Journal of Trauma and Injury

The Korean Society of Traumatology (대한외상학회)
권호 표지
DOI QR코드

DOI QR Code

Blush on Computed Tomography and Transcatheter Arterial Embolization in Pelvic Fracture

  • Gwak, Jihun (Department of Trauma Surgery, Gachon University, Gil Medical Center) ;
  • Yoon, Yong-Cheol (Department of Trauma Surgery, Gachon University, Gil Medical Center) ;
  • Lee, Min A (Department of Trauma Surgery, Gachon University, Gil Medical Center) ;
  • Yu, Byungchul (Department of Trauma Surgery, Gachon University, Gil Medical Center) ;
  • Jang, Myung Jin (Department of Trauma Surgery, Gachon University, Gil Medical Center) ;
  • Choi, Kang Kook (Department of Trauma Surgery, Gachon University, Gil Medical Center)
  • Received : 2016.12.07
  • Accepted : 2017.01.31
  • Published : 2016.12.31
Download PDF
⟨ Previous Next ⟩

Abstract

Purpose: Bleeding is the primary cause of death after severe pelvic fracture. Transcatheter arterial embolization (TAE) is the mainstay of treatment for arterial bleeding. This study aimed to determine the frequency of bleeding by angiography of blush-positive pelvic fractures on computed tomography (CT) images. The bleeding arteries that were involved were investigated by pelvic angiography. Methods: This retrospective cohort study evaluated 83 pelvic fracture patients who were treated in the intensive care unit of the author's trauma center between January 01, 2013 and April 30, 2015. Results: Overall mortality was 9 of 83 patients (10.8%). Blush was observed in 37 patients; blush-positive patients had significantly higher mortality (24.3%) than blush-negative patients (0%). Twenty-four of the 83 patients (28.9%) underwent pelvic angiography. Bleeding was showed in 22 of 24 patients in pelvic angiography. TAE was successfully performed in 21 (95.5%) of the bleeding 22 patients. Angiography was performed in 23 of 37 blush-positive patients, and arterial bleeding was identified in 21 (91.3%). A total 33 bleeding arteries were identified in 22 angiography-positive patients. The most frequent origin of bleeding was internal iliac artery (69.7%) followed by the external iliac artery (18.2%) and lumbar arteries (12.1%). Conclusion: The vascular blush observed in CT scans indicates sites of ongoing bleeding in pelvic angiography. TAE is an excellent therapeutic option for arterial bleeding and has a high success rate with few complications.

