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Kaewlai R, Chomchalerm G, Tongsai S, Chatpuwaphat J, Chatkaewpaisal A, Khamman P, Thamtorawat S, Praditsuktavorn B, Maitriwong W, Matsumoto J. Predictors and pathways of in-hospital mortality in active vascular contrast extravasation detected on abdominopelvic CT. Insights Imaging 2024; 15:174. [PMID: 38992307 PMCID: PMC11239638 DOI: 10.1186/s13244-024-01748-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 06/17/2024] [Indexed: 07/13/2024] Open
Abstract
OBJECTIVES This study aimed to identify factors influencing in-hospital mortality in adult patients with active vascular contrast extravasation (AVCE) on abdominopelvic computed tomography (CT). METHODS All consecutive patients with AVCE detected on CT between January 2019 and May 2022 were retrospectively included. Their data were compared through uni- and multivariable analyses between patients with and without in-hospital mortality. Path analysis was utilized to clarify the relationships among factors affecting mortality. RESULTS There were 272 patients (60.2 ± 19.4 years, 150 men) included, of whom 70 experienced in-hospital mortality. Multivariable analysis revealed nonsurgery, chronic kidney disease (CKD) stage 4-5 or dialysis, prolonged partial thromboplastin time (PTT), minimum AVCE length > 8 mm, and a lower rate of packed red cell (PRC) transfusion were identified as independent predictors of in-hospital mortality (p = 0.005-0.048). Path analysis demonstrated direct influences of CKD4-5 or dialysis, prolonged PTT, and minimum AVCE length on mortality (coefficients 0.525-0.616; p = 0.009 to < 0.001). PRC transfusion impacted mortality through nonsurgery (coefficient 0.798, p = 0.003) and intensive care unit (ICU) admission (coefficients 0.025, p = 0.016), leading to subsequent death. Three AVCE spaces (free, loose, and tight) defined on CT were not directly associated with in-hospital mortality. CONCLUSION In adults with AVCE on CT, AVCE size had a direct independent influence on mortality, highlighting the critical role of radiologists in detecting and characterizing this finding. Additionally, CKD4-5 or dialysis and prolonged PTT also directly influenced mortality, while the lower rate of PRC transfusion impacted mortality through nonsurgery and ICU admission. CLINICAL RELEVANCE STATEMENT In patients with active vascular contrast extravasation (AVCE) on abdominopelvic CT, larger AVCE directly increased in-hospital mortality. Radiologists' detection and characterization of this finding is crucial, along with recognizing factors like CKD4-5, dialysis, and prolonged PTT to improve patient outcomes. KEY POINTS Several factors independently predicted in-hospital mortality in patients with abdominopelvic AVCE. Extravasation length > 8 mm was the only imaging marker predictive of in-hospital mortality. Non-imaging factors correlated with in-hospital mortality, and PRC transfusion impacted mortality through nonsurgery and ICU admission pathways.
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Affiliation(s)
- Rathachai Kaewlai
- Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Rd, Bangkok Noi, Bangkok, 10700, Thailand.
