Angiographic embolization in the treatment of arterial pelvic hemorrhage: evaluation of prognostic mortality-related factors

Abstract

PurposeThe control of arterial bleeding associated with pelvic ring and acetabular fractures (PRAF) remains a challenge for emergency trauma care. The aim of the present study was to uncover early prognostic mortality-related factors in PRAF-related arterial bleedings treated with transcatheter angiographic embolization (TAE).MethodsForty-nine PRAF patients (46 pelvic ring and three acetabular fractures) with arterial pelvic bleeding controlled with TAE (within 24 h) were evaluated.ResultsAll large arterial disruptions (n = 7) were seen in type C pelvic ring injuries. The 30-day mortality in large vessel (iliac artery) bleeding was higher (57 %) than in medium- or small-size artery bleeding (24 %). Overall 30-day mortality was 29 %. No statistically significant difference in the first laboratory values between the survivors and nonsurvivors was found. However, after excluding patients dying of head injuries (n = 5), a reasonable cut-off value was identified for the base excess (BE; lower than −10 mmol/l) obtained on admission.ConclusionsPRAF patients with exsanguinating bleeding from the large pelvic artery have the worst prognosis. Very low BE values (<−10.0 mmol/l) on admission for exsanguinating patients have a negative predictive value for survival, thus anticipating a poor outcome in bleeding controlled with TAE only and an increased risk of death. In critical cases, an aggressive bleeding control protocol prompts extraperitoneal pelvic packing prior to TAE. PRAF-related rupture of the external iliac artery is rare and indicates surgical techniques in controlling and restoring blood supply to the lower leg.

Pelvic trauma and vascular emergencies

“…Recurrent bleeding through vertical and horizontal anastamoses must be excluded with contralateral (internal iliac artery) and ipsilateral (branches of the aorta and external iliac artery) diagnostic arteriography; • damage to the large arterial and venous trunks is rare and carries a high mortality rate. These are managed specifically (obstruction balloon along the injury/sandwich packing pending repair or coated stent bypass) [50,51]; • a target identified in the obturator territory requires external iliac artery angiography to look for a corona mortis artery if internal iliac arteriography is normal.…”

Pelvic ring injuries: Emergency assessment and management

“…22 Bleeding usually originates from cancellous bone, presacral venous plexus, and/or iliac vessels. 23,24 Extra-pelvic hemorrhage can also occur due to the often high-energy trauma required to disrupt the pelvis, with long bones and abdominal viscera being the most common sites. 25 The incidence of associated long bone fractures in unstable pelvic ring injuries has been reported to be over 80%.…”

Haemodynamically unstable pelvic trauma: initial validation of a dedicated protocol by a retrospective cohort study with historical controls

“…Acetabular fractures were considered because they are sometimes responsible for haemodynamic instability due to arterial damage requiring angioembolization. [18][19] Fractures were classified retrospectively by one of the authors (SM) according to ArbeitsgemeinschaftfürOsteosynthesefrag en-American Orthopaedic Trauma Association (AO-OTA) classification, namely pelvic fractures were classified as A (lesion sparing (or with no displacement of) posterior arch), B (incomplete disruption of posterior arch, partially stable) or C (complete disruption of posterior arch, unstable). 20 Our hospital has been designated Level I Trauma Centre.…”