The liver is the largest solid organ in the body and is frequently injured in abdominal trauma.¹ The spectrum of liver trauma can vary from minor subcapsular hematomas to severe parenchymal lacerations or large vessel injuries. The American Association for the Surgery of Trauma (AAST) hepatic injury scale has been applied since the early 1990s and has become popular worldwide.² Treatment choice depends on the grade and type of lesion, the patient’s hemodynamic status, and associated injuries.^1,3–5 While most minor- and moderate-grade liver injuries can be successfully managed by nonsurgical therapies, severe-grade injuries almost always require surgery.^1,3–5 Some recent papers have reported attempting transarterial embolization (TAE) in patients with severe posttraumatic liver injury, even when hemodynamically unstable.^6,7

We describe a 19-year-old male patient with traumatic shock following a motorcycle accident, with AAST grade IV liver lacerations, bilateral displaced femoral fractures, and right patellar fractures. An urgent laparotomy with perihepatic packing and hepatorrhaphy was performed, but could not stop the bleeding. Successful hemostasis was subsequently restored by TAE without any complications.

A 19-year-old male patient with no remarkable medical history was transferred to our institution from a peripheral hospital with a diagnosis of multiple traumas following a motorcycle accident 5 hours earlier. His injuries included AAST grade IV liver lacerations, bilateral displaced femoral fractures, and right patellar fractures (Fig. 1). On admission, he was lethargic and pale. His blood pressure measured 65/30 mmHg with a heart rate of 130 bpm. Abdominal examination showed abdominal distension, diffuse peritoneal tenderness, and a large amount of free intra-abdominal fluid. The bilateral femoral and right patellar fractures were immobilized with traction splints without signs of vascular injury. Whole-body computed tomography (CT) taken at the peripheral hospital (3 hours before admission to our hospital) allowed a diagnosis of grade IV liver injury with two complicated deep lacerations of 15 cm located between the anterior and posterior segments extending to the right hepatic vein, three active contrast extravasations (one from segment VII and two from segment VIII), and extensive hemoperitoneum (Fig. 1A–1C). The Focused Assessment with Sonography in Trauma echo at the emergency department revealed disruption of the right liver, perihepatic hematoma, and excessive hemoperitoneum. The patient was quickly given fluid resuscitation, vasopressors, and analgesia, but he remained pale and hypotensive (85/60 mmHg). Hence, an exploratory laparotomy was immediately performed. During surgery, the abdomen contained approximately 3 liters of blood. There were two deep lacerations of the right liver lobe, which almost separated the anterior and posterior segments, with major hemorrhage from the right anterior section that corresponded to the active contrast extravasation from subsegment VIII on CT. However, active extravasation from subsegment VII was not found intraoperatively. The right anterior hepatic artery was ligated, and perihepatic packing and hepatorrhaphy were performed. One gallbladder and two subhepatic abdominal drains were placed. Intraoperatively, the patient received three units each of concentrated erythrocytes and fresh frozen plasma, tranexamic acid, and crystalloid fluids. The vasopressors were maintained in high doses. However, the patient remained in shock with a blood pressure of 85/50 mmHg and a pulse of 140–145 bpm. More than 150 mL of blood drained through the abdominal drains within the first hour postoperatively.

Figure 1. (A–C) Whole-body CT from the peripheral hospital showing grade IV liver injury (AAST) with complicated lacerations along the right hepatic vein (blue arrow), two active contrast extravasations in the right liver from segments VII and VIII (orange arrows), and hemoperitoneum. The third area of bleeding is not shown in the figures. (D) Right and left femoral X-rays showed bilateral displaced femoral fractures and right patellar fractures. CT, computed tomography; AAST, American Association for the Surgery of Trauma; R, right; L, left.

Interventional radiology was immediately consulted and expeditiously performed TAE via the right femoral route under ultrasound guidance. The aorta, as well as the celiac trunk and its branches, were contracted. An active contrast extravasation of the right posterior hepatic artery (segment VII branch) was found and then super-selected by a microcatheter 1.8 F (Carnelian; Tokai Medical Products Inc.) before completely embolizing with a mixture of n-butyl-2-cyanoacrylate and lipiodol (1:3 ratio) (Fig. 2A–2C). Final angiography showed complete elimination of the lesion. The procedure lasted 20 minutes, and one unit of blood was transfused.