| | - Gun Chomchalerm
- Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Rd, Bangkok Noi, Bangkok, 10700, Thailand
| | - Sasima Tongsai
- Department of Research, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Rd, Bangkok Noi, Bangkok, 10700, Thailand
| | - Jitti Chatpuwaphat
- Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Rd, Bangkok Noi, Bangkok, 10700, Thailand
| | - Anchisa Chatkaewpaisal
- Department of Anatomy, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Rd, Bangkok Noi, Bangkok, 10700, Thailand
| | - Pramuk Khamman
- Department of Anatomy, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Rd, Bangkok Noi, Bangkok, 10700, Thailand
| | - Somrach Thamtorawat
- Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Rd, Bangkok Noi, Bangkok, 10700, Thailand
| | - Banjerd Praditsuktavorn
- Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Rd, Bangkok Noi, Bangkok, 10700, Thailand
| | - Worapat Maitriwong
- Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Rd, Bangkok Noi, Bangkok, 10700, Thailand
| | - Junichi Matsumoto
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
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Jeon S, Yu B, Lee GJ, Lee MA, Lee J, Choi KK. Comparison of Conventional versus Modified Preperitoneal Pelvic Packing in Patients with Bleeding Pelvic Fractures: A Single-Center Retrospective Pilot Study. J Clin Med 2024; 13:4062. [PMID: 39064102 PMCID: PMC11277868 DOI: 10.3390/jcm13144062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 07/07/2024] [Accepted: 07/10/2024] [Indexed: 07/28/2024] Open
Abstract
Background: Bleeding pelvic fractures have high mortality rates, primarily due to severe hemorrhage. Treatment options include mechanical stabilization based on preperitoneal pelvic packing (PPP), resuscitative endovascular balloon occlusion of the aorta, and angioembolization (AE). The bilateral preperitoneal approach, which uses three pads on each side, is the conventional PPP method. We aimed to compare the bilateral preperitoneal approach with a modified approach, involving selectively packing only heavily bleeding areas, in terms of clinical outcomes and mortality risks. Methods: We included patients who underwent PPP and compared the outcomes between conventional (three sponges placed on each side) and modified PPP (selective packing of critical areas). The primary outcome was 30-day mortality; the secondary outcomes included 24 h mortality, pelvic complications, and transfusion requirements. Univariate and multivariate analyses were performed to determine risk factors for 30-day and 24 h mortality. Results: Among the 47 included patients, 19 and 28 underwent conventional and modified PPP, respectively. There were no significant between-group differences in the 24 h (26.3% vs. 42.9%, p = 0.247) and 30-day mortality rates (47.4% vs. 60.7%, p = 0.366). Using univariate and multivariate analyses, initial lactate levels and the decision to perform AE were found to be significant risk factors for mortality. However, the selected PPP method was not a risk factor for 30-day mortality (odds ratio [OR], 2.22; 95% confidence interval [CI], 0.27-18.26; p = 0.457) or 24 hr mortality (OR, 1.77; 95% CI, 0.24-13.19; p = 0.557). Conclusions: The modified PPP method may be considered in patients with bleeding pelvic fractures for effective bleeding control while minimizing potential complications associated with the conventional PPP.
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Affiliation(s)
- Sebeom Jeon
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon 21565, Republic of Korea;
| | - Byungchul Yu
- Department of Traumatology, College of Medicine, Gachon University, Incheon 21565, Republic of Korea; (B.Y.); (G.J.L.); (M.A.L.); (J.L.)
| | - Gil Jae Lee
- Department of Traumatology, College of Medicine, Gachon University, Incheon 21565, Republic of Korea; (B.Y.); (G.J.L.); (M.A.L.); (J.L.)
| | - Min A Lee
- Department of Traumatology, College of Medicine, Gachon University, Incheon 21565, Republic of Korea; (B.Y.); (G.J.L.); (M.A.L.); (J.L.)
| | - Jungnam Lee
- Department of Traumatology, College of Medicine, Gachon University, Incheon 21565, Republic of Korea; (B.Y.); (G.J.L.); (M.A.L.); (J.L.)
| | - Kang Kook Choi
- Department of Traumatology, College of Medicine, Gachon University, Incheon 21565, Republic of Korea; (B.Y.); (G.J.L.); (M.A.L.); (J.L.)
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Cao L, Shen G, Wu R, Shen X, Xu J, Sun H, Xiang X. Spring coil displacement after interventional embolization of severe pelvic fracture: a case report. J Int Med Res 2024; 52:3000605241266219. [PMID: 39075863 PMCID: PMC11289803 DOI: 10.1177/03000605241266219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 06/10/2024] [Indexed: 07/31/2024] Open
Abstract
Haemorrhagic shock, which arises as a complication of pelvic fracture subsequent to severe trauma, represents a perilous state. The utilization of interventional endovascular haemostasis assumes a pivotal role in the management of patients with vascular injury following pelvic fracture. This article reports the treatment of a patient with pelvic fracture caused by a serious work-related vehicle accident. Despite the implementation of timely blood and fluid transfusion to combat shock, the application of aortic balloon obstruction, and interventional iliac artery embolization for haemostasis, the patient's condition failed to display any discernible improvement. Repeat angiography further revealed a displacement of the interventional embolization material, and the patient subsequently died of multiple organ failure. The occurrence of spring coil displacement is infrequent, but the consequences thereof are considered grave, necessitating meticulous discernment in the selection of haemostatic materials for this type of patient. The diagnostic and therapeutic processes encompassing the particular case described here were analysed and are discussed with the objective of augmenting the efficacy and success rate of treatment modalities for patients in similar circumstances.
