Proposal of standardization of every step of angiographic procedure in bleeding patients from pelvic trauma

Abstract

Trauma accounts for a third of the deaths in Western countries, exceeded only by cardiovascular disease and cancer. The high risk of massive bleeding, which depends not only on the type of fractures, but also on the severity of any associated parenchymal injuries, makes pelvic fractures one of the most life-threatening skeletal injuries, with a high mortality rate. Therefore, pelvic trauma represents an important condition to correctly and early recognize, manage, and treat. For this reason, a multidisciplinary approach involving trauma surgeons, orthopedic surgeons, emergency room physicians and interventional radiologists is needed to promptly manage the resuscitation of pelvic trauma patients and ensure the best outcomes, both in terms of time and costs. Over the years, the role of interventional radiology in the management of patient bleeding due to pelvic trauma has been increasing. However, the current guidelines on the management of these patients do not adequately reflect or address the varied nature of injuries faced by the interventional radiologist. In fact, in the therapeutic algorithm of these patients, after the word “ANGIO”, there are no reports on the different possibilities that an interventional radiologist has to face during the procedure. Furthermore, variations exist in the techniques and materials for performing angioembolization in bleeding patients with pelvic trauma. Due to these differences, the outcomes differ among different published series. This article has the aim to review the recent literature on optimal imaging assessment and management of pelvic trauma, defining the role of the interventional radiologist within the multidisciplinary team, suggesting the introduction of common and unequivocal terminology in every step of the angiographic procedure. Moreover, according to these suggestions, the present paper tries to expand the previously drafted algorithm exploring the role of the interventional radiologist in pelvic trauma, especially given the multidisciplinary setting.

Endovascular Management of Pelvic Trauma: The Interventional Radiology Point of View

“…Selective angiographies should always be performed and are of the utmost importance to rule out or confirm bleeding spots [29].…”

“…To overcome the gap in published guidelines, Renzulli et al proposed a possible standardization of the angiographic procedure in the setting of PT, concerning how and when to perform the procedure, the interventional technique, and embolization materials used [29].…”

Transcatheter Arterial Embolization for Bleeding Related to Pelvic Trauma: Comparison of Technical and Clinical Results between Hemodynamically Stable and Unstable Patients

“…Patients with extra-pelvic blood loss, persistent hemodynamic instability, and ongoing bleeding even after surgery and preperitoneal pelvic packing (PPP), or simultaneously to surgery and PPP if a hybrid operating room was available [4,5,18 Hemodynamically stable patients with stable/unstable pelvic fractures or unremarkable CT scans but still clinical signs of significant ongoing bleeding. The rationale was to differentiate venous or bone bleeding from arterial bleeding that may be absent or unidentifiable at the time of CT.…”

“…With a high mortality rate (between 5 and 50%), pelvic fractures are among the most serious skeletal injuries [3]. Endovascular intervention is now the primary line of therapy for arterial injury brought on by pelvic trauma since it can significantly reduce considerable morbidity associated with surgery and can swiftly access and control bleeding sites [4,5].…”

“…Despite international guidelines and widespread awareness of the role of AE in clinical practice [5,8,[18][19][20][21][22][23], evidence directly comparing the outcomes of AE in hemodynamically stable and unstable patients is still lacking. Indeed, it is useful to note that the hemodynamically unstable patient is a critically ill patient with high mortality and that the time-sensitive scenario influences the AE technique and the choice of the embolizing agent [4,24,25]. Therefore, it would be desirable to be aware of any AE procedural or outcome differences between hemodynamically stable and unstable patients.…”