51
|
Transcatheter embolotherapy after external surgical stabilization is a valuable treatment algorithm for patients with persistent haemorrhage from unstable pelvic fractures: outcomes of a single centre experience. Injury 2013; 44:964-8. [PMID: 23398901 DOI: 10.1016/j.injury.2013.01.029] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Revised: 11/23/2012] [Accepted: 01/11/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE The management of hemodynamically unstable patients with severe pelvic fractures remains a challenge. Various treatment strategies have been advocated. This study analyzed the value of transcatheter angiographic embolization (TAE) for persistent haemodynamic instability after initial fracture stabilization. MATERIALS AND METHODS From January 2002 to July 2011, 803 patients were identified with pelvic fractures, 295 of them (37%) were presenting with unstable pelvic fractures. Fifteen patients, all with unstable fractures (2%), remained hypotensive (systolic blood pressure<90 mmHg) despite adequate fluid resuscitation and emergent surgical fracture stabilization, subsequently underwent TAE. RESULTS The median age in the TAE-group was 57.9 years±20.12 (min 22; max 82) and the median ISS (injury severity score) was 35.8±11.7 (min 22; max 66). 13 out of 15 patients (87%) received initial external fixation and 2 patients (13%) where treated with a C-Clamp before TAE. Radiological success, defined as absence of contrast extravasation on completion angiography, was observed in all 15 patients. In total 3 (20%) patients died during the period of hospitalization, none of them owing to persistent or recurrent pelvic haemorrhage. In the remaining 12 patients, no early or late complications of TAE were identified. Preperitoneal pelvic packing was performed in two patients, both had open pelvic fractures. CONCLUSION TAE is a safe and very efficient procedure to treat persistent haemorrhage in patients with unstable pelvic fractures initially treated by surgical fracture stabilization procedures. On the long term, no early or late bleeding recurrence could be demonstrated with an overall survival rate of 80%. Preperitoneal pelvic packing can be reserved for patients with open fractures and active bleeding.
Collapse
|
52
|
Different management strategies for postoperative hematoma after pelvic organ prolapse surgery. Taiwan J Obstet Gynecol 2013; 51:656-9. [PMID: 23276577 DOI: 10.1016/j.tjog.2012.09.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2012] [Indexed: 11/21/2022] Open
|
53
|
Embolization of pelvic arterial injury is a risk factor for deep infection after acetabular fracture surgery. J Orthop Trauma 2013; 27:11-5. [PMID: 22495529 DOI: 10.1097/bot.0b013e31824d96f6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine whether embolization of pelvic arterial injuries before open reduction and internal fixation (ORIF) of acetabular fractures is associated with an increased rate of deep surgical site infection. METHODS Retrospective review of patients who underwent ORIF of acetabular fractures at our institution from 1995 through 2007 (n = 1440). We compared patients with acetabular fractures who underwent angiography and embolization of a pelvic artery (n = 12) with those who underwent angiography but did not undergo embolization (n = 14). Primary outcome was presence of infection requiring return to the operating room. RESULTS Seven (58%) of the 12 patients who underwent embolization developed deep surgical site infection compared with only 2 (14%) of the patients who underwent angiography but did not require pelvic vessel embolization (P < 0.05, Fisher exact test). CONCLUSIONS The combination of an acetabular fracture that requires ORIF and a pelvic arterial injury that requires angiographic embolization is rare. However, the 58% infection rate of the patients who underwent embolization before ORIF is an order of magnitude higher than typical historical controls (2%-5%) and significantly higher than that of the control group of patients who underwent angiography without embolization (14%). In addition, a disproportionate number of the patients who developed infection had their entire internal iliac artery embolized. Surgeons should be aware that embolization of a pelvic arterial injury is associated with a high rate of infection after subsequent ORIF of an acetabular fracture. Embolization of the entire iliac artery should be avoided whenever possible. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
54
|
Abstract
Mortality associated with pelvic and perineal trauma (PPT) has fallen from 25% to 10% in the last decade thanks to progress accomplished in medical, surgical and interventional radiology domains (Dyer and Vrahas, 2006) [1]. The management strategy depends on the hemodynamic status of the patient (stable, unstable or extremely unstable). Open trauma requires specific treatment in addition to control of bleeding. All surgical centers can be confronted some day with patients with hemorrhagic PPT and for this reason, all surgeons should be familiar with the initial management. In expert centers, management of patients with severe PPT is complex, multidisciplinary and often requires several re-interventions. Obstetrical and sexual trauma, also requiring specific management, will not be dealt with herein.