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Affiliation(s)
- Lijun Cao
- Emergency Department, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China
| | - Guoping Shen
- Emergency Department, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China
| | - Renyan Wu
- Department of Ultrasound, Wangdian People’s Hospital, Jiaxing, Zhejiang, China
| | - Xuning Shen
- Emergency Department, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China
| | - Jun Xu
- Emergency Department, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China
| | - Hui Sun
- Emergency Department, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China
| | - Xianhua Xiang
- Outpatient Department, Sunto Women and Children’s Hospital, Jiaxing, Zhejiang, China
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Clements W, Lukies M, Zia A, Fitzgerald M, Kavnoudias H. Let us settle the controversy-gelfoam is a safe intravascular embolic agent. Br J Radiol 2024; 97:933-937. [PMID: 38402518 DOI: 10.1093/bjr/tqae047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 02/08/2024] [Accepted: 02/21/2024] [Indexed: 02/26/2024] Open
Abstract
OBJECTIVES A 2021 safety alert restricted endovascular gelfoam use in Australia and resulted in an embargo on gelfoam sales to Interventional Radiology departments. This study aimed to show that gelfoam is safe in a population of trauma patients with pelvic injury, and discuss the basis of the recent controversies. METHODS Retrospective cohort study was conducted between 1 January 2010 and 21 May 2021 for the patients who underwent gelfoam embolization for pelvic arterial haemorrhage. Primary outcome was the rate of adverse events related to intravascular gelfoam administration. RESULTS Inclusion criteria met in 50 patients, comprising 58% males median age 59.9 years, and median injury severity score 31. There were 0 complications related to gelfoam use and 100% technical success. Thirty-five patients (70%) received a non-targeted embolization approach. All-cause mortality was observed in 5 patients (10%), unrelated to gelfoam. CONCLUSIONS Gelfoam is a safe and effective embolic agent in pelvic trauma. Patients are in urgent need of universal on-label registration of endovascular gelfoam products, as it is life-saving in major haemorrhage after trauma. ADVANCES IN KNOWLEDGE Endovascular gelfoam is mandatory for a high-quality trauma service, and this study shows that it is safe to use intentionally in the endovascular space. Companies should work with interventional radiologists, sharing and collaborating to ensure positive outcomes for patients.
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Affiliation(s)
- Warren Clements
- Department of Radiology, Alfred Health, Melbourne 3004, Australia
- Department of Surgery, Central Clinical School, Monash University, Melbourne 3004, Australia
- National Trauma Research Institute, Central Clinical School, Monash University, Melbourne 3004, Australia
| | - Matthew Lukies
- Department of Radiology, Alfred Health, Melbourne 3004, Australia
| | - Adil Zia
- Department of Radiology, Alfred Health, Melbourne 3004, Australia
| | - Mark Fitzgerald
- Department of Surgery, Central Clinical School, Monash University, Melbourne 3004, Australia
- National Trauma Research Institute, Central Clinical School, Monash University, Melbourne 3004, Australia
- Department of Trauma, Alfred Health, Melbourne 3004, Australia
| | - Helen Kavnoudias
- Department of Radiology, Alfred Health, Melbourne 3004, Australia
- Department of Surgery, Central Clinical School, Monash University, Melbourne 3004, Australia
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Hirata Y, Takahashi Y, Kuramoto S, Nishihiro S, Ono Y, Ichikawa T. The effectiveness of palliative middle meningeal artery embolization prior to craniotomy for large acute epidural hematoma: A case report. Int J Surg Case Rep 2024; 118:109704. [PMID: 38669807 PMCID: PMC11064596 DOI: 10.1016/j.ijscr.2024.109704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/18/2024] [Accepted: 04/21/2024] [Indexed: 04/28/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Acute epidural hematoma is typically managed with craniotomy. However, there are a few reports on transcatheter arterial embolization (TAE) as an adjunctive therapy. CASE PRESENTATION A 70-year-old female with no obvious history of trauma was transported to our hospital. Computed tomography scan revealed an epidural hematoma of approximately 80 ml with a midline shift of 5 mm. We decided to perform an emergency craniotomy. However, the operating room (OR) was already occupied by a scheduled surgery and it would take 30 min to an hour to prepare it. We opted to wait for our OR, considering that, even if the patient was transferred to another hospital, it would take time for the craniotomy to commence. CLINICAL DISCUSSION We performed TAE for the middle meningeal artery (MMA) as a palliative measure to prevent hematoma enlargement. The MMA was selectively embolized with 20 % n-butyl-2-cyanoacrylate (NBCA), resulting in no hematoma enlargement or observed complications. The criteria for endovascular treatment of acute epidural hematoma are not yet well-established. This case demonstrates the potential role of endovascular treatment for large acute epidural hematomas in carefully selected patients. CONCLUSION If there is a time gap before craniotomy, TAE could be considered a viable option for large acute epidural hematomas as a palliative intervention before craniotomy.
