Pelvic angioembolization: how urgently needed?

Abstract

Purpose Angioembolization (AE) has been questioned as first-line modality for hemorrhage control of pelvic fracture (PF)-associated bleeding due to its potential inconsistent timely availability. We aimed to describe the patterns of AE use with hemostatic resuscitation and hypothesized that time to AE improved during the study period. Methods A Level-1 trauma center’s prospective PF database was analyzed. All consecutive PFs referred to angiography between 01/01/2009 and 12/31/2018 were included. All suspected pelvic hemorrhage was managed with AE; pelvic packing was not performed. Demographics, injury/shock severity, 24-h transfusion data, time to AE and mortality were recorded. Data are presented as median (IQR). Results During the 10-year study period, 1270 PF patients were treated. Thirty-six (2.8%) [75% male, 49 (33;65) years, ISS 36 (24;43), base deficit 3.65 (5.9;0.6), transfusions 4(2;7)] had AE. The indication for AE was clinical suspicion (CS) of pelvic bleeding [CS 24(67%)] or arterial blush on CT [CT 12 (33%)]. Median time to AE was 141 min for CS, and 223 min for CT, with no change over the study period. Patients with CS had a higher ISS, worse base deficit, greater transfusion requirements and faster time to AE. Five patients (14%) died. There were no deaths attributed to exsanguination. Conclusions Time to AE did not improve. Patients referred from CT are physiologically different from CS and should be analyzed accordingly, with CS resulting in faster time to AE in sicker patients. Contemporary resuscitation challenges the need for hyperacute AE as no patients exsanguinated despite time to AE of more than 2 h.

Improving Time to Angioembolization for Trauma Care: Novel Smartphone Application

“…Interventional radiology angioembolization has become integral to trauma care but requires a specialized, multidisciplinary team approach (Chehab et al., 2020). The combination of angiography and embolization of bleeding arterial vessels has emerged as an exceptional treatment method to manage vascular lesions in solid organ and pelvic injuries (Aoki et al., 2021; Devaney et al., 2022; Kim et al., 2021; Tan et al., 2023). Advances in CT imaging, more efficient scanning times, and improved image quality have improved the specificity of care (Gilyard et al., 2020).…”

“…Trauma centers must have IR available 24/7, with the interventional radiologist accessible within 30 min of request (Chehab et al., 2020). Timely angioembolization depends on many factors, most importantly the availability of the interventional radiologist and the procedure team (Devaney et al., 2022). Mortality increases from time of presentation to angioembolization (Aoki et al., 2021; Jarvis et al., 2019), as well as increased need for blood transfusion (Chehab et al., 2020).…”

The sequence of the treatment of combined fractures of the pelvis, spine, and extremities in polytraumatized patients

“…In our experience, signs of persistent bleeding after mechanical pelvic stabilization and pre-peritoneal pelvic packing indicate the need for postoperative pelvic angiography. Embolization of residual arterial bleeding can then be performed on the way from the operating theater to the intensive care unit (ICU) in a patient with a more stable hemodynamic status ( 22 ). This concept of pre-peritoneal pelvic packing external fixation of the pelvic ring injury and secondary angioembolization is not new and was previously described by Burlew et al Here in 10% of 75 patients with severe pelvic fractures and life-threatening bleeding, angioembolisation was performed after surgery and none of these patients died due to pelvic bleeding ( 23 ).…”

Predictive factors of mortality in patients with pelvic fracture and shock submitted to extraperitoneal pelvic packing

“…Patients with refractory shock after resuscitation with adequate volume and mechanical stabilization of the pelvis are more likely to have arterial injury 35 , with a reported incidence greater than 50% 7,14,[36][37][38][39][40] , making this the most frequent indication for arteriography 41,42 . In studies on EPP results [5][6][7]9,10,[12][13][14][15][16]21,[26][27][28][29] , arteriography was performed in a complementary way in 13,33% to 100% of patients, and the presence of arterial injury was confirmed in 33.33% to 100% of cases.…”