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Kostov S, Kornovski Y, Watrowski R, Slavchev S, Ivanova Y, Yordanov A. Internal Iliac Artery Ligation in Obstetrics and Gynecology: Surgical Anatomy and Surgical Considerations. Clin Pract 2023; 14:32-51. [PMID: 38248429 PMCID: PMC10801552 DOI: 10.3390/clinpract14010005] [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: 10/15/2023] [Revised: 12/13/2023] [Accepted: 12/22/2023] [Indexed: 01/23/2024] Open
Abstract
The internal iliac artery (IIA) is the main arterial vessel of the pelvis. It supplies the pelvic viscera, pelvic walls, perineum, and gluteal region. In cases of severe obstetrical or gynecologic hemorrhage, IIA ligation can be a lifesaving procedure. Regrettably, IIA ligation has not gained widespread popularity, primarily due to limited surgical training and concerns regarding possible complications, including buttock claudication, impotence, and urinary bladder and rectum necroses. Nowadays, selective arterial embolization or temporary balloon occlusion are increasingly utilized alternatives, which can be applied preoperatively or intraoperatively for threatening severe genital or pelvic bleeding. However, IIA ligation retains its relevance, as the previously described procedures are not always available and have limitations. This article provides a step-by-step guide to the IIA ligation procedure and its possible complications. It also includes a detailed description of the anatomy of the IIA and pelvic arterial anastomoses. This review highlights the importance of a thorough understanding of pelvic anatomy as a prerequisite for safe IIA ligation and posits that training in this procedure should be an integral part of obstetrics and gynecology curricula.
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Affiliation(s)
- Stoyan Kostov
- Research Institute, Medical University Pleven, 5800 Pleven, Bulgaria;
- Department of Gynecology, Hospital “Saint Anna”, Medical University, 9002 Varna, Bulgaria (S.S.); (Y.I.)
| | - Yavor Kornovski
- Department of Gynecology, Hospital “Saint Anna”, Medical University, 9002 Varna, Bulgaria (S.S.); (Y.I.)
| | - Rafał Watrowski
- Department of Obstetrics and Gynecology, Helios Hospital Müllheim, 79379 Müllheim, Germany;
- Faculty Associate, Medical Center, University of Freiburg, 79106 Freiburg, Germany
| | - Stanislav Slavchev
- Department of Gynecology, Hospital “Saint Anna”, Medical University, 9002 Varna, Bulgaria (S.S.); (Y.I.)
| | - Yonka Ivanova
- Department of Gynecology, Hospital “Saint Anna”, Medical University, 9002 Varna, Bulgaria (S.S.); (Y.I.)
| | - Angel Yordanov
- Department of Gynecologic Oncology, Medical University Pleven, 5800 Pleven, Bulgaria
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Chu J, Xie C, Fu J, Yao W. Extraperitoneal pelvic packing versus angiographic embolization for hemodynamically unstable pelvic fractures: a retrospective single-center analysis. J Int Med Res 2023; 51:3000605231208601. [PMID: 37898110 PMCID: PMC10613400 DOI: 10.1177/03000605231208601] [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: 07/06/2023] [Accepted: 10/02/2023] [Indexed: 10/30/2023] Open
Abstract
OBJECTIVE To retrospectively analyze the clinical data and treatment procedures of angiographic embolization (AE) and extraperitoneal pelvic packing (EPP) for traumatic pelvic fractures in our center for the purpose of providing recommendations on the selection of treatment protocols. METHODS We analyzed 110 patients with traumatic pelvic fractures treated with AE and EPP from January 2015 to May 2023. The patients were divided into the AE group (69 men, 41 women) and the EPP group (20 men, 12 women). The primary outcomes were the mortality rate and incidence of complications. RESULTS The mortality rate was slightly lower in the AE than EPP group (7.3% vs. 9.4%). The overall blood transfusion volume was lower and the length of hospital stay was shorter in the AE than EPP group (7.79 ± 12.04 vs. 9.14 ± 14.21 units and 20.48 ± 11.32 vs. 22.14 ± 10.47 days). CONCLUSIONS Both AE and EPP have good treatment effects. AE is preferred for patients in stable condition with severe hemorrhage. This study suggests that EPP should be the primary treatment and that AE should serve as a complementary treatment for critical patients.
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Affiliation(s)
| | | | - Jiaojiao Fu
- Department of Vascular Intervention, Yuyao People’s Hospital, Zhejiang Province, China
| | - Weigen Yao
- Department of Vascular Intervention, Yuyao People’s Hospital, Zhejiang Province, China
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Minici R, Mercurio M, Guzzardi G, Venturini M, Fontana F, Brunese L, Guerriero P, Serra R, Piacentino F, Spinetta M, Zappia L, Costa D, Coppola A, Galasso O, Laganà D. Transcatheter Arterial Embolization for Bleeding Related to Pelvic Trauma: Comparison of Technical and Clinical Results between Hemodynamically Stable and Unstable Patients. Tomography 2023; 9:1660-1682. [PMID: 37736986 PMCID: PMC10514840 DOI: 10.3390/tomography9050133] [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: 07/11/2023] [Revised: 08/11/2023] [Accepted: 08/23/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Endovascular intervention is now the primary line of therapy for arterial injury brought on by pelvic trauma since it can significantly reduce considerable morbidity associated with surgery and can swiftly access and control bleeding sites. Despite international guidelines and widespread awareness of the role of angioembolization in clinical practice, robust evidence comparing the outcomes of angioembolization in hemodynamically stable and unstable patients is still lacking. This study aims to directly compare the outcomes of angioembolization for the treatment of pelvic traumatic arterial injury in patients with hemodynamic stability vs. hemodynamic instability. METHODS In our multicenter retrospective investigation, we analyzed data from consecutive patients who underwent, from January 2020 to May 2023, angioembolization for traumatic pelvic arterial injury. RESULTS In total, 116 angioembolizations were performed. Gelatin sponges (56.9%) and coils (25.9%) were the most widely used embolic agents. The technical and clinical success rates were 100% and 91.4%, respectively. No statistically significant differences were observed between the two groups in terms of technical success, clinical success, procedure-related complication rate, or 30-day bleeding-related mortality. CONCLUSIONS Angioembolization is an effective and safe option for the management of traumatic pelvic arterial lesions even in hemodynamically unstable patients, despite technical variations such as greater use of prophylactic angioembolization.
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Affiliation(s)
- Roberto Minici
- Radiology Unit, Dulbecco University Hospital, 88100 Catanzaro, Italy; (L.Z.); (D.L.)
| | - Michele Mercurio
- Department of Orthopaedic and Trauma Surgery, Magna Græcia University, Dulbecco University Hospital, 88100 Catanzaro, Italy; (M.M.); (O.G.)
| | - Giuseppe Guzzardi
- Radiology Unit, Maggiore della Carità University Hospital, 28100 Novara, Italy; (G.G.); (M.S.)
| | - Massimo Venturini
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy; (M.V.); (F.F.); (F.P.); (A.C.)
| | - Federico Fontana
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy; (M.V.); (F.F.); (F.P.); (A.C.)
| | - Luca Brunese
- Department of Medicine and Health Sciences, University of Molise, 86100 Campobasso, Italy; (L.B.); (P.G.)
| | - Pasquale Guerriero
- Department of Medicine and Health Sciences, University of Molise, 86100 Campobasso, Italy; (L.B.); (P.G.)
| | - Raffaele Serra
- Vascular Surgery Unit, Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Dulbecco University Hospital, 88100 Catanzaro, Italy;
| | - Filippo Piacentino
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy; (M.V.); (F.F.); (F.P.); (A.C.)
| | - Marco Spinetta
- Radiology Unit, Maggiore della Carità University Hospital, 28100 Novara, Italy; (G.G.); (M.S.)
| | - Lorenzo Zappia
- Radiology Unit, Dulbecco University Hospital, 88100 Catanzaro, Italy; (L.Z.); (D.L.)
| | - Davide Costa
- Department of Law, Economics and Sociology, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy;
| | - Andrea Coppola
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy; (M.V.); (F.F.); (F.P.); (A.C.)
| | - MGJR Research Team
- Magna Graecia Junior Radiologists Research Team, 88100 Catanzaro, Italy;
| | - Olimpio Galasso
- Department of Orthopaedic and Trauma Surgery, Magna Græcia University, Dulbecco University Hospital, 88100 Catanzaro, Italy; (M.M.); (O.G.)
| | - Domenico Laganà
- Radiology Unit, Dulbecco University Hospital, 88100 Catanzaro, Italy; (L.Z.); (D.L.)
- Department of Experimental and Clinical Medicine, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy
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Jang H, Jeong ST, Park YC, Kang WS. Nonselective versus Selective Angioembolization for Trauma Patients with Pelvic Injuries Accompanied by Hemorrhage: A Meta-Analysis. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1492. [PMID: 37629782 PMCID: PMC10456831 DOI: 10.3390/medicina59081492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/17/2023] [Accepted: 08/17/2023] [Indexed: 08/27/2023]
Abstract
Background and Objectives: Angioembolization has emerged as an effective therapeutic approach for pelvic hemorrhages; however, its exact effect size concerning the level of embolized artery remains uncertain. Therefore, we conducted this systematic review and meta-analysis to investigate the effect size of embolization-related pelvic complications after nonselective angioembolization compared to that after selective angioembolization in patients with pelvic injury accompanying hemorrhage. Materials and Methods: Relevant articles were collected by searching the PubMed, EMBASE, and Cochrane databases until 24 June 2023. Meta-analyses were conducted using odds ratios (ORs) for binary outcomes. Quality assessment was conducted using the risk of bias tool in non-randomized studies of interventions. Results: Five studies examining 357 patients were included in the meta-analysis. Embolization-related pelvic complications did not significantly differ between patients with nonselective and selective angioembolization (OR 1.581, 95% confidence interval [CI] 0.592 to 4.225, I2 = 0%). However, in-hospital mortality was more likely to be higher in the nonselective group (OR 2.232, 95% CI 1.014 to 4.913, I2 = 0%) than in the selective group. In the quality assessment, two studies were found to have a moderate risk of bias, whereas two studies exhibited a serious risk of bias. Conclusions: Despite the favorable outcomes observed with nonselective angioembolization concerning embolization-related pelvic complications, determining the exact effect sizes was limited owing to the significant risk of bias and heterogeneity. Nonetheless, the low incidence of ischemic pelvic complications appears to be a promising result.