Collapse
|
55
|
Prospective Diagnosis of Corona Mortis Hemorrhage in Pelvic Trauma. J Vasc Interv Radiol 2012; 23:571-3. [DOI: 10.1016/j.jvir.2011.12.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Revised: 12/15/2011] [Accepted: 12/16/2011] [Indexed: 11/23/2022] Open
|
56
|
Hong MK, Liao CY, Chu TY, Chen PC, Ding DC. Internal pudendal artery injury during prolapse surgery using nonanchored mesh. J Minim Invasive Gynecol 2011; 18:678-81. [PMID: 21872176 DOI: 10.1016/j.jmig.2011.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Revised: 06/01/2011] [Accepted: 06/23/2011] [Indexed: 10/17/2022]
Abstract
Herein is presented the case of a patient with stage 2 uterine prolapse treated surgically using nonanchored mesh. Complications were internal pudendal artery injury and a massive presacral hematoma that formed after surgery. Transcatheter arterial embolization was performed immediately, and the bleeding stopped. The patient subsequently experienced difficulty micturating and defecating because of presacral hematoma compression. Self-micturation and defecation capabilities were regained gradually at approximately 1 week after surgery. The hematoma resolved completely by 71 days postoperatively. Comprehensive knowledge of pelvic anatomy is important when performing surgery to treat prolapse using mesh kits. Removing the mesh and prophylactic antibiotic therapy is a means of conservatively managing a pelvic hematoma caused by prolapse surgery.
Collapse
Affiliation(s)
- Mun-Kun Hong
- Department of Obstetrics and Gynecology, Buddhist Tzu Chi General Hospital, Tzu Chi University, Hualien, Taiwan, Republic of China
| | | | | | | | | |
Collapse
|
57
|
Goei AD, Ching BH, Meyermann MW, Nunez T, Sacks D. Tips and tricks for the trauma patient. Semin Intervent Radiol 2011; 27:81-98. [PMID: 21359017 DOI: 10.1055/s-0030-1247894] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Interventions on the trauma patient are an essential component of the complete scope of care that is provided to the multiply injured patient today. The active participation by the interventional radiologist along the entire spectrum of clinical care is very important to optimize patient outcomes. Suggestions on how to establish a clinical presence are presented. A few of the newer concepts and terminology applicable to trauma care are reviewed. Tips useful in the trauma room, in the interventional radiology suite, and during the postprocedural period are discussed.
Collapse
Affiliation(s)
- Anthony D Goei
- Department of Radiology, Brooke Army Medical Center, San Antonio, Texas
| | | | | | | | | |
Collapse
|
58
|
Seif HMAH, Emam Y. Efficacy and procedural time of angioembolization in ongoing pelvic fracture hemorrhage. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2011. [DOI: 10.1016/j.ejrnm.2011.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
|
59
|
Karadimas EJ, Nicolson T, Kakagia DD, Matthews SJ, Richards PJ, Giannoudis PV. Angiographic embolisation of pelvic ring injuries. Treatment algorithm and review of the literature. INTERNATIONAL ORTHOPAEDICS 2011; 35:1381-90. [PMID: 21584644 DOI: 10.1007/s00264-011-1271-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2011] [Accepted: 04/20/2011] [Indexed: 12/11/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the relation between pelvic fracture patterns and the angiographic findings, and to assess the effectiveness of the embolisation. METHODS This retrospective study, included patients with pelvic fractures and angiographic evaluation. Demographics, Injury Severity Score (ISS), associated injuries, embolisation time, blood units needed, method of treatment and complications were recorded and analysed. Fractures were classified according to the Burgess system. RESULTS Between 1998 and 2008, 34 patients with pelvic fractures underwent angiographic investigation. Twenty six were males. The mean age was 41 years. Twenty-seven were motor vehicle accidents and seven were falls. There were 11 anterior posterior (APC) fractures, 12 lateral compression (LC), eight vertical shear (VS) patterns and three with combined mechanical injuries. The median ISS was 33.1 (range 5-66). From the 34 who underwent angiography, 29 had positive vascular extravasations. From them, 21 had embolisation alone, two had vascular repair and embolisation, five required vascular repair alone and one patient died while being prepared for embolisation. Five cases were re-embolised. The findings suggested that AP fractures have a higher tendency to bleeding compared with LC fractures. Both had a higher chance of blood loss compared to VS and complex fracture patterns. We reported 57 additional injuries and 65 fractures. The complications were: one non lethal pulmonary embolism, one renal failure, one liver failure, one systemic infection, two deep infections and two psychological disorientations. Seven patients died in hospital. CONCLUSION Control of pelvic fracture bleeding is based on the multidisciplinary approach mainly related to hospital facilities and medical personnel's awareness. The morphology of the fracture did not have a predictive value of the vascular lesion and the respective bleeding.