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Affiliation(s)
- Yuichi Hirata
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan; Department of Neurological Surgery, Kagawa Prefectural Central Hospital, Takamatsu, Kagawa, Japan.
| | - Yu Takahashi
- Department of Neurological Surgery, Kagawa Prefectural Central Hospital, Takamatsu, Kagawa, Japan
| | - Satoshi Kuramoto
- Department of Neurological Surgery, Kagawa Prefectural Central Hospital, Takamatsu, Kagawa, Japan
| | - Shingo Nishihiro
- Department of Neurological Surgery, Kagawa Prefectural Central Hospital, Takamatsu, Kagawa, Japan
| | - Yasuhiro Ono
- Department of Neurological Surgery, Kagawa Prefectural Central Hospital, Takamatsu, Kagawa, Japan
| | - Tomotsugu Ichikawa
- Department of Neurological Surgery, Kagawa Prefectural Central Hospital, Takamatsu, Kagawa, Japan
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Singh A, Kotzur T, Koslosky E, Gonuguntla R, Canseco L, Momtaz D, Seifi A, Martin C. Angioembolization Has Similar Efficacy and Lower Total Charges than Preperitoneal Pelvic Packing in Patients With Pelvic Ring or Acetabulum Fractures. J Orthop Trauma 2024; 38:254-258. [PMID: 38378177 DOI: 10.1097/bot.0000000000002789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/14/2024] [Indexed: 02/22/2024]
Abstract
OBJECTIVES To compare cost, hospital-related outcomes, and mortality between angioembolization (AE) and preperitoneal pelvic packing (PPP) in the setting of pelvic ring or acetabulum fractures. METHODS . DESIGN Retrospective database review. SETTING National Inpatient Sample, years 2016-2020. PATIENT SELECTION CRITERIA Hospitalized adult patients who underwent AE or PPP in the setting of a pelvic ring or acetabulum fracture. OUTCOME MEASURES AND COMPARISONS Mortality and hospital-associated outcomes, including total charges, following AE versus PPP in the setting of pelvic ring or acetabulum fractures. RESULTS A total of 3780 patients, 3620 undergoing AE and 160 undergoing PPP, were included. No significant differences in mortality, length of stay, time to procedure, or discharge disposition were found ( P > 0.05); however, PPP was associated with significantly greater charges than AE ( P = 0.04). Patients who underwent AE had a mean total charge of $250,062.88 while those undergoing PPP had a mean total charge of $369,137.16. CONCLUSIONS Despite equivalent clinical efficacy in terms of mortality and hospital-related outcomes, PPP was associated with significantly greater charges than AE in the setting of pelvic ring or acetabulum fractures. This data information can inform clinical management of these patients and assist trauma centers in resource allocation. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | | | | | | | | | | | - Ali Seifi
- Department of Neurosurgery, UT Health San Antonio, San Antonio, TX
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Robaix M, Mathais Q, de Malleray H, Guigues S, Meaudre E, Bordes J, Cardinale M. Independent factors of preventable death in a mature trauma center: a propensity-score analysis. Eur J Trauma Emerg Surg 2024; 50:477-487. [PMID: 37749282 DOI: 10.1007/s00068-023-02367-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/09/2023] [Indexed: 09/27/2023]
Abstract
INTRODUCTION The rate of potentially preventable deaths (PPD) and preventable deaths (PD) can reach more than 20% of overall trauma mortality. Bleeding is the leading cause of preventable mortality. The aim of our study is to define the independent factors of preventable or potentially preventable mortality in our mature trauma system. MATERIALS AND METHODS We conducted a single-center retrospective study in the Sainte Anne Military Teaching Hospital, Toulon, France, including all severe trauma patients admitted to our trauma center and discharged alive as well as all severe trauma patients who died with a death considered preventable or potentially preventable from January 2013 to December 2020. We matched the two groups using a propensity score and searched for independent factors using a generalized linear model. RESULTS 846 patients were included and analyzed. After matching, our cohort consisted of 245 patients in the survivor group and 49 patients in the preventable deaths group. Pre-hospital delays (73 min vs 54 min P = 0.003) as well as delays before incision in the operating room (80 min vs 52 min P < 0.001) were significantly longer in the PD group. These delays were independent factors of preventable mortality OR 10.35 (95% CI [3.44-31.11] P < 0.001) and OR 37.53 (95% CI [8.51-165.46] P < 0.001) as well as pelvic trauma OR 6.20 (95% CI [1.53-25.20] P = 0.011). CONCLUSION Delays in pre-hospital care, delays in access to the operating room from arrival at the trauma center, and pelvic injuries are independent factors associated with an increased risk of preventable mortality in trauma.
