JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
Angiogram was performed about 36 hours after the CT scan to further characterize and possibly treat the vascular injury and the shunt. Aortogram was followed by selective catheterization of the superior mesenteric artery (SMA) and celiac arteries (using a 5 Fr Rosch-Celiac catheter) and their DSA, followed by super selective catheterization of the hepatic artery (using a microcatheter and microwire) and DSA evaluation. A total of 60 ml of Visipaque 270 was used and the fluoroscopy time was 4.7 minutes. Transection of the distal proper hepatic artery was seen along with early visualization of the right portal system, confirming the arterioportal fistula (Figure 3 and 4). Injury of the right portal was suspected. There was no evidence of active extravasation. Findings were communicated to the surgery team who contemplated further exploration and surgical management.
It also showed intrahepatic right hepatic artery transection and a suspected abnormal communication between the transected right hepatic artery and the right branch of the portal vein (arterioportal fistula), with more intense enhancement of the right-sided portal venous system (Figure 2). Other findings were right-sided hemothorax and hemoperitoneum, with no evidence of active blood or urine extravasation. Right renal laceration (grade III per AAST kidney injury scale) was also seen. The ballistic fragment was seen in the subcutaneous right-lower chest (Figure 1). Figure 1: Contrast enhanced CT axial image of the upper abdomen demonstrates an extensive bilobar hepatic laceration (arrowheads) after a gunshot wound. A serpiginous focus of contrast material is identified in the hepatic hilum (arrow). The perfusion abnormality is seen in the hepatic segment 8 (P). A right renal laceration and perinephric hematoma are also seen.
Figure 3: Selective early DSA of the celiac trunk demonstrates a contained serpiginous focus of contrast at the level of the main hepatic artery (arrow) and early filling of the right portal branch.
Figure 2: Contrast enhanced CTmaximum intensity projection image at the hepatic hilum shows traumatic injury of the hepatic artery (arrow) with early filling of the main portal vein (arrowhead) suggesting a post traumatic hepatic arterioportal fistula.
Figure 4. Selective delayed DSA of the celiac trunk shows traumatic injury of the hepatic artery (arrow). An early portal venous filling suggests the abnormal communication between the hepatic artery and the main portal vein (arrowhead).
J La State Med Soc VOL 170 MAY/JUNE 2018 89
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