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Affiliation(s)
- Hyunseok Jang
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Hospital, Chonnam National University, Gwangju 61469, Republic of Korea; (H.J.); (Y.C.P.)
| | - Soon Tak Jeong
- Department of Physical Medicine and Rehabilitation, Ansanhyo Hospital, Ansan-si 15457, Republic of Korea;
| | - Yun Chul Park
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Hospital, Chonnam National University, Gwangju 61469, Republic of Korea; (H.J.); (Y.C.P.)
| | - Wu Seong Kang
- Department of Trauma Surgery, Jeju Regional Trauma Center, Cheju Halla General Hospital, Jeju 63127, Republic of Korea
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Choi K, Keum MA, Choi B, Noh M, Choi S, Kyoung KH, Kim S, Hong ES, Kim JT. Effectiveness and safety of bilateral internal iliac artery ligation with pre-peritoneal pelvic packing for life-threatening pelvic trauma. Injury 2023; 54:598-603. [PMID: 36400630 DOI: 10.1016/j.injury.2022.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 10/13/2022] [Accepted: 11/02/2022] [Indexed: 11/06/2022]
Abstract
This study analyzed the outcomes of bilateral internal iliac artery (IIA) ligation with preperitoneal pelvic packing (PPP) in hemodynamically unstable patients with major pelvic fractures. All-cause mortality was examined, periprocedural safety for critical circumstances was reviewed, and iliac artery ligation-related complications of the postoperative phase were evaluated. A total of 20 patients who suffered substantially from severe pelvic trauma with hemodynamic instability and subsequently underwent bilateral IIA ligation with PPP between January 1, 2017, and December 31, 2021, were enrolled in the study. The median participant age was 60.5 years, and 65.0% were male. The median systolic blood pressure was 68.5 mmHg on arrival. Increased lactate level (median, 11.05 mmol/L) suggested that the patients were in shock distinctly due to hypovolemia. It took approximately 1 h to complete the ligation of bilateral IIA to accomplish hemostasis (median, 65.5 min). The iliac vein was injured during dissection in three cases. During the ICU stay (median, 17.5 days), acute kidney injury was identified in 13 patients, likely due to volume depletion. The median ventilator-free days was 13.5; six patients were confirmed with ventilator-associated pneumonia. Moreover, 12 patients were diagnosed with acute respiratory distress syndrome. There was one case in which the lower extremity artery was acutely occluded. Anatomic hemostasis was achieved in 18 patients. The two patients for which anatomic hemostasis failed became two mortality cases from preperitoneal hemorrhage. Our analysis showed that bilateral IIA ligation with PPP was effective as a lifesaving procedure in hemodynamically unstable patients with a major pelvic fracture in terms of mortality due to fracture-related exsanguination. Moreover, the incidence of periprocedural complications was considered tolerable, making the procedure worth a try, especially in austere and underdeveloped healthcare settings.
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Affiliation(s)
- Kyunghak Choi
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, Republic of Korea
| | - Min Ae Keum
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, Republic of Korea
| | - Byungho Choi
- Department of Emergency Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, Republic of Korea
| | - Minsu Noh
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, Republic of Korea
| | - Seongho Choi
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, Republic of Korea
| | - Kyu-Hyouck Kyoung
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, Republic of Korea
| | - Sungjeep Kim
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, Republic of Korea
| | - Eun Seog Hong
- Department of Emergency Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, Republic of Korea
| | - Jihoon T Kim
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, Republic of Korea.
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Zhang J, Chang H, Rockman C, Patel VI, Veeraswamy R, Berland T, Ramkhelawon B, Maldonado T, Cayne N, Jacobowitz G, Garg K. Hypogastric Artery Flow Interruption is Associated with Increased Mortality after Open Aortic Repair. Ann Vasc Surg 2022; 87:270-277. [PMID: 35654287 DOI: 10.1016/j.avsg.2022.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 05/18/2022] [Accepted: 05/19/2022] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Potential complications of pelvic flow disruption during aortic aneurysm repair include buttock ischemia and mesenteric ischemia. Unilateral or bilateral hypogastric artery flow interruption, either from atherosclerosis or intentionally to facilitate aneurysm repair, is considered problematic in endovascular repair; however, it has not been well studied in open abdominal aortic aneurysm (AAA) repair (OAR). We sought to examine the effect of interruption of flow to one or both hypogastric arteries on outcomes after OAR. METHODS The Society for Vascular Surgery Quality Initiative database was queried for all patients undergoing elective open AAA repair between 2003 and 2020. (redundant) Patients with appropriate data on their hypogastric arteries postoperatively were stratified into two groups - patent bilaterally (normal pelvic perfusion, NPP), and unilateral or bilateral occlusion or ligation (compromised pelvic perfusion, CPP). Primary endpoints were 30-day major morbidity (myocardial infarction, respiratory complications, renal injury, and lower extremity or intestinal ischemia) and mortality. RESULTS During the study period, 9.492 patients underwent elective open AAA repair - 860 (9.1%) with compromised pelvic perfusion and 8,632 (90.9%) with patent bilateral hypogastric arteries. The groups had similar cardiac risk factors, including history of coronary artery disease, prior coronary intervention and use of P2Y12 inhibitors and statins. A majority of patients in the CPP cohort had concurrent iliac aneurysms (63.3% versus 24.8%; p<.001). The perioperative mortality was significantly higher in patients with compromised pelvic perfusion (5.5% versus 3.1%; p<.001). Bilateral flow interruption had a trend toward higher perioperative mortality compared to unilateral interruption (7.1% versus 4.7%; p<.147). The CPP group also had increased rates of myocardial injury (6.7% versus 4.7%; p=.012), renal complications (18.9% versus 15.9%; p=.024), leg and bowel ischemia (3.5% versus 2.1%;, p=.008; and 5.7% versus 3.4%; p<.001, respectively). On multivariable analysis, CPP was associated with increased perioperative mortality (OR 1.47, CI 1.14-1.88, p=.003). On Kaplan-Meier analysis, there was no difference in survival at 2 years post discharge, between the NPP and CPP cohorts (86.1% versus 87.5%, logrank-p=0.275). CONCLUSIONS Compromised pelvic perfusion is associated with increased perioperative complications and higher mortality in patients undergoing OAR. The sequalae of losing pelvic perfusion in addition to the presence of more complex atherosclerotic and aneurysmal disease resulting in more difficult dissection likely contribute to these findings. Thus, patients considered for OAR who have occluded hypogastric arteries or aneurysmal involvement of the hypogastric artery preoperatively may be candidates for more conservative management beyond traditional size criteria.
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Affiliation(s)
- Jason Zhang
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY 10016
| | - Heepeel Chang
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY 10016
| | - Caron Rockman
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY 10016
| | - Virendra I Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian / Columbia University Irving Medical Center / Columbia University College of Physicians and Surgeons, New York, NY 10032
| | - Ravi Veeraswamy
- Division of Vascular and Endovascular Surgery, Medical University of South Carolina, Charleston, SC 29425
| | - Todd Berland
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY 10016
| | - Bhama Ramkhelawon
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY 10016
| | - Thomas Maldonado
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY 10016
| | - Neal Cayne
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY 10016
| | - Glenn Jacobowitz
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY 10016
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY 10016.
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Comparative effectiveness of pelvic arterial embolization versus laparotomy in adults with pelvic injuries: A National Trauma Data Bank analysis. Clin Imaging 2022; 86:75-82. [DOI: 10.1016/j.clinimag.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 03/04/2022] [Accepted: 03/08/2022] [Indexed: 11/21/2022]
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Revisiting Role of Bilateral Ligation of Internal Iliac Arteries and Preperitoneal Pelvic Packing for Hemorrhage Control in Patients with Pelvic Injuries in Resource Constraint Settings. Indian J Surg 2022. [DOI: 10.1007/s12262-021-03210-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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9
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Tran S, Wilks M, Dawson J. Endovascular management of haemorrhage in pelvic trauma. SURGERY IN PRACTICE AND SCIENCE 2021. [DOI: 10.1016/j.sipas.2021.100039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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10
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Sherman NC, Williams KN, Hennemeyer CT, Devis P, Chehab M, Joseph B, Tang AL. Effects of nonselective internal iliac artery angioembolization on pelvic venous flow in the swine model. J Trauma Acute Care Surg 2021; 91:318-324. [PMID: 34397953 DOI: 10.1097/ta.0000000000003190] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pelvic angioembolization (AE) is a mainstay in the treatment algorithm for pelvic hemorrhage from pelvic fractures. Nonselective AE refers to embolization of the bilateral internal iliac arteries (IIAs) proximally rather than embolization of their tributaries distally. The aim of this study was to quantify the effect of nonselective pelvic AE on pelvic venous flow in a swine model. We hypothesized that internal iliac vein (IIV) flow following IIA AE is reduced by half. METHODS Nine Yorkshire swine underwent nonselective right IIA gelfoam AE, followed by left. Pelvic arterial and venous diameter, velocity, and flow were recorded at baseline, after right IIA AE and after left IIA AE. Linear mixed-effect model and signed rank test were used to evaluate significant changes between the three time points. RESULTS Eight swine (77.8 ± 7.1 kg) underwent successful nonselective IIA AE based on achieving arterial resistive index of 1.0. One case was aborted because of technical difficulties. Compared with baseline, right IIV flow rate dropped by 36% ± 29% (p < 0.05) and 54% ± 29% (p < 0.01) following right and left IIA AE, respectively. Right IIA AE had no initial effect on left IIV flow (0.37% ± 99%, p = 0.95). However, after left IIA AE, left IIV flow reduced by 54% ± 27% (p < 0.01). Internal iliac artery AE had no effect on the external iliac arterial or venous flow rates and no effect on inferior vena cava flow rate. CONCLUSION The effect of unilateral and bilateral IIA AE on IIV flow appears to be additive. Despite bilateral IIA AE, pelvic venous flow is diminished but not absent. There is abundant collateral circulation between the external and internal iliac vascular systems. Arterial embolization may reduce venous flow and improve on resuscitation efforts in those with unstable pelvic fractures. LEVEL OF EVIDENCE Prognostic, level IV.
