check for Replaced RHA from SMA
If right hepatic artery not visualized from celiac injection, or if CTA suggested variant anatomy, catheterize the SMA and perform SMA arteriogram. Replaced RHA from SMA occurs in 15–20% — missing this is the most common reason for failed hepatic embolization.
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Superselective Microcatheter Access
Coaxial microcatheter (2.4–2.8F) advanced to the injured branch as distally as possible. Superselective positioning is critical to preserve hepatic parenchyma — embolize as close to the injury as feasible. Confirm position with micro-injection before deploying embolic.
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Embolization
Focal injury (PSA, AV fistula): microcoils — pack the pseudoaneurysm or deploy coils proximal and distal to the injury (front-door/back-door technique). Diffuse parenchymal injury: Gelfoam (gelatin sponge) slurry — temporary embolic, preferred for diffuse bleeding; allows potential recanalization. Avoid main hepatic artery coiling if at all possible — risk of hepatic necrosis, especially in post-surgical patients. Liquid embolics (n-BCA glue, Onyx) used selectively for difficult-to-reach lesions.
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Completion Angiography
Post-embolization hepatic arteriogram to confirm cessation of extravasation and resolution of pseudoaneurysm/fistula. Evaluate for additional injury sites. Re-image celiac trunk and SMA if concern for multi-vessel injury. Document distal hepatic perfusion.
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Access Site Management & Transfer
Remove sheath, achieve femoral hemostasis (manual compression or closure device). Transfer to ICU for close monitoring. Communicate findings and embolization details to trauma surgery team. Document vessels embolized, embolic agents used, and post-embolization flow status.
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Angiographic Landmarks
Key vessels to identify, variant anatomy check
Standard Landmarks
- Celiac trunk — first major anterior branch off aorta at T12/L1; origin of common hepatic, splenic, and left gastric arteries
- Common hepatic artery → gives off GDA → continues as proper hepatic artery
- Proper hepatic artery — bifurcates into RHA and LHA; key vessel to identify before deploying microcatheter
- Right hepatic artery — anterior and posterior divisions; cystic artery branch
- Left hepatic artery — segments II, III, IV supply
Variant Anatomy Check
- SMA injection — ALWAYS perform if replaced RHA suspected or if RHA not visualized from celiac injection
- Replaced RHA from SMA — courses posterior to pancreatic head and portal vein to enter hepatic hilum
- Left gastric artery injection — if replaced LHA suspected
- Accessory arteries may supply the injured segment even when standard anatomy appears normal
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Troubleshooting
Difficult anatomy, multiple injuries, persistent bleeding
Variant Anatomy
Replaced Hepatic Artery Not Identified on Celiac Injection
If the right hepatic artery is not seen from the celiac trunk, always inject the SMA. Replaced RHA from SMA is present in 15–20% of patients. Similarly, if LHA not visualized, inject the left gastric artery. Failure to identify variant anatomy is the most common cause of missed injury and failed embolization.
Multiple Injury Sites
Active Extravasation from Multiple Hepatic Branches
Systematically catheterize and embolize each injured branch superselectively. Gelfoam slurry may be preferred for diffuse multi-segment injury. If too many branches are involved for superselective approach, consider more proximal Gelfoam embolization of the right or left hepatic artery — but recognize increased ischemia risk. Completion angiography after each embolization to reassess.
Portal Venous Injury
Suspected Concurrent Portal Vein Injury
Portal venous injury is NOT amenable to arterial embolization. If CTA demonstrates portal vein extravasation or thrombosis, communicate immediately with trauma surgery. Arterial embolization in the setting of portal vein injury significantly increases hepatic necrosis risk due to loss of dual blood supply. Surgical management required for portal venous bleeding.
Biliary Injury
Concurrent Bile Duct Injury Identified
Biliary injury may be identified on CTA (periportal fluid, bile leak) or present as delayed complication. Does not preclude arterial embolization for active hemorrhage — hemorrhage control takes priority. MRCP post-stabilization to characterize biliary injury. May require subsequent percutaneous biliary drainage or ERCP with stenting.
Persistent Bleeding
Continued Hemorrhage Despite Embolization
Re-image from the celiac trunk and SMA to check for missed branches, replaced anatomy, or collateral supply to injury site. Consider hepatic vein or portal vein injury as source (not treatable with embolization). If arterial bleeding persists despite adequate embolization — communicate with surgery for emergent operative management. Ongoing hemodynamic instability = surgical intervention.
