Limits of intravascular contrast extravasation on computed tomography scan to define the need for pelvic angioembolization in pelvic blunt trauma: a specific assessment on the risk of false positives

Ramin, Séverin; Hermida, Margaux; Millet, Ingrid; Murez, Thibault; Monnin, V.; Hamoui, Mazen; Capdevila, Xavier; Charbit, Jonathan

doi:10.1097/ta.0000000000002001

Cited by 16 publications

(16 citation statements)

References 30 publications

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“…For example, 82.4% of patients in the AE group exhibited signs of arterial bleeding during the CT examination, while only 26% of patients exhibited signs of CE during angiography. This corresponds to a PPV of only 29.6% for the use of CT to detect arterial injury in patients with pelvic fractures, which is similar to the results from previous studies [13,20]. We suspect that it may be difficult to differentiate between bone marrow and arterioles as the source of contrast extravasation during CT examination soon after a pelvic fracture, and our results suggest that evidence of CE during CT may not be a suitable major indication for AE, despite this being previously recommended [7,21].…”

Section: Discussionsupporting

confidence: 89%

“…However, AE is associated with various complications, including inadequate hemostasis, gluteal muscle necrosis, and surgical site infection (SSI) [11,12]. Therefore, as an observation of contrast extravasation (CE) during computed tomography (CT) [13] is unreliable as a sole basis for selecting AE, additional information is needed to help determine when AE can help provide optimal outcomes. This study aimed to explore AE-related outcomes following resuscitation at our center and to assess the predictive value of CE during CT for patients with hemodynamically unstable closed pelvic fractures.…”

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

BMC Musculoskelet Disord

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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 of AE are controversial. In this study, we aimed to explore AE-related outcomes following resuscitation at our center and to assess the predictive value of contrast extravasation (CE) during computed tomography (CT) for patients with hemodynamically unstable closed pelvic fractures. 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.

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Section: Discussionsupporting

confidence: 89%

Section: Introductionmentioning

confidence: 99%

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

BMC Musculoskelet Disord

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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 of AE are controversial. In this study, we aimed to explore AE-related outcomes following resuscitation at our center and to assess the predictive value of contrast extravasation (CE) during computed tomography (CT) for patients with hemodynamically unstable closed pelvic fractures. 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.

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“…In the literature, the fraction of patients with contrast extravasation on CT in pelvic trauma varies between 15 and 23% [9,37,39], similar to our study (19%). It has been shown in several studies that not all patients with contrast extravasation on CT require angiography [22,39]. This was also observed in our study population, where 33% of patients with CT extravasation were referred to angiographic intervention (10/30).…”

Section: Imaging Findings On Computed Tomographysupporting

confidence: 82%

“…in early arterial phase scanning [19]. Furthermore, some studies debate the clinical significance of contrast extravasation on CT because of its high false-positive rate [21,22].…”

Section: Introductionmentioning

confidence: 99%

Do we really need the arterial phase on CT in pelvic trauma patients?

et al. 2020

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Purpose To evaluate whether an arterial phase scan improves the diagnostic performance of computed tomography to identify pelvic trauma patients who received angiographic intervention on demand of the trauma surgeon. Methods This retrospective single-center study was performed at an academic Scandinavian trauma center with approximately 2000 trauma admissions annually. Pelvic trauma patients with arterial and portal venous phase CT from 2009 to 2015 were included. The patients were identified from the institutional trauma registry. Images were interpreted by two radiologists with more than 10 years of trauma radiology experience. Positive findings for extravasation on portal venous phase alone or on both arterial and portal venous phase were compared, with angiographic intervention as clinical outcome. Results One hundred fifty-seven patients (54 females, 103 males) with a median age of 45 years were enrolled. Sixteen patients received angiographic intervention. Positive CT findings on portal venous phase only had a sensitivity and specificity of 62% and 86%, vs. 56% and 93% for simultaneous findings on arterial and portal venous phase. Specificity was significantly higher for positive findings in both phases compared with portal venous phase only. Applying a threshold > 0.9 cm of extravasation diameter to portal venous phase only resulted in sensitivity and specificity identical to those of both phases. Conclusion Arterial phase scan in addition to portal venous phase scan did not improve patient selection for angiography. Portal venous phase extravasation size alone may be used as an imaging-based biomarker of the need for angiographic intervention.

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“…However, AE is associated with various complications, including inadequate hemostasis, gluteal muscle necrosis, and surgical site infection (SSI) [11,12]. In addition, it can be unreliable to select AE for a patient based solely on observing contrast extravasation (CE) during computed tomography (CT) [13].…”

Section: Introductionmentioning

confidence: 99%

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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Limits of intravascular contrast extravasation on computed tomography scan to define the need for pelvic angioembolization in pelvic blunt trauma: a specific assessment on the risk of false positives

Abstract: Therapeutic study, level IV.

Cited by 16 publications

References 30 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

Do we really need the arterial phase on CT in pelvic trauma patients?

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

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