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Affiliation(s)
- Nathan C Sherman
- From the Department of Orthopaedic Surgery (N.C.S.), University of Arizona, Tucson, AZ; Department of Surgery (K.N.W.), Emory University, Atlanta, GA; Department of Medical Imaging (C.T.H.), University of Arizona, Tucson, AZ; Interventional Radiology (P.D.), Southern Arizona VA Healthcare System, Tucson, AZ; and Department of Surgery (M.C., B.J., A.L.T.), University of Arizona, Tucson, AZ
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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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12
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Cheon SJ, Ahn TY, Jung SJ, Jang JH, Kim JH, Jeon CH. Does transarterial pelvic embolization have a negative effect on perioperative outcomes in pelvic ring injury and acetabular fracture? Asian J Surg 2021; 45:239-245. [PMID: 34078580 DOI: 10.1016/j.asjsur.2021.05.009] [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: 06/25/2020] [Revised: 01/17/2021] [Accepted: 05/10/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE The purpose of this study was to determine whether TAE negatively impacted perioperative outcomes in patients who underwent open surgery for pelvic trauma. METHODS We retrospectively reviewed the medical records and radiographs of patients who had open surgery for an acute pelvic trauma between February 2014 and May 2017. The patients were classified into two groups: those who underwent TAE and those who did not. We evaluated preoperative demographics and perioperative outcomes between the two groups. Injury type-specific comparisons were also performed. RESULTS A total of 136 patients (50 TAE and 86 non-TAE) were included in this study. There were significant differences in preoperative demographics including the type of injury, injury severity score, revised trauma score, surgical approach, initial blood pressure, and the amount of transfusion within 24 h between the two groups. However, no differences in perioperative outcomes were identified except for the amount of total transfusion. There were significant differences between the two groups in the injury type-specific comparisons, specifically in the amount of transfusion within 24 h in patients with pelvic ring injury and in the injury severity score in patients with acetabular fracture. However, there was no difference in perioperative outcomes between the groups for either injury type. CONCLUSION In the present study, we were unable to identify negative effects of TAE on perioperative outcomes. Therefore, when considering open surgery subsequent to TAE, there is no evidence of increased risk for negative perioperative outcomes, especially with respect to bone healing and deep infection.
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Affiliation(s)
- Sang Jin Cheon
- Department of Orthopaedic Surgery, Bio-medical Research Institute, Pusan National University Hospital, Republic of Korea
| | - Tae Young Ahn
- Department of Orthopaedic Surgery, Bio-medical Research Institute, Pusan National University Hospital, Republic of Korea
| | - Seok Jin Jung
- Department of Orthopaedic Surgery, Bio-medical Research Institute, Pusan National University Hospital, Republic of Korea
| | - Jae Hoon Jang
- Department of Orthopaedic Surgery, Bio-medical Research Institute, Trauma Center, Pusan National University Hospital, Republic of Korea.
| | - Jae Hun Kim
- Department of Trauma Surgery, Trauma Center, Pusan National University Hospital, Republic of Korea
| | - Chang Ho Jeon
- Department of Radiology, The Catholic University of Korea, Eunpyeong St. Mary's Hospital, Repubilic of Korea
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The Frequency of Parenchimatous Lesions in Patients with Traumatic Retroperitoneal Hematoma. ARS MEDICA TOMITANA 2021. [DOI: 10.2478/arsm-2020-0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Objective: The retroperitoneum represent the anatomical region with the highest mortality rates, in which lesions in this region need special relevance. The aim of this study is to find out the frequency of different parenchimatous injuries related to different zones.
Methods: In this retrospective study, all cases who presented to the emergency room and/or admitted to our center with retroperitoneal hematoma (RPH) complicated with parenchimatous lesions from January 2016 to December 2019 were included (4-years data). Data collected included age, hematoma zones, the production mechanisms, mortality, surgical interventions, parenchymatous lesions, complications and biochemical and hematological analysis (e.g. hemoglobin (Hb), hematocrit (Ht), platelets (PLT), leukocytes (Leu), aspartate aminotransferase level (AST), alanine aminotransferase level (ALT) and creatinine (Cr). All RPHs were diagnosed using computed tomography scan.
Results: A total number of 119 RPH cases with parenchimatous lesions were included with a mean age of 45.56±2.52. The most common type of RPH was located in lateral zone (zone II) with 65 cases, followed by pelvic zone (zone III) with 36 cases. The main production mechanism for parenchimatous lesions was by road accident (n=57). The highest prevalence of parenchimatous lesions was seen in both lung and splenic lesions (n=54), followed by liver lesion (n=36) and kidney lesions (n=11), without any statistical significance. The complications showed a statistical significance when 2016 year was compare with 2018 (p=0.013). Regarding the biochemical and hematological analysis, a statistical significance was seen at PLT (when 2016 was compared with 2017, p=0.03 and 2018, p=0.008). Only 67 patients were treated by surgical interventions, and the highest mortality was registered in 2019 (n=11).
Conclusion: There is a lack of evidence in the frequency of different parenchimatous lesions in RPH cases. We conclude on the basis of our study that mandatory exploration of zone II and III haematoma in parenchimatous lesions should be early diagnosed in order to reduce the morbidity and mortality of the patients.
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El Khudari H, Abdel Aal AK. Endovascular Management of Pelvic Trauma. Semin Intervent Radiol 2021; 38:123-130. [PMID: 33883809 DOI: 10.1055/s-0041-1725112] [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: 10/21/2022]
Abstract
Major pelvic fractures result from high-energy trauma including traffic accidents and falls, which usually leads to multiple injuries complicating the patient's management. Management of these patients requires a coordinated multidisciplinary approach. Transcatheter embolization is a minimally invasive and effective technique to control massive hemorrhage and can be performed using a variety of embolic agents. It has become an accepted first-line management option for retroperitoneal bleeds in many centers. In this article, the indications for endovascular management of hemorrhage from pelvic trauma, the various embolization techniques, and potential complications will be discussed.
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Affiliation(s)
- Husameddin El Khudari
- Division of Interventional Radiology, Department of Radiology, The University of Alabama at Birmingham (UAB), Birmingham, Alabama
| | - Ahmed Kamel Abdel Aal
- Department of Diagnostic and Interventional Imaging, The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
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15
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Hundersmarck D, Hietbrink F, Leenen LPH, Heng M. Pelvic packing and angio-embolization after blunt pelvic trauma: a retrospective 18-year analysis. Injury 2021; 52:946-955. [PMID: 33223257 DOI: 10.1016/j.injury.2020.11.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 11/14/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Treatment of pelvic trauma related hemorrhage is challenging and remains controversial. In hemodynamically unstable patients suspected for massive bleeding, pre-peritoneal packing (PPP) with temporary external fixation (EF) and subsequent trans-arterial embolization (TAE) can be performed in order to control bleeding. In hemodynamically stable patients suspected for minor to moderate bleeding, primary TAE with EF may be performed. The goal of this study was to determine effectiveness and safety of both strategies. METHODS Retrospectively, patients that received treatment for pelvic trauma-related hemorrhage at two level 1 trauma centers located in the United States between January 2001 and January 2019 were evaluated. Both centers advocate subsequent TAE in addition to PPP and EF in hemodynamically unstable patients, and primary TAE in stable patients. Demographic and clinical data was collected and mortality, ischemic and infectious complications were determined. RESULTS In total, 135 patients met the inclusion criteria. Of these, 61 hemodynamically unstable patients suspected for massive pelvic bleeding underwent primary PPP (45%) and 74 stable patients suspected for minor/moderate bleeding underwent primary TAE (55%). In total, 37/61 primary PPP patients underwent EF (61%) and 48 underwent adjunct TAE (79%), performed bilaterally in 77% and unselective by use of gelfoam in 72% of cases. Primary TAE patients received embolization bilaterally in 49% and unselective in 35% of cases. Exsanguination-related deaths were found in 7/61 primary PPP patients (11%). There were none among the primary TAE patients. Potentially ischemic in-hospital complications, of which one could be considered severe (gluteal necrosis), occurred more in patients that received bilateral unselective TAE compared to all other TAE patients (p=0.02). CONCLUSION Primary TAE appears to be an effective and safe adjunct for (minor) pelvic hemorrhage in hemodynamically stable patients. Primary PPP followed by EF and adjunct bilateral unselective TAE with gelfoam appears effective for those suspected of massive pelvic bleeding. This unselective embolization approach using gelfoam might be related to (ischemic) complications. When considering the amount and severity of complications and the severity of pelvic trauma, these might not outweigh the benefit of fast hemorrhage control.
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Affiliation(s)
- Dennis Hundersmarck
- Harvard Medical School Orthopedic Trauma Initiative, Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, USA.
| | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Marilyn Heng
- Harvard Medical School Orthopedic Trauma Initiative, Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, USA.