Collapse
|
60
|
Cherry RA, Goodspeed DC, Lynch FC, Delgado J, Reid SJ. Intraoperative angioembolization in the management of pelvic-fracture related hemodynamic instability. J Trauma Manag Outcomes 2011; 5:6. [PMID: 21569480 PMCID: PMC3113950 DOI: 10.1186/1752-2897-5-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Accepted: 05/13/2011] [Indexed: 11/23/2022]
Abstract
Background This case series report discusses patients presenting with hemorrhage and hemodymanic compromise due to severe pelvic fractures and undergoing intraoperative angioembolization (IAE) with other resuscitative procedures. Methods We used portable digital subtraction fluoroscopy units for IAE in patients with severe pelvic hemorrhage and hemodynamic instability (5/03-4/09). Data was collected on demographics, injury severity, resource utilization, and outcomes at our Level 1 trauma center. Results There were 6,538 adult admissions with 912 having pelvic fractures and 65 of these undergoing pelvic angioembolization. Twelve hemodynamically compromised patients (10 males, 2 females) had intraoperative pelvic angiography (age: 22-79 years; mean 51.3 ± 17.4). Injury severity score (ISS) was 37.5 ± 8.4 (22-50). Mean emergency department (ED) length of stay (LOS) was 57.4 min ± 47.9 with 10 patients transported directly to the OR and 2 to the SICU prior to OR. Ten of 12 patients underwent exploratory laparotomy followed by angioembolization. Mortality was 50%. Among the 6 survivors (ISS 22 - 50), all had a pre-op CT scan, five had an initial base deficit <13, and four were transfused ≤ 6 units pre-incision/pre-procedure. Four of the 6 survivors had unilateral embolization. In contrast, all 6 non-survivors (ISS 29-41) required massive transfusion prior to OR (>6 units PRBCs) with 4 having a based deficit >13. Three of these patients bypassed CT and five underwent bilateral internal iliac embolization (BIIE). Conclusions IAE for severe pelvic hemorrhage can be successfully performed concurrently with exploratory laparotomy, pelvic packing or other resuscitative procedures. Patients most likely to benefit have a base deficit <13, and do not require massive transfusion prior to IAE or suffer from a vertically unstable pelvis fracture.
Collapse
Affiliation(s)
- Robert A Cherry
- University of Wisconsin Hospital & Clinics Department of Orthopaedics & Rehabilitation 1685 Highland Avenue Madison, WI 53705 (608) 263-9456, USA.
