Successful Non-Operative Management of Middle Colic Artery Injury Using Transcatheter Arterial Embolization Performed in a Hybrid Emergency Room System

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J Acute Care Surg. 2025;15(1):30-33

Publication date (electronic) : 2025 March 31

doi : https://doi.org/10.17479/jacs.2025.15.1.30

Joo Hyun Lee^a, So Ra Ahn^b, Sang Hyun Seo^c, Chan Yong Park^d,

^aDepartment of Surgery, Wonkwang University School of Medicine, Iksan, Republic of Korea

^bDepartment of Trauma Surgery, Wonkwang University School of Medicine, Iksan, Republic of Korea

^cDepartment of Radiology, Wonkwang University School of Medicine, Iksan, Republic of Korea

^dDivision of Trauma and Acute Care Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea

^*Corresponding Author: Chan Yong Park, Division of Trauma and Acute Care Surgery, Department of Surgery, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul 03080, Republic of Korea, Email: trauma-park@naver.com

Received 2024 November 23; Revised 2024 December 16; Accepted 2024 December 20.

Abstract

Introduction

Transcatheter arterial embolization (TAE) has become an established hemostatic method for managing traumatic hemorrhages in various settings. Its effectiveness has been well documented in cases of bleeding from solid organ injuries such as those involving the liver, spleen, and kidneys [1,2]. However, injuries to the mesentery present complications such as uncontrolled massive bleeding, bowel ischemia, necrosis, and perforation due to mesenteric disruption are common; and surgical intervention is often the preferred treatment approach. However, recent case reports have demonstrated the successful use of TAE as a nonsurgical alternative for mesenteric artery injuries in patients with trauma [1,3–7]. In this report, we describe a case of successful nonoperative management of a middle colic artery (MCA) injury resulting from blunt trauma, treated exclusively with TAE.

Case Report

A 47-year-old male presented with chest pain after falling from a height of 3 meters. The initial vital signs were: blood pressure of 80/50 mmHg, pulse rate 122 beats/minute, respiratory rate 28 breaths/minute, body temperature 36.0°C, O₂ saturation 92%, and a Glasgow Coma Scale score of 15. After fluid resuscitation and emergency transfusion of 2 units of universal O⁺ red blood cells, the patient’s systolic blood pressure recovered to approximately 100 mmHg. The door-to-transfusion time was 8 minutes. Initial abdominal computed tomography (CT) revealed hemoperitoneum with massive contrast extravasation from the MCA (Figure 1) and fractures of both pubic ramus. Chest CT revealed fractures of the left 1^st– 7^th anterior rib arcs, 4^th–11^th posterior rib arcs, and a small left hemothorax. The patient’s injury severity score was 41. Due to significant extravasation observed on the abdominal CT scan, TAE was initially planned as a bridge modality before surgery.

Figure 1

Initial abdominal computed tomography. (A) The arterial phase where massive contrast extravasation was observed in the right upper quadrant area (white arrow), and a large amount of hematoma was visible surrounding it. (B) The middle colic artery was (yellow arrow) connected with contrast extravasation.

Angiography confirmed massive contrast extravasation from the MCA (Figure 2A). The vessel was selectively catheterized, and embolization was performed using 0.5 mL of n-butyl cyanoacrylate and 1.0 mL of ethiodized oil (Figure 2B). Our trauma center is equipped with a hybrid emergency room system (HERS) consisting of a sliding gantry CT (SOMATOM Definition Edge, Siemens Healthineers AG, Erlangen, Germany), an angiography system (Artis Q Ceiling), and had a 24/7 in-house interventional radiology team present when the patient was admitted. The HERS allowed commencement of angiography without the patient being moved. The door-topuncture time was 39 minutes, and embolization was completed within 24 minutes. After TAE, the patient’s vital signs stabilized; however, his chest pain and dyspnea worsened, necessitating endotracheal intubation and admission to the Trauma Intensive Care Unit.

Figure 2

Angiography of superior mesenteric artery. (A) The superior mesenteric artery angiography showed a middle colic artery rupture and severe contrast extravasation (black arrow). (B) Following embolization using n-butyl cyanoacrylate, accumulated embolic material was observed within the middle colic artery (yellow arrow).

The following day, the trauma surgeon requested a serial complete blood count, lactate levels, a follow-up CT and a physical examination was performed. Abdominal CT revealed no further extravasation; however, submucosal edema extending from the ascending colon to the proximal transverse colon raised concerns regarding ischemic damage (Figure 3A). Since transmural ischemia was not confirmed, and there were no other significant findings, it was decided that close monitoring should be continued. Follow-up CT scans on the 7^th and 19^th hospital day, post-TAE, showed improvement in the ischemic damage (Figures 3B and 3C). On the 8^th hospital day, post-TAE, the patient was started on still water and carbohydrate drinks using a nasogastric tube, and no significant gastrointestinal troubles were observed (except for mild abdominal pain).

Figure 3

Follow-up computed tomography. (A) Performed on the 2^nd, (B) 7^th, (C) 19^th, and (D) 40^th hospital day, after transcatheter arterial embolization. The wall of the hepatic flexure initially showed severe submucosal ischemic damage, although this improved over time (yellow arrow).