Keywords

References

  1. Starr AJ, Griffin DR, Reinert CM, Frawley WH, Walker J, Whitlock SN, et al. Pelvic ring disruptions: prediction of associated injuries, transfusion requirement, pelvic arteriography, complications, and mortality. J Orthop Trauma 2002; 16: 553-61. https://doi.org/10.1097/00005131-200209000-00003
  2. Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography: competitive or complementary? Injury 2009; 40: 343-53. https://doi.org/10.1016/j.injury.2008.12.006
  3. Osborn PM, Smith WR, Moore EE, Cothren CC, Morgan SJ, Williams AE, et al. Direct retroperitoneal pelvic packing versus pelvic angiography: A comparison of two management protocols for haemodynamically unstable pelvic fractures. Injury 2009; 40: 54-60. https://doi.org/10.1016/j.injury.2008.08.038
  4. Marzi I, Lustenberger T. Management of Bleeding Pelvic Fractures. Scand J Surg 2014; 103: 104-11. https://doi.org/10.1177/1457496914525604
  5. Eastridge BJ, Starr A, Minei JP, O'Keefe GE, Scalea TM. The importance of fracture pattern in guiding therapeutic decisionmaking in patients with hemorrhagic shock and pelvic ring disruptions. J Trauma 2002; 53: 446-50; discussion 50-1. https://doi.org/10.1097/00005373-200209000-00009
  6. Agolini SF, Shah K, Jaffe J, Newcomb J, Rhodes M, Reed JF, 3rd. Arterial embolization is a rapid and effective technique for controlling pelvic fracture hemorrhage. J Trauma 1997; 43: 395-9. https://doi.org/10.1097/00005373-199709000-00001
  7. Cullinane DC, Schiller HJ, Zielinski MD, Bilaniuk JW, Collier BR, Como J, et al. Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture--update and systematic review. J Trauma 2011; 71: 1850-68.
  8. Bozeman MC, Cannon RM, Trombold JM, Smith JW, Franklin GA, Miller FB, et al. Use of computed tomography findings and contrast extravasation in predicting the need for embolization with pelvic fractures. Am Surg 2012; 78: 825-30.
  9. Anandakumar V, Hussein FK, Varuun B, Zhu R. Predictive parameters for angiography and embolization in the bleeding pelvic fracture. J Clin Orthop Trauma 2013; 4: 70-4. https://doi.org/10.1016/j.jcot.2013.01.005
  10. Papakostidis C, Kanakaris N, Dimitriou R, Giannoudis PV. The role of arterial embolization in controlling pelvic fracture haemorrhage: a systematic review of the literature. Eur J Radiol 2012; 81: 897-904. https://doi.org/10.1016/j.ejrad.2011.02.049
  11. Brasel KJ, Pham K, Yang H, Christensen R, Weigelt JA. Significance of contrast extravasation in patients with pelvic fracture. J Trauma 2007; 62: 1149-52. https://doi.org/10.1097/TA.0b013e3180479827
  12. Diamond IR, Hamilton PA, Garber AB, Tien HC, Chughtai T, Rizoli SB, et al. Extravasation of intravenous computed tomography scan contrast in blunt abdominal and pelvic trauma. J Trauma 2009; 66: 1102-7. https://doi.org/10.1097/TA.0b013e318174f13d
  13. Verbeek DO, Zijlstra IA, van der Leij C, Ponsen KJ, van Delden OM, Goslings JC. Management of pelvic ring fracture patients with a pelvic "blush" on early computed tomography. The journal of trauma and acute care surgery 2014; 76: 374-9. https://doi.org/10.1097/TA.0000000000000094
  14. Costantini TW, Bosarge PL, Fortlage D, Bansal V, Coimbra R. Arterial embolization for pelvic fractures after blunt trauma: are we all talk? American journal of surgery 2010; 200: 752-7; discussion 7-8. https://doi.org/10.1016/j.amjsurg.2010.06.006
  15. Ono Y, Ishida T, Iwasaki Y, Kawakami Y, Inokuchi R, Tase C, et al. The off-hour effect on trauma patients requiring subspecialty intervention at a community hospital in Japan: a retrospective cohort study. Scand J Trauma Resusc Emerg Med 2015; 23: 20. https://doi.org/10.1186/s13049-015-0095-1
  16. Balogh Z, Caldwell E, Heetveld M, D'Amours S, Schlaphoff G, Harris I, et al. Institutional practice guidelines on management of pelvic fracture-related hemodynamic instability: do they make a difference? J Trauma 2005; 58: 778-82. https://doi.org/10.1097/01.TA.0000158251.40760.B2
  17. Manson TT, Nascone JW, Sciadini MF, O'Toole RV. Does fracture pattern predict death with lateral compression type 1 pelvic fractures? J Trauma 2010; 69 : 876-9. https://doi.org/10.1097/TA.0b013e3181e785bf
  18. Sarin EL, Moore JB, Moore EE, Shannon MR, Ray CE, Morgan SJ, et al. Pelvic fracture pattern does not always predict the need for urgent embolization. J Trauma 2005; 58: 973-7. https://doi.org/10.1097/01.TA.0000171985.33322.b4
  19. Wright V, Zelle BA, Prayson M. Bilateral sacroiliac joint dislocation without associated fracture or anterior pelvic ring injuries. J Orthop Trauma 2004; 18: 634-7. https://doi.org/10.1097/00005131-200410000-00010
  20. DuBose J, Inaba K, Barmparas G, Teixeira PG, Schnuriger B, Talving P, et al. Bilateral internal iliac artery ligation as a damage control approach in massive retroperitoneal bleeding after pelvic fracture. J Trauma 2010; 69: 1507-14. https://doi.org/10.1097/TA.0b013e3181d74c2f