| | | | | | | | | |
Collapse
|
61
|
Bae SH, Han DK, Baek HJ, Park SJ, Chang NK, Kook H, Hwang TJ. Selective embolization of the internal iliac arteries for the treatment of intractable hemorrhage in children with malignancies. KOREAN JOURNAL OF PEDIATRICS 2011; 54:169-75. [PMID: 21738551 PMCID: PMC3127151 DOI: 10.3345/kjp.2011.54.4.169] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Revised: 10/14/2010] [Accepted: 12/29/2010] [Indexed: 11/27/2022]
Abstract
Purpose Acute internal hemorrhage is an occasionally life-threatening complication in pediatric cancer patients. Many therapeutic approaches have been used to control bleeding with various degrees of success. In this study, we evaluated the efficacy of selective internal iliac artery embolization for controlling acute intractable bleeding in children with malignancies. Methods We retrospectively evaluated the cases of 6 children with various malignancies (acute lymphoblastic leukemia, acute myelogenous leukemia, chronic myelogenous leukemia, T-cell prolymphocytic leukemia, Langerhans cell histiocytosis, and rhabdomyosarcoma), who had undergone selective arterial embolization (SAE) of the internal iliac artery at the Chonnam National University Hwasun Hospital between January 2004 and December 2009. SAE was performed by an interventional radiologist using Gelfoam® and/or Tornado® coils. Results The patients were 5 boys and 1 girl with median age of 6.9 years (range, 0.7-14.8 years) at the time of SAE. SAE was performed once in 4 patients and twice in 2, and the procedure was unilateral in 2 and bilateral in 4. The causes of hemorrhage were as follows: hemorrhagic cystitis (HC) in 3 patients, procedure-related internal iliac artery injuries in 2 patients, and tumor rupture in 1 patient. Initial attempt at conservative management was unsuccessful. Of the 6 patients, 5 (83.3%) showed improvement after SAE without complications. Conclusion SAE may be a safe and effective procedure for controlling acute intractable hemorrhage in pediatric malignancy patients. This procedure may obviate the need for surgery, which carries an attendant risk of morbidity and mortality in cancer patients with critical conditions.
Collapse
Affiliation(s)
- Sul Hee Bae
- Department of Pediatrics, Chonnam National University Medical School, Gwangju, Korea
| | | | | | | | | | | | | |
Collapse
|
62
|
Müller-Wille R, Heiss P, Herold T, Jung EM, Schreyer AG, Hamer OW, Rennert J, Hoffstetter P, Stroszczynski C, Zorger N. Endovascular Treatment of Acute Arterial Hemorrhage in Trauma Patients Using Ethylene Vinyl Alcohol Copolymer (Onyx). Cardiovasc Intervent Radiol 2011; 35:65-75. [DOI: 10.1007/s00270-011-0134-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Accepted: 02/15/2011] [Indexed: 10/18/2022]
|
63
|
Angioembolization provides benefits in patients with concomitant unstable pelvic fracture and unstable hemodynamics. Am J Emerg Med 2010; 30:207-13. [PMID: 21159470 DOI: 10.1016/j.ajem.2010.11.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Revised: 11/05/2010] [Accepted: 11/05/2010] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Pelvic fractures result in hemodynamic instability in 5% to 20% of patients, and the reported mortality rate is 18% to 40%. Previous studies have reported the application of angioembolization in pelvic fracture patients with a systolic blood pressure (SBP) less than 90 mm Hg, a fluid resuscitation requirement of more than 2000 mL, or a blood transfusion of more than 4 to 6 units within 24 hours. In the current study, we attempted to delineate the efficacy and outcome of angioembolization in unstable pelvic fracture patients with concomitant unstable hypotension status. METHODS We retrospectively reviewed the charts of patients with pelvic fractures between January 2005 and May 2010. We focused on unstable pelvic fracture patients with an SBP less than 90 mm Hg after fluid resuscitation who did not receive computed tomography scans. The demographics, injury severity score, abbreviated injury scale, and hemodynamic status after angioembolization were analyzed. RESULTS In total, 26 patients were enrolled. There were 16 patients receiving angioembolization directly without computed tomography scans and 12 patients receiving emergency laparotomy due to a finding of hemoperitoneum on sonography, followed by angioembolization. In both groups, the SBP improved significantly after angioembolization. The overall survival rate was 85.7%. CONCLUSIONS In patients with concomitant unstable hemodynamics and unstable pelvic fracture, angioembolization serves as an effective adjunct to hemostasis. Aggressive embolization should be performed even in patients without contrast extravasation in angiography.