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Surgical Wound Complications After Percutaneous Posterior Pelvic Ring Fixation in Patients Who Undergo Pelvic Arterial Embolization. J Orthop Trauma 2021; 35:167-170. [PMID: 32931686 DOI: 10.1097/bot.0000000000001956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/28/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To report on the incidence of surgical wound complications after percutaneous posterior pelvic ring fixation in patients who have also undergone pelvic arterial embolization (PAE) and determine whether the risks outweigh the benefits. DESIGN Retrospective cohort study. SETTING Academic level 1 trauma center. PATIENTS Two hundred one consecutive patients who underwent percutaneous posterior pelvic fixation at our institution were included in this study. Of these, 27 patients underwent pelvic arterial embolization. INTERVENTION Percutaneous posterior pelvic fixation and pelvic arterial embolization. MAIN OUTCOME MEASUREMENTS Charts were reviewed for posterior percutaneous surgical wound complications including infection, dehiscence, seroma, tissue necrosis, and return to OR for debridement in all patients. RESULTS Of the 27 patients who received PAE, none developed posterior surgical wound complications. Of those who did not receive PAE, there was one posterior surgical wound complication documented. There were no cases of wound infection in either group. CONCLUSION Pelvic arterial embolization can be a valuable intervention in treating hemodynamically unstable patients with pelvic ring injuries. Although even selective pelvic arterial embolization is not entirely benign, there seems to be minimal risk of wound complications when percutaneous posterior pelvic ring fixation is performed. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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17
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Haraguchi T, Hamaguchi S. Nonselective Bilateral Embolization of Internal Iliac Arteries with N-Butyl-2-Cyanoacrylate in Hemodynamically Unstable Patients with Pelvic Fracture. INTERVENTIONAL RADIOLOGY 2021; 6:37-43. [PMID: 35909907 PMCID: PMC9327384 DOI: 10.22575/interventionalradiology.2019-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 04/08/2021] [Indexed: 11/17/2022]
Abstract
Purpose: This study was designed to evaluate the efficacy and safety of nonselective bilateral embolization of the internal iliac arteries (IIAs) with n-butyl-2-cyanoacrylate (NBCA) in hemodynamically unstable patients with pelvic fractures. Material and Methods: Twelve patients underwent nonselective bilateral embolization of the IIAs using NBCA diluted with lipiodol at our institution between January 2004 and March 2014. We analyzed the time of bilateral occlusion of the IIAs, the time from admission to entrance into the interventional radiology room, the need for repeat embolization, outcomes, cause of death, follow-up period, and complications. Results: The mean duration of bilateral occlusion of the IIAs was 17 min (range, 4-34 min), and the mean time from admission to entrance into the interventional radiology room was 89 min (range, 28-168 min). All patients underwent technically successful embolization. Repeat embolization was required after treatment in three patients. The mortality rate was 33.3%. Complications after embolization were suspected in one patient. Conclusions: Nonselective bilateral embolization of IIAs with NBCA could be a choice of treatment for hemodynamically unstable patients with severe pelvic fracture hemorrhage.
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Affiliation(s)
| | - Shingo Hamaguchi
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine
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18
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Ierardi AM, Piacentino F, Pesapane F, Carnevale A, Curti M, Fontana F, Venturini M, Pinto A, Gentili F, Guerrini S, De Filippo M, Giganti M, Carrafiello G. Basic embolization techniques: tips and tricks. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:71-80. [PMID: 32945281 PMCID: PMC7944672 DOI: 10.23750/abm.v91i8-s.9974] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/12/2020] [Indexed: 12/12/2022]
Abstract
Good knowledge of the various approaches of embolization of peripheral bleedings and different embolic materials available is of paramount importance for successful and safe embolization. We review and illustrate the main endovascular and percutaneous techniques used for embolization, along with the characteristics of the different embolic materials, and the potential complications.
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Affiliation(s)
- Anna Maria Ierardi
- Radiology Department, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy.
| | - Filippo Piacentino
- Department of Diagnostic and Interventional Radiology, University of Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy.
| | - Filippo Pesapane
- Breast Imaging Unit, IEO European Institute of Oncology IRCCS, Milan, Italy.
| | - Aldo Carnevale
- University Radiology Unit, Radiology Department, Arcispedale Sant'Anna, Via A. Moro 8, Ferrara, 44123, Italy.
| | - Marco Curti
- Department of Diagnostic and Interventional Radiology, University of Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy.
| | - Federico Fontana
- Department of Diagnostic and Interventional Radiology, University of Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy.
| | - Massimo Venturini
- Department of Diagnostic and Interventional Radiology, University of Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy.
| | - Antonio Pinto
- Department of Radiology, CTO Hospital, Azienda dei Colli, Naples, Italy.
| | - Francesco Gentili
- Section of Radiology, Unit of Surgical Sciences, Department of Medicine and Surgery, Azienda Ospedaliero-Universitaria di Parma, University of Parma, Parma, Italy.
| | - Susanna Guerrini
- Department of Radiological Sciences, Diagnostic Imaging Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy.
| | - Massimo De Filippo
- Section of Radiology, Unit of Surgical Sciences, Department of Medicine and Surgery, Azienda Ospedaliero-Universitaria di Parma, University of Parma, Parma, Italy.
| | - Melchiore Giganti
- Department of Morphology, Surgery and Experimental Medicine, Radiology Section, University of Ferrara, Via L. Ariosto 35, Ferrara, 44121, Italy.
| | - Gianpaolo Carrafiello
- Radiology Department, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan and Department of Health Sciences, Università degli Studi di Milano, Milan, Italy.
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Kato T, Chinzei N, Katayama N, Hirota S, Takahashi M. Successful Transcatheter Arterial Embolisation for a Traumatic Iliacus Hematoma: A Case Report. Malays Orthop J 2020; 14:92-95. [PMID: 32296490 PMCID: PMC7156174 DOI: 10.5704/moj.2003.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
A traumatic iliacus hematoma is rare and usually occurs in patients after a fall involving a lower back injury. Although the hematoma may compress the femoral nerve causing femoral nerve palsy, the gold standard treatment for this condition has not been established. Here we report transcatheter arterial embolisation as a useful treatment strategy for a traumatic iliacus hematoma.
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Affiliation(s)
- T Kato
- Department of Orthopaedic Surgery, Konan Hospital, Kobe, Japan
| | - N Chinzei
- Department of Orthopaedic Surgery, Konan Hospital, Kobe, Japan
| | - N Katayama
- Department of Radiology, Konan Hospital, Kobe, Japan
| | - S Hirota
- Department of Radiology, Konan Hospital, Kobe, Japan
| | - M Takahashi
- Department of Orthopaedic Surgery, Konan Hospital, Kobe, Japan
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20
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Ren C, Wang Q, Ma T, Li Z, Yuan H, Huang Y, Xue H, Zhang K. Pseudoaneurysm of the internal iliac artery caused by proximal femoral nail antirotation following intertrochanteric fracture: a case report. J Int Med Res 2019:300060519892381. [PMID: 31847641 DOI: 10.1177/0300060519892381] [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: 11/17/2022] Open
Abstract
Pseudoaneurysm of the internal iliac artery is a very rare complication of intertrochanteric fracture. Here, the case of an 88-year-old female patient, who presented with intense pain following surgery for intertrochanteric fracture of the femur, is reported. Radiography revealed intertrochanteric fracture of the left femur fixed by proximal femoral nail antirotation (PFNA). The PFNA was found to have disassembled, and the screw had penetrated through the acetabulum. As computed tomography (CT) revealed a haematoma behind the acetabulum, CT angiography was immediately performed. A pseudoaneurysm of the internal iliac artery caused by PFNA was revealed. Percutaneous endovascular treatment of the pseudoaneurysm was undertaken on an urgent basis. Three days later, the PFNA was removed, and the fracture was reduced and fixed with locking proximal femoral plate. The patient's pain was significantly reduced following this corrective surgery. This case illustrates that substandard PFNA surgery for intertrochanteric fracture may result in pseudoaneurysm of the internal iliac artery.
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Affiliation(s)
- Cheng Ren
- Department of Orthopaedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Qian Wang
- Department of Orthopaedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Teng Ma
- Department of Orthopaedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Zhong Li
- Department of Orthopaedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Huijun Yuan
- Department of Peripheral Vascular Disease, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Yan Huang
- Department of Peripheral Vascular Disease, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Hanzhong Xue
- Department of Orthopaedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Kun Zhang
- Department of Orthopaedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
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Hsu SD, Chen CJ, Wang ID, Lin KT, Wang CC, Chien WC, Chung CH, Chang WK. The Risk of Erectile Dysfunction Following Pelvic Angiographic Embolization in Pelvic Fracture Patients: A Nationwide Population-Based Cohort Study in Taiwan. World J Surg 2019; 43:476-485. [PMID: 30242456 DOI: 10.1007/s00268-018-4803-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Pelvic fracture with hypovolemic shock is a known crucial injury in trauma patients. Pelvic fracture with vessel injury often leads to hemodynamic complications; in a trauma scenario, evidence of other systems being affected is often absent. Bleeding cessation and resuscitation are important for these types of trauma patients. For this purpose, pelvic angiographic embolization is frequently used. Multiple studies have reported that angiographic embolization may cause erectile dysfunction (ED) in hemodynamically stable patients with pelvic fracture. However, no study has evaluated a large patient cohort with a long-term follow-up. We hypothesized that angiographic embolization to control bleeding may compromise blood supply to the genitourinary organs or cause secondary neurogenic injury that increases the risk of ED. Our goal was to evaluate the risk of ED following pelvic fractures in male patients treated with pelvic angiographic embolization. METHODS We used data from the National Health Insurance Research Database (NHIRD) from 1997 to 2010 provided by the Bureau of National Health Insurance of the Department of Health in Taiwan. We collected disease histories from inpatient files. The disease diagnoses were based on the International Classification of Diseases (ICD), Ninth Revision, Clinical Modification. These data were all deidentified, and we did not contact the patients. As such, informed consent was not needed. RESULTS Eighty-five and 82,802 patients were included in the case and control cohorts, respectively. All patients were aged 15-45, and the proportion of pelvic fracture locations was equal between the groups. After investigating the causes of ED among male patients aged 15-45 with pelvic fractures using logistic regression analysis in a generalized estimating equations model and after adjusting for the influence of confounders, we found that these patients had high risks (odds ratio (OR): 32.637; 95% confidence interval: 14.137-75.346; P < 0.001) of developing ED post-angiographic embolization. CONCLUSIONS Male patients in Taiwan with pelvic fractures who undergo angiographic embolization to control bleeding have a higher risk of ED than those who do not undergo the procedure. Physicians should practice caution and inform patients of this connection before the procedure.
