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CASE REPORT
Year : 2020  |  Volume : 36  |  Issue : 1  |  Page : 59-61
 

Successful angioembolization for blunt adrenal gland trauma


1 Department of Surgical Gastroenterology, Apollo Speciality Hospitals, Madurai, Tamil Nadu, India
2 Department of Interventional Radiology, Apollo Speciality Hospitals, Madurai, Tamil Nadu, India

Date of Submission31-May-2019
Date of Acceptance08-Oct-2019
Date of Web Publication2-Jan-2020

Correspondence Address:
Madhusudhanan Jegadeesan
Department of Surgical Gastroenterology, Apollo Speciality Hospitals, Madurai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/iju.IJU_166_19

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   Abstract 

Blunt adrenal gland trauma is an uncommon injury owing to the location of the adrenal gland in the retroperitoneum surrounded by major viscera and bony structures. We present a case of a 23-year-old male, who had sustained multiple injuries following a road traffic accident. Computed tomography scan revealed a large retroperitoneal hematoma, and active contrast extravasation was noted in the retroperitoneum adjacent to the bare area of the liver and right adrenal gland. After a trial of initial conservative management, he had expanding retroperitoneal hematoma with dropping hemoglobin. Angiography showed posttraumatic aneurysm from the adrenal artery that was successfully embolized with microcoils. As blunt adrenal gland trauma is rare, a high degree of clinical suspicion is required for the diagnosis, and multidisciplinary discussion is essential for the successful management of adrenal gland trauma.



How to cite this article:
Jegadeesan M, Robert A J, Sekar TV. Successful angioembolization for blunt adrenal gland trauma. Indian J Urol 2020;36:59-61

How to cite this URL:
Jegadeesan M, Robert A J, Sekar TV. Successful angioembolization for blunt adrenal gland trauma. Indian J Urol [serial online] 2020 [cited 2020 Jan 18];36:59-61. Available from: http://www.indianjurol.com/text.asp?2020/36/1/59/274684



   Introduction Top


Blunt adrenal gland trauma is an uncommon injury. The adrenal gland is located deep in the retroperitoneum, surrounded by organs and fasciae, and clinically significant hemorrhage necessitating intervention is rare. Diagnosis requires a high degree of clinical suspicion. We report a patient who successfully underwent angioembolization for traumatic adrenal gland hemorrhage.


   Case Report Top


A 23-year-old male was brought to our hospital following a motor vehicle accident. He was conscious and obeying commands. His oxygen saturation was 100%, with 4L of oxygen by mask. He was normotensive and had a respiratory rate of 24/min. His abdomen was soft with no external injuries. Primary survey revealed injury to the right shoulder and both lower limbs. An initial computed tomography (CT) scan revealed a large retroperitoneal hematoma, and active contrast extravasation was noted in the retroperitoneum adjacent to the bare area of the liver and right adrenal gland. Hemoglobin significantly dropped (from 9 g/dL to 5.8 g/dL) after 48 h, along with severe tachycardia (135–140 beats/min). There was a mild drop in blood pressure to 90/60 mmHg and an increasing requirement of oxygen. However, during this period, his sensorium was normal, urine output was adequate, and the abdomen was soft with audible bowel sounds. A repeat CT scan of the abdomen revealed an increasing retroperitoneal hematoma with persistent active arterial contrast extravasation into the retroperitoneum. As there was coexistent liver injury, the bleed was initially attributed to laceration of the bare area of the liver; however, the exact injured vessel could not be identified. Careful analysis of CT images revealed the site of origin of bleed to be below the liver with no contrast extravasation from any of the hepatic arterial branches. As the patient was becoming unstable with further drop in hemoglobin, an urgent multidisciplinary team discussion involving surgeons, interventional radiologists, and emergency physicians was convened. As per the decision, the patient was taken for digital subtraction angiography to identify the source of active contrast extravasation in the retroperitoneum. Angiography of the hepatic, lumbar, intercostal, and renal arteries was done. Right renal angiogram revealed aberrant origin of the right inferior phrenic artery [Figure 1]. A posttraumatic aneurysm was seen in the adrenal branch of the right inferior phrenic artery. Following this, a microcatheter was placed distally into the feeding vessel of the aneurysm and multiple 0.018 microcoils were deployed [Figure 2]. 5-Fr Sim 1 Catheter (100 cm) and 2.4-Fr Progreat Microcatheter (150 cm) were used. Post coiling angiogram showed complete exclusion with no further opacification of the pseudoaneurysm and preserved right renal artery flow. Over the next 48-72 hours, the patient became hemodynamically stable without any need for further transfusion. He developed acute kidney injury, probably related to trauma, shock, and radiologic contrast agent which settled with conservative management. The contrast used was nonionic iodinated contrast medium totaling up to 180 ml (Iohexol OMNIPAQUE – 80 ml for the CT abdominal angiogram; Iodixanol VISIPAQUE – 100 ml for the Digital subtraction angiogram and coil embolization). At admission, serum creatinine was 1.2 mg/dL, and post coiling, it was 2.6 mg/dL. Few days after the successful angioembolization, he underwent internal fixation for shoulder and limb trauma. At the time of discharge, he was ambulant without support.
Figure 1: Right renal angiogram (thick black arrow) reveals the common origin a b of the right inferior adrenal artery (black arrow) and right inferior phrenic artery (white arrow) (a). Right inferior phrenic angiogram reveals pseudoaneurysm (black arrow) from the right superior adrenal artery (thick white arrow) (b)