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Affiliation(s)
- Marion Robaix
- Anaesthesiology and Intensive Care Department, Military Teaching Hospital Sainte Anne, Toulon, France
| | - Quentin Mathais
- Anaesthesiology and Intensive Care Department, Military Teaching Hospital Sainte Anne, Toulon, France
| | - Hilaire de Malleray
- Anaesthesiology and Intensive Care Department, Military Teaching Hospital Sainte Anne, Toulon, France
| | - Sarah Guigues
- Anaesthesiology and Intensive Care Department, Military Teaching Hospital Sainte Anne, Toulon, France
| | - Eric Meaudre
- Anaesthesiology and Intensive Care Department, Military Teaching Hospital Sainte Anne, Toulon, France
- Ecole du Val de Grâce, French Military Medical Academy, Paris, France
| | - Julien Bordes
- Anaesthesiology and Intensive Care Department, Military Teaching Hospital Sainte Anne, Toulon, France
- Ecole du Val de Grâce, French Military Medical Academy, Paris, France
| | - Michael Cardinale
- Anaesthesiology and Intensive Care Department, Military Teaching Hospital Sainte Anne, Toulon, France.
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Migliorini F, Cocconi F, Schipper I, Ten Duis K, Marzi I, Komadina R, Hildebrand F, Wendt K. Arterial angioembolisation versus pre-peritoneal pelvic packing in haemodynamically unstable patients with complex pelvic fractures: a meta-analysis. Eur J Trauma Emerg Surg 2023:10.1007/s00068-023-02389-4. [PMID: 37962595 DOI: 10.1007/s00068-023-02389-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023]
Abstract
INTRODUCTION Angioembolisation (AE) and/or pre-peritoneal pelvic packing (PPP) may be necessary for patients with complex pelvic fractures who are haemodynamically unstable. However, it remains unclear whether AE or PPP should be performed as an initial intervention and ongoing debates exist. This meta-analysis aimed to compare AE versus PPP in haemodynamically unstable patients with acute pelvic fractures. The primary outcomes of interest were to compare in-hospital mortality rate and number of blood units transfused. Secondary outcomes included evaluating differences in the time from diagnosis to treatment, as well as the length of stay in the intensive care unit (ICU) and hospital. METHODS All clinically relevant studies comparing AE versus PPP in patients with complex pelvic fractures and haemodynamic instability were accessed. The 2020 PRISMA guidelines were followed. In September 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar and Embase, without constraint. RESULTS Data from 320 patients were collected (AE: 174; PPP: 146). The mean age on admission was 47.4 ± 7.2 years. The mean Injury Severity Score (ISS) on admission was 43.5 + 5.4 points. Baseline comparability was observed in ISS (P = 0.5, Table 3) and mean age (P = 0.7, Table 3). No difference was reported in mortality rate (P = 0.2) or rate of blood units transfused (P = 0.3). AE had a longer mean time to the procedure of 44.6 min compared to PPP (P = 0.04). The mean length of ICU and hospital stay were similar in both groups. CONCLUSION Despite the longer mean time from admission to the procedure, no significant differences were found between AE and PPP in terms of in-hospital mortality, blood units transfused, or length of ICU, and hospital stay. These findings should be interpreted considering the limitations of the present study. High-quality comparative research is strongly warranted. LEVEL OF EVIDENCE Level IV, meta-analysis.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedics, Trauma and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
- Department of Orthopaedic and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical University, 39100, Bolzano, Italy.