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Affiliation(s)
- Sheng-Der Hsu
- Division of Traumatic and General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Cheng-Jueng Chen
- Division of Traumatic and General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - I-Duo Wang
- Department of General Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Kuen-Tze Lin
- Department of Radiation Oncology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chia-Chi Wang
- Department of Family Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wu-Chien Chien
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chi-Hsiang Chung
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Kuo Chang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, No. 325, Chengong Rd, Sec. 2, Neihu, Taipei, 114, Taiwan.
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Gürünlüoğlu K, Yıldırım İO, Kutlu R, Saraç K, Sığırcı A, Bağ HG, Demircan M. Advantages of early intervention with arterial embolization for intra-abdominal solid organ injuries in children. Diagn Interv Radiol 2019; 25:310-319. [PMID: 31199287 PMCID: PMC6622444 DOI: 10.5152/dir.2019.18559] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/05/2019] [Accepted: 03/07/2019] [Indexed: 12/25/2022]
Abstract
PURPOSE Active bleeding due to abdominal trauma is an important cause of mortality in childhood. The aim of this study is to demonstrate the advantages of early percutaneous transcatheter arterial embolization (PTAE) procedures in children with intra-abdominal hemorrhage due to blunt trauma. METHODS Children with blunt abdominal trauma were retrospectively included. Two groups were identified for inclusion: patients with early embolization (EE group, n=10) and patients with late embolization (LE group, n=11). Both groups were investigated retrospectively and statistically analyzed with regard to lengths of stay in the intensive care unit and in the hospital, first enteral feeding after trauma, blood transfusion requirements, and cost. RESULTS The duration of stay in the intensive care unit was greater in the LE group than in the EE group (4 days vs. 2 days, respectively). The duration of hospital stay was greater in the LE group than in the EE group (14 days vs. 6 days, respectively). Blood transfusion requirements (15 cc/kg of RBC packs) were greater in the LE group than in the EE group (3 vs. 1, respectively). The total hospital cost was higher in the LE group than in the EE group (4502 USD vs. 1371.5 USD, respectively). The time before starting enteral feeding after first admission was higher in the LE group than in the EE group (4 days vs. 1 day, respectively). CONCLUSION Early embolization with PTAE results in shorter intensive care and hospitalization stays, earlier enteral feeding, and lower hospital costs for pediatric patients with intra-abdominal hemorrhage due to blunt trauma.
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Affiliation(s)
- Kubilay Gürünlüoğlu
- From the Departments of Pediatric Surgery (K.G., M.D. ), Radiology (İ.O.Y., R.K., K.S., A.S.) and Biostatistics and Medical Informatics (H.G.B.), İnönü University School of Medicine, Malatya, Turkey
| | - İsmail Okan Yıldırım
- From the Departments of Pediatric Surgery (K.G., M.D. ), Radiology (İ.O.Y., R.K., K.S., A.S.) and Biostatistics and Medical Informatics (H.G.B.), İnönü University School of Medicine, Malatya, Turkey
| | - Ramazan Kutlu
- From the Departments of Pediatric Surgery (K.G., M.D. ), Radiology (İ.O.Y., R.K., K.S., A.S.) and Biostatistics and Medical Informatics (H.G.B.), İnönü University School of Medicine, Malatya, Turkey
| | - Kaya Saraç
- From the Departments of Pediatric Surgery (K.G., M.D. ), Radiology (İ.O.Y., R.K., K.S., A.S.) and Biostatistics and Medical Informatics (H.G.B.), İnönü University School of Medicine, Malatya, Turkey
| | - Ahmet Sığırcı
- From the Departments of Pediatric Surgery (K.G., M.D. ), Radiology (İ.O.Y., R.K., K.S., A.S.) and Biostatistics and Medical Informatics (H.G.B.), İnönü University School of Medicine, Malatya, Turkey
| | - Harika Gözükara Bağ
- From the Departments of Pediatric Surgery (K.G., M.D. ), Radiology (İ.O.Y., R.K., K.S., A.S.) and Biostatistics and Medical Informatics (H.G.B.), İnönü University School of Medicine, Malatya, Turkey
| | - Mehmet Demircan
- From the Departments of Pediatric Surgery (K.G., M.D. ), Radiology (İ.O.Y., R.K., K.S., A.S.) and Biostatistics and Medical Informatics (H.G.B.), İnönü University School of Medicine, Malatya, Turkey
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Awwad A, Dhillon PS, Ramjas G, Habib SB, Al-Obaydi W. Trans-arterial embolisation (TAE) in haemorrhagic pelvic injury: review of management and mid-term outcome of a major trauma centre. CVIR Endovasc 2018; 1:32. [PMID: 30652163 PMCID: PMC6319536 DOI: 10.1186/s42155-018-0031-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 10/01/2018] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Management of pelvic fracture associated haemorrhage is often complex with high morbidity and mortality rates. Different treatment options are used to control bleeding with an on-going discussion in the trauma community regarding the best management algorithm. MAIN BODY Recent studies have shown trans-arterial embolisation (TAE) to be a safe and effective technique to control pelvic fracture associated haemorrhage. Computed tomography (CT) evidence of active bleeding, haemodynamic instability, and pelvic fracture patterns are amongst important indicators for TAE. CONCLUSION Herein, we aim to provide a comprehensive literature review of the effectiveness of TAE in controlling haemorrhage secondary to pelvic fracture according to the indications, technique and embolic agents, and outcomes, whilst incorporating our Level 1 major trauma centre's (MTC) results between 2014-2017.
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Affiliation(s)
- Amir Awwad
- NIHR Nottingham Biomedical Research Centre, Sir Peter Mansfield Imaging Centre, School of Medicine, University of Nottingham, Nottingham, NG72UH UK
- Radiology Department, Royal Papworth Hospital NHS Foundation Trust, Cambridge, CB23 3RE UK
| | - Permesh Singh Dhillon
- Interventional Radiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH UK
- NIHR Nottingham Biomedical Research Centre, Sir Peter Mansfield Imaging Centre, School of Medicine, University of Nottingham, Nottingham, NG72UH UK
| | - Greg Ramjas
- Interventional Radiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH UK
| | - Said B. Habib
- Interventional Radiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH UK
| | - Waleed Al-Obaydi
- Interventional Radiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH UK
- Interventional Radiology, Royal Derby Teaching Hospitals NHS Foundation Trust, Uttoxeter Road, Derby, DE22 3NE UK
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Abstract
INTRODUCTION Pelvic angiography with transcatheter arterial embolization (TAE) is an established intervention for management of pelvic arterial hemorrhage. This study analyzes complication rates after angiography among patients with pelvic trauma treated in the context of a multidisciplinary institutional pelvic fracture protocol. METHODS Retrospective analysis of prospectively collected data was conducted. Demographics, fracture type, embolization (ie, unilateral versus bilateral and selective versus nonselective), and complications (ie, pseudoaneurysm, renal failure, soft-tissue necrosis/infection, and anaphylactic reactions) were noted. RESULTS Eighty-one patients with pelvic ring injuries underwent angiography from 2009 to 2013. Complications among 41 patients who underwent angiography with TAE were compared with a control group of 40 patients who underwent angiography without TAE. Eight of 41 patients with TAE had complications (19.5%) compared with 3 of 40 (7.5%) in the control group (P = 0.19). The overall complication rate was 13.6%. CONCLUSION The use of angiography with TAE as part of an institutional pelvic fracture protocol involves an acceptable rate of complications. LEVEL OF EVIDENCE III.
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25
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van den Berg JC. Imaging and endovascular management of traumatic pelvic fractures with vascular injuries. VASA 2018; 48:47-55. [PMID: 30362910 DOI: 10.1024/0301-1526/a000757] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
This paper will give an overview of the relevant anatomy, management and imaging, aspects as well as therapeutic aspects of traumatic pelvic fractures with vascular injuries.
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Affiliation(s)
- Jos C van den Berg
- 1 Ospedale Regionale di Lugano, Sede Civico, Lugano, Switzerland / University Institute for Diagnostic, Interventional and Pediatric Radiology, Inselspital - University Hospital Berne, Switzerland
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Imaging and Endovascular Treatment of Bleeding Pelvic Fractures: Review Article. Cardiovasc Intervent Radiol 2018; 42:10-18. [PMID: 30225676 PMCID: PMC6267662 DOI: 10.1007/s00270-018-2071-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 08/30/2018] [Indexed: 11/27/2022]
Abstract
Pelvic fractures are potentially life-threatening injuries with high mortality rates, mainly due to intractable pelvic arterial bleeding. However, concomitant injuries are frequent and may also be the cause of significant blood loss. As treatment varies depending on location and type of hemorrhage, timely imaging is of critical importance. Contrast-enhanced CT offers fast and detailed information on location and type of bleeding. Angiography with embolization for pelvic fracture hemorrhage, particularly when performed early, has shown high success rates as well as low complication rates and is currently accepted as the first method of bleeding control in pelvic fracture-related arterial hemorrhage. In the current review imaging workup, patient selection, technique, results and complications of pelvic embolization are described.