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Complications
Post-embolization morbidity, hepatic-specific risks
Hepatic Complications
- Hepatic infarction/necrosis (8.6%) — less common than other solid organs due to dual blood supply; risk increases with proximal embolization, concurrent portal vein injury, or post-surgical state
- Biloma (2.8%) — bile collection from injured bile ducts; may present days to weeks post-embolization; diagnose with CT or MRCP; treat with percutaneous drainage
- Hepatic abscess (6.8%) — secondary infection of necrotic/devitalized hepatic tissue; broad-spectrum antibiotics + percutaneous drainage
- Gallbladder infarction (3.6%) — cystic artery arises from RHA; risk with proximal RHA embolization; may require cholecystectomy
- Bile duct stricture — delayed complication from peribiliary ischemia; presents weeks to months later with biliary obstruction; MRCP for diagnosis
General & Vascular Complications
- Re-bleeding (6%) — post-embolization rebleeding from recanalization, missed branches, or new injury; monitor with serial H/H; repeat angiography if needed
- Abdominal compartment syndrome (2%) — massive hemorrhage or fluid resuscitation; bladder pressure monitoring; surgical decompression if needed
- Septic complications (0.6%) — peritonitis, sepsis from devitalized tissue or concurrent bowel injury
- Access site complications — hematoma, pseudoaneurysm, retroperitoneal hemorrhage from femoral access
- Non-target embolization — coil/particle migration to GDA, gastric, or splenic territories; superselective technique minimizes risk
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Pearls & Pitfalls
High-yield tips for hepatic trauma embolization
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Dual blood supply is your friend. The liver tolerates arterial embolization well because the portal vein provides ~75% of hepatic blood flow. This is why hepatic embolization has lower ischemic complication rates than splenic or renal embolization.
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Always check for replaced RHA from SMA. Present in 15–20% of patients. Missing a replaced RHA is the most common cause of failed hepatic embolization. If the RHA is not seen from celiac injection, inject the SMA before concluding.
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Gelfoam for diffuse, coils for focal. Gelfoam (gelatin sponge) is preferred for diffuse parenchymal hemorrhage — it is a temporary embolic agent allowing potential recanalization and hepatic recovery. Coils are best for focal pseudoaneurysms and AV fistulae.
✦
Superselective is key. Embolize as distally as possible to preserve hepatic parenchyma. Avoid main hepatic artery coiling unless absolutely necessary — proximal embolization dramatically increases necrosis risk, especially in post-surgical patients or those with portal vein compromise.
✦
Biliary complications present delayed. Bilomas and bile duct strictures may not manifest for days to weeks post-embolization. Follow LFTs and obtain MRCP if there is any concern for biliary injury. Early percutaneous drainage of bilomas prevents secondary infection.
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Do not embolize proximally in the setting of portal vein injury. If the portal vein is thrombosed or injured, the protective dual blood supply is lost. Proximal hepatic artery embolization in this setting leads to extensive hepatic necrosis. Communicate with surgery immediately.
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Do not assume a negative celiac arteriogram excludes hepatic arterial injury. Replaced anatomy is common. Always interrogate the SMA if there is any clinical suspicion for ongoing hepatic hemorrhage.
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Hepatic vein injuries are surgical. Retrohepatic IVC and central hepatic vein injuries (grade V) are not amenable to arterial embolization. Attempting embolization in these patients wastes critical time — communicate with trauma surgery for operative management.
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References & Resources
Primary sources and related procedures
Key Concepts
- Nonoperative management (NOM) is successful in ~80% of blunt hepatic trauma; embolization is critical adjunct when NOM fails
- Angiographic embolization has ~83% success rate for grade III–IV injuries
- Complication rates: ~28% overall; 6% rebleeding; 0.7% procedure-related mortality
Primary References
- Pillai AS, Kumar G, Pillai AK. Hepatic trauma interventions. Semin Intervent Radiol. 2021;38(1):96–104. DOI: 10.1055/s-0041-1724014
- Kozar RA, Crandall M, Shanmuganathan K, et al. Organ injury scaling 2018 update: spleen, liver, and kidney. J Trauma Acute Care Surg. 2018;85(6):1119–1122.
- Virdis F, Reccia I, Di Saverio S, et al. Clinical outcomes of primary arterial embolization in severe hepatic trauma: a systematic review. Diagn Interv Imaging. 2019;100(2):65–75.
- Padia SA, Ingraham CR, Moriarty JM, et al. Society of Interventional Radiology position statement on endovascular intervention for trauma. J Vasc Interv Radiol. 2020;31(3):363–369.
- Feliciano DV, Rozycki GS. Hepatic trauma. Scand J Surg. 2002;91(1):72–79.
- Taghavi S, Askari R. Liver Trauma. Treasure Island, FL: StatPearls; 2020.