| | - Federico Cocconi
- Department of Orthopaedic and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical University, 39100, Bolzano, Italy
| | - Inger Schipper
- Department of Orthopaedic and Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Kaj Ten Duis
- Department of Orthopaedic and Trauma Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Ingo Marzi
- Department of Orthopaedic and Trauma Surgery, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Radko Komadina
- Department of Orthopaedic and Trauma Surgery, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Frank Hildebrand
- Department of Orthopaedics, Trauma and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Klaus Wendt
- Department of Orthopaedic and Trauma Surgery, University Medical Center Groningen, Groningen, The Netherlands
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Klingebiel FKL, Hasegawa M, Parry J, Balogh ZJ, Sen RK, Kalbas Y, Teuben M, Halvachizadeh S, Pape HC, Pfeifer R. Standard practice in the treatment of unstable pelvic ring injuries: an international survey. INTERNATIONAL ORTHOPAEDICS 2023; 47:2301-2318. [PMID: 37328569 PMCID: PMC10439026 DOI: 10.1007/s00264-023-05859-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 05/27/2023] [Indexed: 06/18/2023]
Abstract
PURPOSE Unstable pelvic ring injury can result in a life-threatening situation and lead to long-term disability. Established classification systems, recently emerged resuscitative and treatment options as well as techniques, have facilitated expansion in how these injuries can be studied and managed. This study aims to access practice variation in the management of unstable pelvic injuries around the globe. METHODS A standardized questionnaire including 15 questions was developed by experts from the SICOT trauma committee (Société Internationale de Chirurgie Orthopédique et de Traumatologie) and then distributed among members. The survey was conducted online for one month in 2022 with 358 trauma surgeons, encompassing responses from 80 countries (experience > 5 years = 79%). Topics in the questionnaire included surgical and interventional treatment strategies, classification, staging/reconstruction procedures, and preoperative imaging. Answer options for treatment strategies were ranked on a 4-point rating scale with following options: (1) always (A), (2) often (O), (3) seldom (S), and (4) never (N). Stratification was performed according to geographic regions (continents). RESULTS The Young and Burgess (52%) and Tile/AO (47%) classification systems were commonly used. Preoperative three-dimensional (3D) computed tomography (CT) scans were utilized by 93% of respondents. Rescue screws (RS), C-clamps (CC), angioembolization (AE), and pelvic packing (PP) were observed to be rarely implemented in practice (A + O: RS = 24%, CC = 25%, AE = 21%, PP = 25%). External fixation was the most common method temporized fixation (A + O = 71%). Percutaneous screw fixation was the most common definitive fixation technique (A + O = 57%). In contrast, 3D navigation techniques were rarely utilized (A + O = 15%). Most standards in treatment of unstable pelvic ring injuries are implemented equally across the globe. The greatest differences were observed in augmented techniques to bleeding control, such as angioembolization and REBOA, more commonly used in Europe (both), North America (both), and Oceania (only angioembolization). CONCLUSION The Young-Burgess and Tile/AO classifications are used approximately equally across the world. Initial non-invasive stabilization with binders and temporary external fixation are commonly utilized, while specific haemorrhage control techniques such as pelvic packing and angioembolization are rarely and REBOA almost never considered. The substantial regional differences' impact on outcomes needs to be further explored.