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Bilateral Internal Iliac Artery Embolization Results in an Unacceptably High Rate of Complications in Patients Requiring Pelvic/Acetabular Surgery. J Orthop Trauma 2018; 32:445-451. [PMID: 30130304 DOI: 10.1097/bot.0000000000001240] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To assess complication rates in patients undergoing open reduction internal fixation (ORIF) of pelvic/acetabular fractures with and without pelvic angiography embolization (PAE). DESIGN Retrospective case series. SETTING Level 1 Trauma Center. PATIENTS/PARTICIPANTS One hundred eleven patients with pelvic or acetabular fractures that required orthopaedic fixation. INTERVENTION Retrospective analysis of outcomes in patients who underwent ORIF of pelvic/acetabular fractures with and without PAE. MAIN OUTCOME MEASUREMENTS Comparison of surgical wound infections, necrosis, and/or fracture nonunions between the PAE group and a control group (no PAE). RESULTS Final study groups consisted of 50 patients in the PAE group and 61 patients in the control group. Ninety-six percent of patients underwent nonselective PAE. Significantly higher complications were noted in the PAE group than in the control group (20% compared with 4.9%; P = 0.020). In addition, posterior surgical approaches combined with internal iliac artery embolization represented the highest complication rate. CONCLUSIONS Patients requiring PAE and pelvic/acetabular ORIF should undergo a multidisciplinary treatment approach with the trauma surgeon, interventional radiologist, and orthopaedic surgeon before PAE being performed to decrease complications and avoid nonselective bilateral internal iliac artery embolization. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Approach and Management of Traumatic Retroperitoneal Injuries. Cir Esp 2018; 96:250-259. [PMID: 29656797 DOI: 10.1016/j.ciresp.2018.02.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 02/26/2018] [Accepted: 02/27/2018] [Indexed: 11/23/2022]
Abstract
Traumatic retroperitoneal injuries constitute a challenge for trauma surgeons. They usually occur in the context of a trauma patient with multiple associated injuries, in whom invasive procedures have an important role in the diagnosis of these injuries. The retroperitoneum is the anatomical region with the highest mortality rates, therefore early diagnosis and treatment of these lesions acquire special relevance. The aim of this study is to present current published scientific evidence regarding incidence, mechanism of injury, diagnostic methods and treatment through a review of the international literature from the last 70 years. In conclusion, this systematic review showed an increasing trend towards non-surgical management of retroperitoneal injuries.
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Abstract
The use, timing, and priority of angioembolization in the management of bleeding pelvic fractures remain ambiguous. The most common vessels for angioembolization are, in decreasing order, the internal iliac artery and its branches, the superior gluteal artery, the obturator artery, and the internal pudendal artery. Technical success rates for this treatment option range from 74% to 100%. The fracture patterns most commonly requiring angioembolization are the Young and Burgess lateral compression and anterior-posterior compression types and Tile type C. Mortality rates after angioembolization of 16% to 50% have been reported, but deaths are usually related to concomitant injuries. The sensitivity and specificity of contrast-enhanced CT in detecting the need for angioembolization range from 60% to 90% and 92% to 100%, respectively. Angioembolization can be effective in the management of bleeding pelvic fractures, but as with any treatment, the risks of complications must be considered. Availability of angioembolization and institutional expertise/preference for the alternative strategy of pelvic packing influence its use.
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Cho J, Benjamin E, Inaba K, Lam L, Demetriades D. Severe Bleeding in Pelvic Fractures: Considerations in Planning Damage Control. Am Surg 2018. [DOI: 10.1177/000313481808400236] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Severe bleeding due to pelvic fractures may require damage control procedures, such as preperitoneal packing. In many cases, preperitoneal packing is performed without full abdominal exploration. There are concerns that such an approach may miss major iliac vascular injuries or other intraabdominal injuries. This analysis assessed the incidence of iliac vascular and intraabdominal injuries in patients with pelvic fractures. The National Trauma Data Bank was queried for blunt trauma patients. Patients with severe pelvic fractures were observed. Common or external iliac vascular lacerations (CEIVL) and associated intraabdominal injuries were recorded. The study comprised 42,122 patients with pelvic fractures, of which 3,221 (7.6%) were severe pelvic fractures. The incidence of CEIVL in patients with severe pelvic fractures was 10.7 per cent. Patient age greater than or equal to 65 years was an independent predictor of CEIVL. A total of 34.3 per cent of severe pelvic fracture patients had severe associated intraabdominal injuries, including injuries to the bladder (26.5%) and bowel (16.7%). Severe pelvic fractures are associated with a high incidence of iliac vascular and intraabdominal injuries. Preperitoneal pelvic packing without abdominal exploration may miss these injuries.
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Affiliation(s)
- Jayun Cho
- From the Division of Trauma and Critical Care, University of Southern California, Los Angeles, California
| | - Elizabeth Benjamin
- From the Division of Trauma and Critical Care, University of Southern California, Los Angeles, California
| | - Kenji Inaba
- From the Division of Trauma and Critical Care, University of Southern California, Los Angeles, California
| | - Lydia Lam
- From the Division of Trauma and Critical Care, University of Southern California, Los Angeles, California
| | - Demetrios Demetriades
- From the Division of Trauma and Critical Care, University of Southern California, Los Angeles, California
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Kim SK, Park YC, Jo YG, Kang WS, Kim JC. Internal Iliac Artery Ligation with Pad Packing for Hemodynamic Unstable Open Comminuted Sacral Fracture. JOURNAL OF TRAUMA AND INJURY 2017. [DOI: 10.20408/jti.2017.30.4.238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Sung Kyu Kim
- Department of Orthopaedics, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Yun Chul Park
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Young Goun Jo
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Wu Seong Kang
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Jung Chul Kim
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
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Lai YC, Wu CH, Chen HW, Wang LJ, Wong YC. Predictors of active arterial hemorrhage on angiography in pelvic fracture patients. Jpn J Radiol 2017; 36:223-230. [PMID: 29282615 DOI: 10.1007/s11604-017-0716-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 12/17/2017] [Indexed: 01/02/2023]
Abstract
PURPOSE To determine predictors of active angiographic hemorrhage in pelvic fracture patients. MATERIALS AND METHODS This retrospective study included 66 trauma patients who had major hemorrhages due to pelvic fractures, and who underwent pelvic angiography between January 2012 and December 2014. The study population comprised 31 males and 35 females (mean age 44.2 ± 20.7 years). The main outcome was active hemorrhage on pelvic angiography. Clinical and imaging variables including demographics, hemodynamic parameters, injury severity, types of pelvic fracture, laboratory data, blood transfusions and CT findings were analyzed. Multivariate logistic regression was used to identify predictors of active angiographic hemorrhage. RESULTS Of the 66 study patients included, 41 patients had active angiographic hemorrhage. These patients had more blood transfusions, higher activated partial thromboplastin times and higher rates of contrast extravasation on CT (p < 0.05). Three independent predictors of active angiographic hemorrhage were identified, including contrast extravasation on CT (OR: 74.6, p < 0.001), more than 8 units of RBC transfusions (OR: 12.5, p = 0.018) and ISS ≥ 16 (OR: 11.1, p = 0.029). CONCLUSION Contrast extravasation on CT, high volume RBC transfusions and ISS ≥ 16 can help us to select pelvic fracture patients for angiography more precisely.
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Affiliation(s)
- Ying-Chieh Lai
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Gueishan, Taoyuan, 333, Taiwan
| | - Cheng-Hsien Wu
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Gueishan, Taoyuan, 333, Taiwan
| | - Huan-Wu Chen
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Gueishan, Taoyuan, 333, Taiwan
| | - Li-Jen Wang
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Gueishan, Taoyuan, 333, Taiwan
| | - Yon-Cheong Wong
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Gueishan, Taoyuan, 333, Taiwan.
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Ramasamy B, Thewlis D, Moss MJ, Fraysse F, Rickman M, Solomon LB. Complications of trans arterial embolization during the resuscitation of pelvic fractures. Injury 2017; 48:2724-2729. [PMID: 29096928 DOI: 10.1016/j.injury.2017.10.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 10/26/2017] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Trans arterial embolization (TAE) can stem uncontrolled bleeding associated with pelvic fractures, but is associated with potential complications. This study investigated and compared the early to midterm complications in two patient cohorts: one who did and one who did not undergo TAE. METHODOLOGY The results of 14 patients who underwent TAE in the resuscitation phase, and then had their pelvic fractures managed non-operatively, the study group (Group 1), were compared with those of a control group (Group 2) of 14 patients matched for age, sex, injury and management, that did not undergo TAE. All patients were examined clinically and answered a questionnaire on bowel and urinary function, pain and limp. Gluteus medius structure and volume were assessed on MRI. The hip girdle muscle function was assessed using a hand held dynamometer, surface electromyography as well as quantitative gait analysis. RESULTS Seven patients in Group 1 (50%), but none in Group 2, had persistent urological dysfunctions, in the absence of any recognized previous pathology or urologic trauma at the time of injury. No gluteal muscle demonstrated fibrosis or fatty infiltration. The median gluteal muscle volume was not significantly decreased compared with the uninjured side in either group (P=0.421). The muscle strengths of gluteus maximus, gluteus medius, tensor fasciae latae and iliopsoas when compared to the uninjured side were significantly less in Group 1 compared to Group 2. However, no patient had a discernable limp and gait analysis showed no significant differences between the left and right sides in the study and control groups in the gluteal activation timing (p=0.171 and 0.354) and duration (p=0.622 and 0.435). There were no skin complications, and no patient reported any persistent bowel dysfunction. CONCLUSION TAE was associated with a high rate of persistent urological dysfunction. TAE could lead to decreased hip muscles strength, however this does not seem to affect gait.
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Affiliation(s)
- Boopalan Ramasamy
- Department of Orthopaedics 3, Paul Brand Building, Christian Medical College, Vellore, 632004, Tamil Nadu, India; Centre for Stem Cell Research (A unit of inStem), Christian Medical College, Vellore 632002, Tamil Nadu, India.
| | - Dominic Thewlis
- Centre for Orthopaedic & Trauma Research and Discipline of Orthopaedics and Trauma, The University of Adelaide, Adelaide, SA 5000, Australia.
| | - Mary J Moss
- Department of Radiology, Royal Adelaide Hospital, Adelaide, SA 5000, Australia.
| | - Francois Fraysse
- School of Health Sciences, University of South Australia, Adelaide, SA 5000, Australia.
| | - Mark Rickman
- Centre for Orthopaedic & Trauma Research and Discipline of Orthopaedics and Trauma, The University of Adelaide, Adelaide, SA 5000, Australia; Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA 5000, Australia.
| | - Lucian Bogdan Solomon
- Centre for Orthopaedic & Trauma Research and Discipline of Orthopaedics and Trauma, The University of Adelaide, Adelaide, SA 5000, Australia; Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA 5000, Australia.
