High incidence of surgical site infection may be related to suboptimal case selection for non-selective arterial embolization during resuscitation of patients with pelvic fractures: A retrospective study

Abstract

Background : In most institutions, arterial embolization (AE) remains a standard procedure to achieve hemostasis during the resuscitation of patients with pelvic fractures. However, the actual benefits from AE are controversial. Methods : We retrospectively reviewed data from patients who were treated for closed pelvic fractures at a single center between 2014 and 2017. Data regarding the AE and clinical parameters were analyzed to determine whether poor outcomes could be predicted. Results : During the study period, 545 patients were treated for closed pelvic fractures, including 131 patients who underwent angiography and 129 patients who underwent AE. Nonselective bilateral internal iliac artery embolization (nBIIAE) was the major AE strategy (74%). Relative to the non-AE group, the AE group had higher values for the injury severity score, shock at hospital arrival, and unstable fracture patterns. Furthermore, relative to the non-AE group, the AE group was more likely to require osteosynthesis and experience surgical site infection (SSI). Fourteen patients (10.9%) experienced late complications following the AE intervention, including 3 men who had impotence at the 12-month follow-up visit and 11 patients who experienced SSIs after undergoing AE and osteosynthesis (incidence of SSI: 11/75 patients, 14.7%). Nine of the 11 patients who experienced SSI after AE had undergone nBIIAE. The positive predictive value of contrast extravasation (CE) during computed tomography (CT) was 29.6%, with a negative predictive value of 91.3%. Relative to patients with identifiable CE, patients without identifiable CE during CT had a higher mortality rate (30.0% vs. 11.0%, p = 0.03). Conclusion : Performing AE for pelvic fracture-related hemorrhage may not be the best practice for patients with no CE detected during CT or for unstable patients who do not respond to resuscitation after excluding other sources of hemorrhage. Given the high incidence of SSI following nBIIAE, this procedure should be carefully selected. Other hemostasis procedures, such as preperitoneal pelvic packing, might be appropriate for patients without CE during imaging, based on their high mortality rate.

Endovascular Management of Pelvic Trauma

“…18 Selective or superselective embolization also decreases the risk of surgical-site infection in patients who require subsequent internal fixation (osteosynthesis). 32 Timing of the intervention is an important predictor for the outcome. Higher mortality is seen in patients arriving late in the angiography suite than those arriving within 60 minutes.…”