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Affiliation(s)
- Felix Karl-Ludwig Klingebiel
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Morgan Hasegawa
- Division of Orthopaedic Surgery, John A. Burns School of Medicine, University of Hawai’i, Honolulu, HI USA
| | - Joshua Parry
- Department of Orthopaedics, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO USA
| | - Zsolt J. Balogh
- Department of Traumatology, John Hunter Hospital, Hunter Medical Research Institute and University of Newcastle, Newcastle, NSW Australia
| | | | - Yannik Kalbas
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Michel Teuben
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Sascha Halvachizadeh
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Hans-Christoph Pape
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Roman Pfeifer
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
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Gong SC, Park JE, Kang S, An S, Kim MJ, Kim K, Shin IS. Preperitoneal Pelvic Packing versus Angioembolization for Patients with Hemodynamically Unstable Pelvic Fractures with Pelvic Bleeding: A Single-Centered Retrospective Study. Healthcare (Basel) 2023; 11:1784. [PMID: 37372902 DOI: 10.3390/healthcare11121784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 05/24/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
The aim of this study was to compare the outcomes of preperitoneal pelvic packing (PPP) and angioembolization (AE) for patients with equivocal vital signs after initial resuscitation. This single-centered retrospective study included information from the database of a regional trauma center from April 2014 to December 2022 for patients with pelvic fractures with a systolic blood pressure of 80-100 mmHg after initial fluid resuscitation. The patients' characteristics, outcomes, and details of AE after resuscitative endovascular balloon occlusion of the aorta (REBOA) placed in zone III were collected. The follow-up duration was from hospital admission to discharge. A total of 65 patients were enrolled in this study. Their mean age was 59.2 ± 18.1 years, and 40 were males. We divided the enrolled patients into PPP (n = 43) and AE (n = 22) groups. The median time from emergency department (ED) to procedure and the median duration of ED stay were significantly longer in the AE group than in the PPP group (p ≤ 0.001 for both). The median mechanical ventilation (MV) duration was significantly shorter (p = 0.046) in the AE group. The number of patients with complications, overall mortality, and mortality due to hemorrhage did not differ between the two groups. Three patients (13.6%) were successfully treated with AE after REBOA. AE may be beneficial for patients with hemodynamically unstable pelvic fractures who show equivocal vital signs after initial fluid resuscitation in terms of reducing the MV duration and incidence of infectious complications.
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Affiliation(s)
- Seong Chan Gong
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - Ji Eun Park
- Department of Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - Sooyeon Kang
- Department of Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - Sanghyun An
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - Myoung Jun Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - Kwangmin Kim
- Graduate School, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - In Sik Shin
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
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Schellenberg M, Gallegos H, Owattanapanich N, Wong MD, Bardes JM, Joos E, Vogt KN, Inaba K. Complications Following Temporary Bilateral Internal Iliac Artery Ligation for Pelvic Hemorrhage Control in Trauma. Am Surg 2022; 88:2475-2479. [PMID: 35537815 DOI: 10.1177/00031348221101509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Temporary bilateral internal iliac artery ligation (TBIIAL) is an option for surgical control of pelvic hemorrhage after trauma. Concerns persist that complications, particularly gluteal necrosis, following TBIIAL should preclude its use, despite a lack of formal research on TBIIAL complications. This study aimed to define complications following TBIIAL for emergent control of traumatic pelvic bleeding.Study Design: Patients undergoing TBIIAL after blunt trauma (2008-2020) at our level 1 trauma center were included without exclusions. Demographics, clinical/injury data, and outcomes were collected. Descriptive statistics summarized study variables. Multivariable analysis of factors independently associated with mortality after TBIIAL was performed.Results: In total, 77 patients undergoing emergent TBIIAL after blunt trauma were identified. Median age was 46 [IQR 29-63] years. Most patients (n = 70, 91%) were severely injured (ISS ≥16), with 43% undergoing resuscitative thoracotomy prior to TBIIAL. No local complications (gluteal necrosis, iatrogenic injury, fascial dehiscence, surgical site infection) after TBIIAL occurred over the 13-year study period. In the first 28 days after injury, median hospital-, ICU-, and ventilator-free days were 0. Mortality was 70% (n = 54). On multivariable analysis, older age was the only variable independently associated with in-hospital mortality (OR 1.081, P = .028).Conclusion: Zero cases of gluteal necrosis, iatrogenic injury to surrounding structures, or surgical site infection/fascial dehiscence of the exploratory laparotomy occurred over the study period. High concern for gluteal necrosis after TBIIAL in severely injured trauma patients is unfounded and should not prevent a surgeon from obtaining prompt pelvic hemorrhage control with this technique among patients in extremis.