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Martin JG, Kassin M, Park P, Ermentrout RM, Dariushnia S. Evaluation and Treatment of Blunt Pelvic Trauma. Tech Vasc Interv Radiol 2017; 20:237-242. [PMID: 29224655 DOI: 10.1053/j.tvir.2017.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Trauma is a significant contributor to mortality, especially in the young. Pelvic trauma with pelvic ring fractures may result in associated arterial injury, necessitating endovascular intervention. As a result, interventional radiology plays a critical role in partnering with trauma providers in the care of these patients. Management is determined by the acuity of the patient's clinical status, radiographs, ultrasound, and the results of computed tomography imaging when available. Numerous embolic agents are available for treatment of arterial hemorrhage.
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Affiliation(s)
- Jonathan G Martin
- Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, GA.
| | - Michael Kassin
- Department of Radiology and Imaging Sciences, Emory University Hospital, Emory University School of Medicine, Atlanta, GA
| | - Peter Park
- Department of Radiology and Imaging Sciences, Emory University Hospital, Emory University School of Medicine, Atlanta, GA
| | - R Mitchell Ermentrout
- Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, GA
| | - Sean Dariushnia
- Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, GA
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Selective versus nonselective embolization versus no embolization in pelvic trauma. J Trauma Acute Care Surg 2017; 83:361-367. [DOI: 10.1097/ta.0000000000001554] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
A pelvic fracture usually indicates high energy transfer from a significant mechanism and a high likelihood of associated injuries. Mortality from pelvic trauma is usually due to massive haemorrhage mandating expedient resuscitation of the patient and immediate control of exsanguinating haemorrhage. Damage control resuscitation incorporates permissive hypotensive resuscitation and early replacement of clotting factors with early aggressive surgical control of bleeding. A commercially available pelvic binder provides circumferential compression and rapidly closes the pelvis, leading to fracture splintage and reduction in pelvic volume, both of which reduce haemorrhage. It is critical to distinguish ongoing bleeding due to a pelvic ring injury from intra-peritoneal haemorrhage. The identification of intra-peritoneal bleeding in a haemodynamically unstable patient mandates laparotomy. On-going haemorrhage from the pelvis requires diagnostic pelvic angiography, followed by selective embolisation if a source of bleeding is identified. If angiography is not available pelvic packing can be life-saving.
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Affiliation(s)
- Jonathan A Clamp
- Trauma and Orthopaedic Surgery, University Hospital Nottingham Queen’s Medical Centre Campus, Derbyshire, UK
| | - Christopher G Moran
- Trauma and Orthopaedic Surgery, University Hospital Nottingham Queen’s Medical Centre Campus, Derbyshire, UK
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Does Pelvic Embolization Increase Infection Rates in Patients Who Undergo Open Treatment of Acetabular Fractures? J Orthop Trauma 2017; 31:185-188. [PMID: 28207477 DOI: 10.1097/bot.0000000000000771] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Evaluate the impact of pelvic embolization on postoperative infection rate after acetabular fracture fixation. DESIGN Retrospective study of 3 separate cohorts. SETTING Level I Trauma Center. PATIENTS/PARTICIPANTS Identified patients who underwent angiography of the pelvis as well as required an open reduction internal fixation (ORIF) of an acetabular fracture. This group was compared to a control group of patients with an acetabular fracture, which did not undergo angiography, and underwent ORIF. INTERVENTION ORIF of an aectabular fracture with angiography ± embolization. MAIN OUTCOME MEASUREMENTS Deep infection rate. RESULTS Seventy-two patients remained for final analysis; 25 patients underwent embolization, 16 patients underwent angiography without embolization, and 31 patients did not undergo angiography. Two out of 25 (8%) patients developed infections in the embolization group, one deep infection and one superficial infection. Five out of 16 (31%) patients developed deep infections in the nonembolization group. Control group of patients who did not undergo angiography had a deep infection rate of 9.6%. CONCLUSION Despite previous reports of high infection rates after pelvic embolization, the deep infection rate was only 4% after embolization in our cohort. This suggests that concerns for higher rates of infection are not substantiated, and pelvic embolization should be performed when indicated. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Sammour T, An V, Thomas ML. Bleeding iliac artery pseudoaneurysm after colorectal anastomotic leak. SURGICAL PRACTICE 2016. [DOI: 10.1111/1744-1633.12214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Tarik Sammour
- Department of Surgery; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Vinna An
- Department of Surgery; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Michelle L. Thomas
- Department of Surgery; Royal Adelaide Hospital; Adelaide South Australia Australia
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Shi J, Gomes A, Lee E, Kee S, Moriarty J, Cryer H, McWilliams J. Complications after transcatheter arterial embolization for pelvic trauma: relationship to level and laterality of embolization. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 26:877-883. [DOI: 10.1007/s00590-016-1832-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 08/07/2016] [Indexed: 10/21/2022]
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Salcedo ES, Brown IE, Corwin MT, Galante JM. Pelvic angioembolization in trauma - Indications and outcomes. Int J Surg 2016; 33:231-236. [PMID: 26912018 DOI: 10.1016/j.ijsu.2016.02.057] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 01/25/2016] [Accepted: 02/13/2016] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Pelvic stabilization with angioembolization (AE) is steadily supplanting operative management for the treatment of pelvic hemorrhage in trauma. We aimed to provide a brief review of the indications, effectiveness and complications associated with AE for pelvic injuries. METHODS We conducted a literature search using the terms "trauma," "angioembolization," and "pelvis" limited to studies published in the English language. Abstracts and full text were manually reviewed to identify suitable articles. RESULTS The current brief review is based on content from articles published in the last 10 years related to pelvic AE for retroperitoneal hemorrhage after trauma. DISCUSSION Pelvic injuries often require complex management because the high energy transfer causes concomitant injuries. Outcomes for hemodynamically unstable patients may be better with AE than with operative management. CONCLUSION Pelvic AE is the most effective intervention for management of hemorrhage associated with pelvic fracture in both hemodynamically stable and unstable patients. It can be used as the primary definitive intervention or in conjunction with operative management in the setting of concomitant intra-abdominal injury.
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Affiliation(s)
- Edgardo S Salcedo
- University of California, Davis School of Medicine, Department of Surgery, Division of Trauma, Acute Care Surgery and Surgical Critical Care, 2315 Stockton Blvd, Room 4206, Sacramento, CA 95817, USA.
| | - Ian E Brown
- University of California, Davis School of Medicine, Department of Surgery, Division of Trauma, Acute Care Surgery and Surgical Critical Care, 2315 Stockton Blvd, Room 4206, Sacramento, CA 95817, USA.
| | - Michael T Corwin
- University of California, Davis School of Medicine, Department of Radiology, 4860 Y Street, ACC Suite 3100, Sacramento, CA 95817, USA.
| | - Joseph M Galante
- University of California, Davis School of Medicine, Department of Surgery, Division of Trauma, Acute Care Surgery and Surgical Critical Care, 2315 Stockton Blvd, Room 4206, Sacramento, CA 95817, USA.
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Chu CH, Tennakoon L, Maggio PM, Weiser TG, Spain DA, Staudenmayer KL. Trends in the management of pelvic fractures, 2008-2010. J Surg Res 2016; 202:335-40. [PMID: 27229108 DOI: 10.1016/j.jss.2015.12.052] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 12/10/2015] [Accepted: 12/31/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND Bleeding from pelvic fractures can be lethal. Angioembolization (AE) and external fixation (EXFIX) are common treatments to control bleeding, but it is not known how frequently they are used. We hypothesized that AE would be increasingly more common compared with EXFIX over time. METHODS The National Trauma Data Bank for the years from 2008-2010 were used. Patients were included in the study if they had an International Classification of Diseases, ninth edition, Clinical Modification codes for pelvic fractures and were aged ≥18 y. Patients were excluded if they had isolated acetabular fractures, were not admitted, or had minor injuries. Outcomes included receiving a procedure and in-hospital mortality. RESULTS A total of 22,568 patients met study criteria. AE and EXFIX were performed in 746 (3.3%) and 663 (2.9%) patients, respectively. AE was performed more often as the study period progressed (2.5% in 2007 to 3.7% in 2010; P < 0.001). This remained significant in adjusted analysis (odds ratio per year 1.15; P = 0.008). Having a procedure was associated with higher mortality in unadjusted analyses compared with those with no procedure (11.0% for no procedure versus 20.5% and 13.4% for AE or EXFIX, respectively; P < 0.001). In adjusted analyses, only AE remained associated with higher mortality (odds ratio 1.63; P < 0.001). CONCLUSIONS AE in severely injured pelvic fracture patients is increasing. AE is associated with higher mortality, which may reflect the fact that it is used for patients at higher risk of death. The role of AE for bleeding should be examined in future studies.