Collapse
|
64
|
Bilateral Internal Iliac Artery Ligation as a Damage Control Approach in Massive Retroperitoneal Bleeding AfterPelvic Fracture. ACTA ACUST UNITED AC 2010; 69:1507-14. [DOI: 10.1097/ta.0b013e3181d74c2f] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
65
|
Transcatheter arterial chemoembolization (TACE) or embolization (TAE) for symptomatic bone metastases as a palliative treatment. Cardiovasc Intervent Radiol 2010; 34:793-801. [PMID: 21076921 DOI: 10.1007/s00270-010-0031-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Accepted: 10/24/2010] [Indexed: 12/21/2022]
Abstract
PURPOSE This study was designed to evaluate the effect of transcatheter arterial chemoembolization (TACE)/embolization (TAE) for symptomatic bone metastases especially in palliation. METHODS Between April 2006 and December 2009, 24 bone metastatic lesions of 18 patients (8 women and 10 men; mean age, 64 years) underwent palliative TACE or TAE. A total of 40 sessions were performed, with 1-4 sessions per lesion. The primary lesions included hepatocellular carcinoma, colorectal cancer, renal cell cancer, ovarian cancer, thyroid cancer, uterine cervical cancer, and esophageal cancer. Symptomatic lesions involved thoracic spine, lumbar spine, pelvis, rib, and femur. The procedures were performed with a coaxial catheter technique to catheterize selectively target arteries. If not possible due to small branches, blood flow alteration by coil was achieved. Gelatin sponge was the initial embolic materials. As anti-cancer agents, epirubicin, fluorouracil, and mitomycin were mainly used in consideration for primary lesion and past treatment. RESULTS Sufficient devascularization of targeted lesions was obtained in 18 of 24 (75%) lesions without any serious complication. Pain relief was obtained in 20 lesions (83%), with significantly decrease in the visual analogue scale score (P < 0.001). A relationship was found between the devascularization grade and pain relief (r = 0.49, P < 0.05). Follow-up CT images at 1 month of nine lesions (50%) revealed necrotic change in the tumors. CONCLUSIONS Palliative TACE/TAE for symptomatic bone metastases could be a suitable treatment method because it is minimally invasive, repeatable, effective, and rapid-acting.
Collapse
|
66
|
Sepsis caused by peripelvic soft tissue infections in critically injured patients with multiple injuries and unstable pelvic fracture. ACTA ACUST UNITED AC 2009; 66:1548-54; discussion 1554-5. [PMID: 19509613 DOI: 10.1097/ta.0b013e3181a51b0e] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND In critically injured patients with multiple injuries and unstable pelvic fracture, late mortality almost invariably results from sepsis. METHODS We analyzed the clinical features of 11 patients with sepsis caused by soft tissue infections surrounding the fractured pelvis, of 830 patients with pelvic fracture after blunt trauma treated at our level I trauma center over the past 25 years. Soft tissue infection was defined as abscess formation in subcutaneous tissue or muscle diagnosed by computed tomography or an operation. RESULTS Mean injury severity score was 48, and mean systolic blood pressure on arrival was 66 mm Hg. All patients had multiple concomitant injuries and prolonged hemorrhagic shock. Open pelvic fracture was present in five patients. Mean blood transfusion volume within 24 hours was 12,611 mL. Intra-aortic balloon occlusion was performed in three patients and transcatheter angiographic embolization in nine patients. Embolic sites of transcatheter angiographic embolization were bilateral internal iliac arteries (n = 9), lumbar artery (n = 5), median sacral artery (n = 2), and circumflex femoral artery (n = 2). Infection sites included the gluteal (n = 11), femoral (n = 6), sacral (n = 4), lumbar (n = 4), anterior iliac (n = 2), inguinal (n = 1), and perineal (n = 1) regions. Necrotic changes of infected soft tissue were found in all patients. They underwent open drainage and daily debridement with pulsatile irrigation followed by intravenous antibiotics. All patients developed severe sepsis, five of whom subsequently died of multiple organ failure. CONCLUSIONS In critically injured patients with multiple injuries and unstable pelvic fracture, peripelvic soft tissue infections occasionally cause sepsis. Peripelvic infections are often accompanied by necrotic changes and easily develop into severe sepsis or multiple organ failure. Identifying high-risk patients and early diagnosis with prompt surgical treatment are indispensable for the patients' survival.
Collapse
|
67
|
Degani S, Leibovitz Z, Shapiro I, Ohel G. Expectant management of pregnancy-related high-velocity uterine arteriovenous shunt diagnosed after abortion. Int J Gynaecol Obstet 2009; 106:46-9. [PMID: 19375703 DOI: 10.1016/j.ijgo.2009.03.039] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Revised: 02/19/2009] [Accepted: 03/17/2009] [Indexed: 11/25/2022]
|