The endotracheal tube was successfully removed on the 15^th hospital day, post-TAE, and the patient was transferred to the General Ward. The patient was started on a soft diet on the 18^th hospital day, post-TAE, which was tolerated. The plan was to discharge the patient on the 20^th hospital day, post-TAE, but the patient wanted to continue rehabilitation in hospital. Follow-up CT was performed on the 40^th hospital day, post-TAE, and showed near-complete resolution of the hematoma (Figure 3D). The patient was discharged on the 42^nd hospital day, post-TAE, after rehabilitation, without significant abdominal complications.

Discussion

Mesenteric injuries due to blunt trauma are rare, accounting for approximately 1%–5% of cases, and typically follow injuries to solid organs such as the liver and spleen in the abdomen. However, the incidence of mesenteric injuries is increasing because of the prevalence of high-speed motor vehicle accidents and the widespread use of seatbelts [5,8]. Blunt abdominal trauma leads to intra-abdominal injuries through deceleration, external compression, and crushing forces. Deceleration generates shearing forces at fixed points in the mesentery, resulting in damage, whereas sudden external pressure or increased intra-abdominal pressure can cause intestinal rupture. Mesenteric injuries primarily affect areas such as the ligament of Treitz and ileocecal region [5,9,10].

Disruption of the mesentery can lead to significant hemorrhage, bowel ischemia, perforation, and other life-threatening complications. Therefore, prompt treatment of this condition is essential. Surgical intervention is typically the gold standard intervention in cases of bowel ischemia, perforation, or hemodynamic instability due to hemorrhage [6,9]. However, surgery carries risks, particularly in patients with polytrauma, such as complications from general anesthesia, and postoperative issues such as bowel adhesions. Consequently, it has been suggested that TAE can be a viable alternative for patients who are hemodynamically stable, and do not exhibit signs of peritonitis or bowel injury [1,4,5,7,11,12].

This current case is unique in that it involved an isolated injury to the MCA in the abdomen. Although the MCA is not a fully attached vessel, it is presumed that the injury resulted from the impact of the steering wheel or the shearing force due to deceleration. At our institution, the number of mesenteric TAE cases is limited, and precise indications are yet to be established. Generally, TAE is considered for hemodynamically stable patients following resuscitation, in the absence of peritoneal signs or bowel ischemia on CT scans, and when the injury is isolated. Importantly, the availability of an intervention radiologist and access to a HERS enabled us to initiate TAE rapidly without moving the patient and the procedure began just 39 minutes after the patient’s arrival. If there is a delay due to moving the patient or any other reason, prompt surgery can help reduce the risk of complications.

In 2011, after a HERS was first installed in Osaka General Medical Center (Osaka, Japan), a study by Wada et al [13] reported that the time to TAE (door-to-puncture time) was significantly reduced when compared with the conventional system (54 vs. 75 minutes, p = 0.007). In the current case, the door-to-puncture time was just 39 minutes, however, a direct comparison was not possible because TAE was not performed exclusively for the mesentery injuries as in the Wada et al [13] study.

Although surgical treatment allows direct visualization and definitive management of bowel perforation and ischemia, TAE relies primarily on indirect assessment, often guided by CT, and this can be a limitation. However, multidetector CT technology has significantly improved diagnostic accuracy, with increased sensitivity and specificity exceeding 80%. In cases where diagnostic uncertainty persists, a follow-up CT scan, 4–6 hours after the initial examination, may enhance the detection of injuries. In addition, in cases of mesentery avulsion, where the bowel completely detaches from the mesentery border, surgical intervention is required, following initial CT scans which may not show specific findings. Therefore, it is crucial to carefully compare pre- and post-TAE CT images to identify signs such as interloop fluid or bowel perfusion defects. Based on these findings, trauma surgeons should determine treatment options by correlating vital signs, physical examination, and laboratory results [4,5,11,12,14,15].

Major complications like re-bleeding or bowel ischemia due to reduced intestinal blood flow may necessitate surgical intervention [5,7,11]. In a study by Shin et al [1], bowel ischemia was not observed in 15 patients who underwent TAE. Similarly, Ghelfi et al [5] and Bertelli et al [7] documented only one case of ischemia in 7, and 4 cases, respectively. Super-selective embolization, which preserves collateral circulation, significantly reduces the risk of bowel ischemia. The colon benefits from collateral blood supply via the marginal artery of Drummond, which connects the superior and inferior mesenteric arteries. However, the colon receives less blood flow compared with the small bowel, is more sensitive to autonomic nerve stimulation, and contains watershed areas, making it more vulnerable to ischemia. [16,17].

In the current case, embolization was performed on the proximal MCA to preserve the marginal artery, ensuring that the colon segment affected embolization did not become the watershed area, thereby minimizing the risk of ischemia. Nevertheless, vigilant monitoring of the patient’s vital signs, laboratory tests, physical examination, and imaging by the trauma surgeon is crucial for promptly detecting any signs of ischemia or perforation. Surgical intervention should not be delayed in the event of complications.

In conclusion, we present a case of successful management of an MCA injury due to blunt trauma using TAE without surgical intervention. TAE may be considered a nonsurgical treatment option for mesenteric injuries in patients who are hemodynamically stable after resuscitation, and do not show signs of bowel injury on CT or other assessments. This approach is particularly advantageous when there is a high risk of complications from surgery or general anesthesia. However, careful observation by the trauma surgeon is necessary, always keeping the possibility of surgery in mind. Further studies are necessary to establish the optimal selection criteria for TAE for mesenteric injuries.

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