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Affiliation(s)
- Christopher H Chu
- University of South Carolina School of Medicine, Columbia, South Carolina
| | - Lakshika Tennakoon
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - Paul M Maggio
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - Tom G Weiser
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - David A Spain
- Department of Surgery, Stanford University Medical Center, Stanford, California
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Xie B, Liang M, Zhou DP, Zhao W, Sun JY, Rong JJ, Tian J. Effects of internal iliac artery embolization on systemic inflammatory response syndrome in dogs with simulated-pelvic-fracture combined with massive bleeding. Mil Med Res 2016; 3:14. [PMID: 27123314 PMCID: PMC4847365 DOI: 10.1186/s40779-016-0085-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 04/21/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Pelvic fracture combined with massive bleeding (PFCMB) is a complex issue in clinical practice. Currently, the use of angiography and embolization for the treatment of PFCMB obtains good results. The aim of this study is to observe the effects of early internal iliac artery embolization on the SIRS in dogs with simulated-pelvic-fracture combined with massive bleeding. METHODS Twenty adult dogs were randomly divided into an embolization group (EG) and a control group (CG). For the two groups, heart rate, respiratory rate and body temperature and other physiological variables were measured, and IL-6, TNF-α and arterial blood gas levels were monitored. These variables were assayed every 30 min until death in the CG, while dogs in the EG underwent arterial angiography after 60 min of modeling. The internal iliac artery was embolized on the injured side. RESULTS The average time to SIRS in the CG was 3.56 h, occurring at a rate of 90 % (9/10) within 24 h, with a mortality rate of 50 % (5/10); the average time to SIRS for the EG was 5.33 h, occurring at a rate of 30 % (3/10) within 24 h, with a mortality rate of 10 % (1/10). When SIRS occurred in the EG, the mean plasma IL-6 level was 52.66 ± 7.38 pg/ml and the TNF-α level was 11.45 ± 2.72 ng/ml, showing a significant difference with those of the CG (P < 0.05). In the two groups, the respiratory rate and leukocyte levels were higher at each monitored time after modeling than those before modeling; the mean arterial pressure, levels of hemoglobin and oxygen partial pressure were significantly lower at each time point after modeling than those before modeling except for the mean arterial pressure at 0 h in EG; the platelet levels at 4 and 8 h were higher than those before modeling; and the differences were statistically significant (P < 0.05). In the EG, the mean arterial pressure, heart rate, respiratory rate and hemoglobin levels at 2 , 4 and 8 h were lower than those at 0 h; the levels of leukocytes, platelets and carbon dioxide partial pressure at 4 and 8 h after modeling were higher than those at 0 h, and the differences were statistically significant (P < 0.05, P < 0.01); in the CG after modeling, the mean arterial pressure, levels of hemoglobin and carbon dioxide partial pressure at 2, 4 and 8 h were lower than those at 0 h; the levels of heart rate and leukocytes were higher than those before modeling; the respiratory rate and platelet levels at 4 and 8 h were higher than those at 0 h; and the differences were statistically significant (P < 0.05). The levels of the mean arterial pressure and hemoglobin at 4 and 8 h and the pH values at 8 h after modeling in the EG were significantly higher than those in the CG, while the heart rate and respiratory rate at 4 and 8 h were significantly lower than those in the CG. The pH values at 8 h after modeling were significantly lower than those of the other monitored times in the CG (P < 0.05, P < 0.01). The two groups had elevated levels of alkaline phosphatase after injury induction. CONCLUSION Through the use of an on-spot interventional treatment cabin, early internal iliac artery embolization can control bleeding associated with pelvic fractures, delay the occurrence of SIRS, and improve the success rate of the treatment of pelvic fracture combined with bleeding.
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Affiliation(s)
- Bing Xie
- Department of Orthopedics, General Hospital of Shenyang Military Region, Shenyang, 110016 China
| | - Ming Liang
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016 China
| | - Da-Peng Zhou
- Department of Orthopedics, General Hospital of Shenyang Military Region, Shenyang, 110016 China
| | - Wen Zhao
- Department of Orthopedics, General Hospital of Shenyang Military Region, Shenyang, 110016 China
| | - Jing-Yang Sun
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016 China
| | - Jing-Jing Rong
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, 110016 China
| | - Jing Tian
- Department of Orthopedics, General Hospital of Shenyang Military Region, Shenyang, 110016 China
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Chitragari G, Schlosser FJ, Ochoa Chaar CI, Sumpio BE. Consequences of hypogastric artery ligation, embolization, or coverage. J Vasc Surg 2015; 62:1340-7.e1. [DOI: 10.1016/j.jvs.2015.08.053] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Accepted: 08/04/2015] [Indexed: 10/23/2022]
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Mauffrey C, Cuellar DO, Pieracci F, Hak DJ, Hammerberg EM, Stahel PF, Burlew CC, Moore EE. Strategies for the management of haemorrhage following pelvic fractures and associated trauma-induced coagulopathy. Bone Joint J 2014; 96-B:1143-54. [PMID: 25183582 DOI: 10.1302/0301-620x.96b9.33914] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Exsanguination is the second most common cause of death in patients who suffer severe trauma. The management of haemodynamically unstable high-energy pelvic injuries remains controversial, as there are no universally accepted guidelines to direct surgeons on the ideal use of pelvic packing or early angio-embolisation. Additionally, the optimal resuscitation strategy, which prevents or halts the progression of the trauma-induced coagulopathy, remains unknown. Although early and aggressive use of blood products in these patients appears to improve survival, over-enthusiastic resuscitative measures may not be the safest strategy. This paper provides an overview of the classification of pelvic injuries and the current evidence on best-practice management of high-energy pelvic fractures, including resuscitation, transfusion of blood components, monitoring of coagulopathy, and procedural interventions including pre-peritoneal pelvic packing, external fixation and angiographic embolisation.
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Affiliation(s)
- C Mauffrey
- Denver Health Medical Center, 655 Broadway, Suite 365 Denver, Colorado 80203, USA
| | - D O Cuellar
- Denver Health Medical Center, 655 Broadway, Suite 365 Denver, Colorado 80203, USA
| | - F Pieracci
- Denver Health Medical Center, 655 Broadway, Suite 365 Denver, Colorado 80203, USA
| | - D J Hak
- Denver Health Medical Center, 655 Broadway, Suite 365 Denver, Colorado 80203, USA
| | - E M Hammerberg
- Denver Health Medical Center, 655 Broadway, Suite 365 Denver, Colorado 80203, USA
| | - P F Stahel
- Denver Health Medical Center, 655 Broadway, Suite 365 Denver, Colorado 80203, USA
| | - C C Burlew
- Denver Health Medical Center, 655 Broadway, Suite 365 Denver, Colorado 80203, USA
| | - E E Moore
- Denver Health Medical Center, 655 Broadway, Suite 365 Denver, Colorado 80203, USA
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Fu CY, Wang SY, Liao CH, Kang SC, Hsu YP, Lin BC, Yuan KC, Ouyang CH. Computed tomography angiography provides limited benefit in the evaluation of patients with pelvic fractures. Am J Emerg Med 2014; 32:1220-4. [DOI: 10.1016/j.ajem.2014.07.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 07/24/2014] [Indexed: 11/25/2022] Open
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Arthur TI, Gillespie CJ, Butcher W, Lu CT. Pseudoaneurysm of the internal iliac artery resulting in massive per-rectal bleeding. J Surg Case Rep 2013; 2013:rjt069. [PMID: 24964318 PMCID: PMC3855167 DOI: 10.1093/jscr/rjt069] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Rectal bleeding is a common reason for presentation to hospital, with large bleeds most commonly caused by diverticular disease and angiodysplasia. Here we present an unusual aetiology of massive per-rectal bleeding attributable to pseudoaneurysm of the internal iliac artery leading to an arterial fistula to the distal large bowel. It is hoped the case will serve as a reminder that rectal bleeding can have a less common aetiology.
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Affiliation(s)
- T I Arthur
- Department of General Surgery, Gold Coast Hospital, Gold Coast, Australia
| | - C J Gillespie
- Department of General Surgery, Gold Coast Hospital, Gold Coast, Australia
| | - W Butcher
- Department of Vascular Surgery, Gold Coast Hospital, Gold Coast, Australia
| | - C T Lu
- Department of General Surgery, Gold Coast Hospital, Gold Coast, Australia
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Khanna P, Phan H, Hardy AH, Nolan T, Dong P. Multidisciplinary management of blunt pelvic trauma. Semin Intervent Radiol 2013; 29:187-91. [PMID: 23997410 DOI: 10.1055/s-0032-1326927] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Pelvic fractures account for ∼3% of all fractures and usually occur in patients with polytrauma. Pelvic fractures usually indicate high energy transfer and a significant mechanism of injury, and they can involve massive hemorrhage. For this reason, mortality from pelvic trauma is high, ranging from 40% to 60% among patients in shock, and up to 90% in patients considered to be in extremis. Multidisciplinary approaches in the treatment of patients with pelvic fractures have resulted in improved outcomes for these complex and challenging injuries. In this article, we describe a case of a pediatric patient who suffered severe pelvic fracture with massive hemorrhage, requiring a multidisciplinary approach for control of hemorrhage and definitive repair of injuries.
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Abstract
BACKGROUND Hemodynamically unstable patients with a pelvic fracture and arterial pelvic bleeding frequently are treated with pelvic angiographic embolization (PAE). PAE is reported to be a safe and effective method of controlling hemorrhage. However, the loss of blood supply and subsequent ischemia from embolization may lead to adverse consequences. OBJECTIVES/PURPOSES We sought to determine (1) the frequency and types of complications observed after PAE; (2) the mortality after PAE; and (3) the clinical factors associated with complications and mortality after PAE. METHODS We conducted a retrospective case series descriptive study at a Level I trauma center. Using our institution's trauma registry, we isolated patients with pelvic fractures treated with PAE admitted between June 1999 and December 2007. Complications attributed to PAE occurring in the initial hospital stay were recorded. We identified 98 patients with pelvic fractures treated by PAE with an average hospital stay of 25.3 days. RESULTS The complication rate was 11% and included six patients with gluteal muscle necrosis (6%), five with surgical wound breakdown (5%), four deep infections (4%), one superficial infection, two patients with of impotence (2%), and one with bladder necrosis. The mortality rate in the PAE group reached 20%. Bilateral embolization was performed in 100% of the patients with complications. Nonselective embolization was performed in 81% of patients with complications. All of the patients with gluteal necrosis had bilateral nonselective embolization. CONCLUSIONS Bilateral or nonselective PAE is associated with significant complications during the initial hospital stay. The value of PAE should be weighed against its possible adverse consequences. Selective unilateral arterial embolization should be considered whenever possible.
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