The effect of angioembolization for life-threatening retroperitoneal hemorrhage in patients with pelvic fracture

Fu, Chih-Yuan; Chan, Sheng Yu; Wang, Shang‐Yu; Hsieh, Chi-Hsun; Liao, Chien‐Hung; Huang, Jen‐Seng; Hsu, Yung‐Heng; Kang, Shih‐Ching

doi:10.1016/j.ajem.2018.06.043

Cited by 19 publications

(27 citation statements)

References 23 publications

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“…We suspect that the presence of contrast extravasation may be difficult to differentiate between bone marrow and arterioles during CT examination soon after a pelvic fracture. Furthermore, our results suggest that evidence of CE during CT may not be a suitable major indication for AE, despite this being previously reported [7,22]. Dreizin et al [27] have suggested that the use of AE should be instead guided by the hematoma volume when arterial bleeding is detected during CT. We believe that angiography and AE should be performed more selectively, such as based on non-response to resuscitation, a continuing decrease in hemoglobin concentration without evidence of bleeding from other sources, and the absence of arterial blush during CT.…”

Section: Discussioncontrasting

confidence: 67%

“…Non-selective embolization is considered a hemostatic procedure for hemodynamically unstable patients with pelvic fractures [7,23], although recent studies have focused on selective or superselective embolization to decrease the negative effects of non-selective embolization in cases of vasospasm or rich collateral arterial networks within the pelvis [24,25]. Thus, we evaluated the outcomes of different AE strategies, given the fact that AE interventions might be accompanied by a high complication rate after these patients undergo osteosynthesis to treat their unstable pelvis.…”

Section: Discussionmentioning

confidence: 99%

“…Some reports have described AE as an effective procedure for managing pelvic fracture-related retroperitoneal arterial hemorrhage [6,7]. Furthermore, AE is a classical treatment and remains a standard hemostatic procedure in many institutions [7][8][9], including our institution, based on reports regarding its efficacy during the management of pelvic fracture-related hemorrhage [8,10]. However, AE is associated with various complications, including inadequate hemostasis, gluteal muscle necrosis, and surgical site infection (SSI) [11,12].…”

Section: Introductionmentioning

confidence: 99%

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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

Lai

Tseng

et al. 2020

Preprint

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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.

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Section: Discussioncontrasting

confidence: 67%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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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

Lai

Tseng

et al. 2020

Preprint

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“…In addition, the above ndings were still true even if only those patients with an ISS >=16 were considered. According to the current AIS scoring system for pelvic fractures, the AIS score is 4 for a moderate pelvic hematoma with an estimated blood loss <= 20% by volume, while it is 5 for a large hematoma with an estimated blood loss volume >= 20% [27]. That is, a pelvic injury with the same fracture pattern would be given a different AIS score according to the size of the hematoma or the volume of blood loss.…”

Section: Discussionmentioning

confidence: 99%

“…The most critical factor of this result was that interventional radiologists were available at our institution for 24 hours along with trauma surgeons. Most exsanguinating patients could be stabilized by transarterial embolization shortly after initial resuscitation whenever indicated [20,25,27,28]. Another reason for the lack of mortality was that pelvic trauma patients with associated injuries that were con rmed to be the principal cause of death, such as severe brain injury, were not included in the current study [17,[21][22][23].…”

Section: Discussionmentioning

confidence: 99%

Pelvic injury prognosis is more closely related to vascular injury severity than anatomical fracture complexity: The WSES classification for pelvic trauma makes sense

Cheng

Tee

et al. 2020

Preprint

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Background: The most common cause of death in cases of pelvic trauma is exsanguination caused by associated injuries, not the pelvic injury itself. For patients with relatively isolated pelvic trauma, the impact of vascular injury severity on outcome remains unclear. We hypothesized that the severity of the pelvic vascular injury plays a more decisive role in outcome than fracture pattern complexity. Methods: Medical records of patients with pelvic fracture at a single center between Jan 2016 and Dec 2017 were retrospectively reviewed. Those with an abbreviated injury scale (AIS) score ≥3 in areas other than the pelvis were excluded. Lateral compression (LC) type 1 fractures and anteroposterior compression (APC) type 1 fractures according to the Young-Burgess classification and ischial fractures were defined as simple pelvic fractures, while other fracture types were considered complicated pelvic fractures. Based on CT, vascular injury severity was defined as minor (fracture with or without hematoma) or severe (hematoma with contrast pooling/extravasation). Patient demographics, clinical parameters, and outcome measures were compared between the groups.Results: Severe vascular injuries occurred in 26 of the 155 patients and were associated with poorer hemodynamics, a higher injury severity score (ISS), more blood transfusions, and a longer ICU stay (3.81 vs. 0.86 days, p=0.000) and total hospital stay (20.7 vs. 10.1 days, p=0.002) compared with minor vascular injuries. By contrast, those with complicated pelvic fractures (LC II/III, APC II/III, vertical shear and combined type fracture) required a similar number of transfusions and had a similar length of ICU stay as those with simple pelvic fractures (LC I, APC I and ischium fracture) but had a longer total hospital stay (13.6 vs. 10.3 days, p=0.034). These findings were similar even if only patients with ISS >=16 were considered.Conclusions: Our results indicate that even in patients with relatively isolated pelvic injuries, vascular injury severity is more closely correlated to outcome than the type of anatomical fracture. Therefore, a more balanced classification of pelvic injury that takes both the fracture pattern and hemodynamic status into consideration, such as the WSES classification, seems to have better utility for clinical practice.Trial registration: This is a retrospective review study, not a clinical trial.

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Transarterial embolisation is associated with improved survival in patients with pelvic fracture: propensity score matching analyses

Kim

Jeon

Kim

et al. 2020

Eur J Trauma Emerg Surg

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Introduction Transarterial embolisation (TAE) is an effective intervention for management of arterial haemorrhage associated with pelvic fracture. However, its effects on survival and clinical outcomes are unclear. Methods Trauma patients with survival data between November 2015 and December 2019 were identified using a trauma database. Patients were divided between TAE and non-TAE groups, and a propensity score was developed using multivariate logistic regression. Survival at 28 days was compared between the groups after propensity score matching. Results Among 881 patients included in this study, 308 (35.0%) were treated with TAE. After propensity score matching, 130 pairs were selected. Survival at 28 days was significantly higher among patients treated with TAE than among those treated without TAE [122 (93.9%) vs. 112 (86.2%); odds ratio = 2.45; 95% CI 1.02–5.86; p = 0.039]. Conclusions TAE use was associated with improved survival at 28 days in patients with pelvic fracture and should therefore be considered in the management of severely injured patients with pelvic fracture.

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The effect of angioembolization for life-threatening retroperitoneal hemorrhage in patients with pelvic fracture

Cited by 19 publications

References 23 publications

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

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

Pelvic injury prognosis is more closely related to vascular injury severity than anatomical fracture complexity: The WSES classification for pelvic trauma makes sense

Transarterial embolisation is associated with improved survival in patients with pelvic fracture: propensity score matching analyses

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