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Figure 2: Coils deployed in the right superior adrenal artery and right inferior phrenic artery (a) and final check angiogram reveals nonopacification of the aneurysm (b)

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   Discussion Top


Blunt adrenal gland trauma causing massive retroperitoneal hemorrhage is very uncommon, occurring in <1% of patients. With the widespread availability of CT scans, especially in surgical trauma centers, retroperitoneal bleeds are increasingly diagnosed and reported.[1],[2] As retroperitoneum is a closed space with its fascial limitations, retroperitoneal hemorrhage causing hemodynamic instability is uncommon unless major blood vessels such as the aorta and the vena cava are directly injured. Any retroperitoneal traumatic event severe enough to cause adrenal gland trauma will have associated visceral injuries involving the liver, kidneys, spleen, and the ribs.[2] Hence, for accurate diagnosis of adrenal gland trauma, a high degree of clinical suspicion along with careful study of CT images is mandatory.[3]

Arterial supply of the adrenal gland arises from three sources. The superior adrenal arteries are a group of 6–8 arteries coming from the inferior phrenic artery. One of the vessels may be dominant or all may be of similar size. The middle adrenal artery arises from the aorta just proximal to the origin of the renal artery and the inferior adrenal artery arises from the renal artery proper or the superior polar artery.[4] Variations are common in adrenal arterial supply. Superior adrenal arteries are the most constant source, absent in only 5% individuals, whereas in up to 61%, middle or inferior adrenal arteries may be lacking.[5] Knowledge of the arterial supply is helpful in the interpretation of angiographic images and planning embolization. Adrenal gland trauma is common on the right side compared to the left side. There are no specific guidelines for the management of blunt adrenal gland trauma. The hemodynamic status, severity of adrenal artery bleed, and concomitant injuries should be taken into consideration while deciding on management.[6] In hemodynamically stable patients with nonexpanding retroperitoneal hematoma, a trial of conservative treatment with close monitoring is preferable.[1] In a hemodynamically unstable patient with retroperitoneal hemorrhage, an immediate surgical intervention with retroperitoneal exploration is warranted.[3] In a stable patient, with active contrast extravasation, a diagnostic digital subtraction angiography will help in the identification of bleeding vessel which can be embolized instantly. A review of the literature on angiographic embolization of adrenal gland trauma, only eight cases have been reported to the present date.[1],[7],[8] Among them, seven patients had right inferior adrenal artery bleed and one patient had left adrenal artery bleed which was successfully embolized. All the patients were alive at the time of their reporting. As the adrenal gland has multiple arterial supplies, embolization of a single artery will not result in total adrenal necrosis, and adrenal insufficiency is uncommon due to its healthy counterpart.


   Conclusion Top


Adrenal gland trauma should be considered in the differential diagnosis of a traumatic retroperitoneal hematoma. Interdisciplinary discussion between the surgeon and the radiologist is crucial for the diagnosis. Accurate diagnosis of this condition can help in a timely radiological intervention. It can help avoid a difficult and sometimes futile retroperitoneal exploration or laparotomy and its attendant morbidly and mortality.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.

 
   References Top

1.
Liao CH, Ouyang CH, Fu CY, Wang SY, Lin KJ, Kuo IM, et al. The current status and management of blunt adrenal gland trauma. Surgery 2015;157:338-43.  Back to cited text no. 1
    
2.
Stawicki SP, Hoey BA, Grossman MD, Anderson HL 3rd, Reed JF 3rd. Adrenal gland trauma is associated with high injury severity and mortality. Curr Surg 2003;60:431-6.  Back to cited text no. 2
    
3.
Chen KT, Lin TY, Foo NP, Lin HJ, Guo HR. Traumatic adrenal haematoma: A condition rarely recognised in the emergency department. Injury 2007;38:584-7.  Back to cited text no. 3
    
4.
Skandalakis JE, Skandalakis LJ, Skandalakis PN editors. Adrenal Glands Surgical Anatomy and Technique: A Pocket Manual. New York: Springer New York; 2000. p. 643-71.  Back to cited text no. 4
    
5.
Merklin RJ. Arterial supply of the suprarenal gland. Anat Rec 1962;144:359-71.  Back to cited text no. 5
    
6.
Lee YS, Jeong JJ, Nam KH, Chung WY, Chang HS, Park CS. Adrenal injury following blunt abdominal trauma. World J Surg 2010;34:1971-4.  Back to cited text no. 6
    
7.
Igwilo OC, Sulkowski RJ, Shah MR, Messink WF, Kinnas NC. Embolization of traumatic adrenal hemorrhage. J Trauma 1999;47:1153-5.  Back to cited text no. 7
    
8.
Dinc H, Simşek A, Ozyavuz R, Ozgür GK, Gümele HR. Endovascular treatment of massive retroperitoneal haemorrhage due to inferior adrenal artery injury. A case report. Acta Radiol 2002;43:326-8.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2]



 

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