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Affiliation(s)
- Morgan Schellenberg
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Hannah Gallegos
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Natthida Owattanapanich
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Monica D Wong
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - James M Bardes
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Emilie Joos
- Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Kelly N Vogt
- Department of Surgery, London Health Sciences Center, University of Western Ontario, London, ON, Canada
| | - Kenji Inaba
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA
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12
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Posterior hinge fixation for the treatment of unstable traumatic sacroiliac joint injuries. Orthop Traumatol Surg Res 2022; 108:103203. [PMID: 35051633 DOI: 10.1016/j.otsr.2022.103203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 10/14/2021] [Accepted: 10/19/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Posterior hinge fixation (PHF) is a sacroiliac joint fixation method indicated for the surgical treatment of unstable pelvic ring fractures (tile C). HYPOTHESIS PHF yields good functional outcomes based on the Majeed score at more than 1 year of follow-up. METHODS A single-center, retrospective study of patients who had a Tile C pelvic ring fracture, who were operated by PHF and who were evaluated at a minimum follow-up of 1 year. The functional outcome was determined using the Majeed score and pain was evaluated by the patients using a visual analog scale (VAS). The preoperative, intraoperative and postoperative data, complications and sequelae were documented. A CT-scan was done at least 1 year after the surgical treatment to determine the SI joint's reduction and fusion. RESULTS Included were 22 patients (59% men) who had a mean age of 37.3±11.9 years; 21 of these patients were reviewed at a mean of 4.8±4 years. The mean Majeed score at the final assessment was 76.4 points±15.3, with 24% of patients having excellent results (n=5), 53% having good results (n=11), 19% having average results (n=4) and 5% having poor results (n=1). The mean pain level on VAS was 28±23mm. Of the eight surgical site infections, seven occurred in the PHF (88%). CT-scans taken at 1 year postoperative were compared to the preoperative scans. The pelvic opening was reduced by -9±6 (p<0.01), SI diastasis by -11mm±9 (p<0.001), vertical displacement by-7mm±8 (p<0.001), symphysis opening by -15mm±15 (p<0.001), median transverse diameter by -10mm±9 (p<0.001) and bispinal diameter by -5mm±7 (p<0.001). SI fusion was confirmed in 43% of patients (n=9). CONCLUSION PHF is a surgical instrumentation method that provides satisfactory long-term reduction of Tile C pelvic ring fractures. The clinical outcomes are good or excellent in 77% of cases. The perioperative morbidity is marked by surgical site infections, all of which healed. LEVEL OF EVIDENCE IV; retrospective, non-comparative cohort study.
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Armbruster M, Seidensticker M. [Interventional radiology as emergency treatment for pelvic injuries]. Unfallchirurg 2021; 124:627-634. [PMID: 34283262 DOI: 10.1007/s00113-021-01045-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2021] [Indexed: 11/28/2022]
Abstract
CLINICAL ISSUE Pelvic arterial bleeding constitutes a potentially life-threatening event, which can be difficult to control with surgical procedures alone, especially in the case of ligamentous ruptures and a subsequently increased pelvic volume. STANDARD RADIOLOGICAL PROCEDURES Using angiography and embolization (AE) with resorbable gelatine-based particles or permanent coils, plugs, liquid embolic systems or by vascular stenting, in most cases traumatic pelvic arterial bleeding can be stopped and can also be used to close pseudoaneurysms, arteriovenous fistulas or dissections. METHODOLOGICAL INNOVATION AND EVALUATION The AE has become established as a fast and effective minimally invasive procedure in the treatment of traumatic pelvic vascular injuries with an advantageous risk-benefit ratio. PRACTICAL RECOMMENDATIONS An interdisciplinary approach should be used in the indications for AE; which can be used as definitive treatment as well as in combination with surgical procedures. To improve the clinical outcome any delay between establishing the indications and the start of the intervention must be avoided.
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Affiliation(s)
- Marco Armbruster
- Klinik und Poliklinik für Radiologie, Klinikum der Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland.
| | - Max Seidensticker
- Klinik und Poliklinik für Radiologie, Klinikum der Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland
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