Figure 2. (A, B) Postoperative celiac arteriography showing active extravasation of the right posterior hepatic artery (white arrows). (A) A small caliber was seen in the celiac artery and its branches. (B, C) The lesion was super-selectively embolized with a mixture of NBCA and lipiodol (ratio 1:3, 0.5 mL). (D) The ultrasound 2 months after treatment showed a posttraumatic hepatic parenchymal scar at the posterior segment (white star). NBCA, n- butyl-2-cyanoacrylate.

After the procedure, the patient was admitted to the intensive care unit. He had a difficult first three postoperative days, then gradually improved with medical treatment. A second laparotomy was performed on day 6 to remove the intra-abdominal pack, showing viable hepatic parenchyma without bleeding. The bilateral femoral and right patellar fractures were surgically repaired on day 15. The patient improved and was discharged after 30 days of hospitalization. At the 2-month follow-up, the patient had no clinical abnormalities, and his liver function had returned to normal. Abdominal ultrasonography showed a posttraumatic hepatic parenchymal scar at the posterior segment without other hepatic anomalies (Fig. 2D).

Formal approval was not required for this type of study. Consent for publication of data included in the study was obtained from the patient during the follow-up visit, and was noted in the patient's paper medical record.

In recent decades, advances in nonoperative management have significantly changed the management of liver trauma, and the proportion of trauma patients requiring surgery has decreased over time. TAE is now recommended as the preferred treatment for arterial injuries in hemodynamically stable patients.^1,4,8 This technique also extends to patients with initial hypotension that improves after resuscitation.⁶ Elkbuli et al⁶ reported on a patient with AAST grade V liver trauma who initially presented with hemorrhagic shock at admission and then achieved successful hemostasis with TAE. Their patient underwent delayed laparotomy on day 4 due to biliary peritonitis.

For severe liver injuries with hemodynamic instability (World Society of Emergency Surgery [WSES] grade IV), it is challenging to use TAE as the first choice of treatment due to the high rates of failure.¹ Transarterial intervention in the setting of shock and the use of high-dose vasopressors may make it difficult to detect and approach lesions due to blood vessel constriction. Moreover, although this method helps treat arterial lesions, it does not treat venous injuries (vena cava, hepatic, or portal veins) or nonvascular injuries. Therefore, initial damage control surgery still plays a significant role because it helps directly evaluate the injuries and allows immediate hemostasis regardless of the arterial or venous source.^1,9,10 This method also permits the direct removal of devitalized tissue, controls peritonitis, and identifies injuries to other structures that may not be easily detected on CT (such as bowel injuries or major vein injuries). Although laparotomy still has a very high mortality rate, it is mostly related to residual postoperative bleeding.^1,3,10–13 According to the study by Lin et al,¹⁰ the overall mortality rate was 52% for 58 patients who underwent emergency laparotomy for severe liver injuries, 83% of whom died from bleeding within the first 24 hours after surgery.

Only when patients have failed to achieve hemostasis after the initial damage control surgery do hepatic arteriography and TAE play a role in hemodynamically unstable patients.⁷ For example, in our case, although three active arterial bleeds were seen on preoperative CT, only one was found and treated intraoperatively. Because repeat laparotomy in this situation would be severely invasive, TAE was a good alternative for arterial hemostasis and outweighed the disadvantages of surgery. Misselbeck et al⁷ reported that 52% of patients who underwent initial damage control laparotomy still presented arterial injuries requiring embolization. The current WSES guidelines suggest that hepatic angiography should be performed in cases of persistent bleeding after non-hemostatic or damage control procedures.¹

It is noted that several potential complications of TAE can occur, such as liver abscess and ischemia or necrosis of the biliary tract, gallbladder, or parenchyma.^7,14,15 Misselbeck et al⁷ reported that 9 out of 79 patients presented with liver-related complications after TAE, including one death related to liver failure. The super-selective technique should be performed as much as possible to minimize these complications.¹⁵

In conclusion, high-grade liver trauma is common in clinical practice. Management is based not only on the severity of the liver injuries but also on the patient’s hemodynamic stability. With advances in interventional radiology, increasing numbers of patients receive nonsurgical management instead of surgery. TAE is mainly indicated for arterial injuries in patients with hemodynamically stable liver trauma or even in patients who are initially hypotensive but respond to resuscitation. Although this technique has not replaced surgery in hemodynamically unstable patients with liver lacerations, it can be considered in cases of residual bleeding after the initial damage control surgery.

None.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

No potential conflict of interest relevant to this article was reported.