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Madsen JE, Flugsrud GB, Hammer N, Puchwein P. Emergency treatment of pelvic ring injuries: state of the art. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05447-7. [PMID: 38970673 DOI: 10.1007/s00402-024-05447-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 06/29/2024] [Indexed: 07/08/2024]
Abstract
High energy pelvic injuries sustain significant mortality rates, due to acute exsanguination and severe associated injuries. Managing the hemodynamically unstable trauma patient with a bleeding pelvic fracture still forms a major challenge in acute trauma care. Various approaches have been applied through the last decades. At present the concept of Damage Control Resuscitation (DCR) is universally accepted and applied in major trauma centers internationally. DCR combines hemostatic blood transfusions to restore blood volume and physiologic stability, reduced crystalloid fluid administration, permissive hypotension, and immediate hemorrhage control by operative or angiographic means. Different detailed algorithms and orders of hemostatic procedures exist, without clear consensus or guidelines, depending on local traditions and institutional setups. Fracture reduction and immediate stabilization with a binder constitute the basis for angiography and embolization (AE) or pelvic packing (PP) in the hemodynamically unstable patient. AE is time consuming and may not be available 24/7, whereas PP offers a quick and technically easy procedure well suited for the patient in extremis. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has also been described as a valuable adjunct in hemostatic non-responders, but merely constitute a bridge to surgical or angiographic hemostasis and its definitive role in DCR is not yet clearly established. A swift algorithmic approach to the hemodynamically unstable pelvic injury patient is required to achieve optimum results. The present paper summarizes the available literature on the acute management of the bleeding pelvic trauma patient, with emphasis on initial assessment and damage control resuscitation including surgical and angiographic hemostatic procedures. Furthermore, initial treatment of open fractures and associated injuries to the nervous and genitourinary system is outlined.
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Affiliation(s)
- Jan Erik Madsen
- Division of Orthopaedic Surgery, Oslo University Hospital, Kirkeveien 166, 0450, Oslo, Norway.
- Institute of Clinical Medicine, University of Oslo, Klaus Torgårds Vei 3, 0372, Oslo, Norway.
| | | | - Niels Hammer
- Division of Macroscopic and Clinical Anatomy Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria
- Department of Orthopaedic and Trauma Surgery, University of Leipzig, Leipzig, Germany
- Division of Medical Technology, Fraunhofer Institute for Machine Tools and Forming Technology (Fraunhofer IWU), Dresden, Germany
| | - Paul Puchwein
- Department of Orthopaedic and Trauma Surgery, University of Leipzig, Leipzig, Germany
- Division of Medical Technology, Fraunhofer Institute for Machine Tools and Forming Technology (Fraunhofer IWU), Dresden, Germany
- Department of Orthopedics and Trauma Surgery, Medical University of Graz, Graz, Austria
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Ahmed N, Kuo YH. Resuscitative Endovascular Balloon Occlusion of The Aorta (REBOA) And Mortality in Hemorrhagic Shock Associated with Severe Pelvic Fracture: a National Data Analysis. BMC Emerg Med 2024; 24:104. [PMID: 38910235 PMCID: PMC11194952 DOI: 10.1186/s12873-024-01020-y] [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: 08/21/2023] [Accepted: 06/07/2024] [Indexed: 06/25/2024] Open
Abstract
BACKGROUND The purpose of the study was to evaluate the mortality of patients who received Resuscitative Endovascular Balloon Occlusion of The Aorta (REBOA) in severe pelvic fracture with hemorrhagic shock. METHODS The American College of Surgeon Trauma Quality Improvement Program (ACS-TQIP) database for the calendar years 2017-2019 was accessed for the study. The study included all patients aged 15 years and older who sustained severe pelvic fractures, defined as an injury with an abbreviated injury scale (AIS) score of ≥ 3, and who presented with the lowest systolic blood pressure (SBP) of < 90 mmHg. Patients with severe brain injury were excluded from the study. Propensity score matching was used to compare the patients who received REBOA with similar characteristics to patients who did not receive REBOA. RESULTS Out of 3,186 patients who qualified for the study, 35(1.1%) patients received REBOA for an ongoing hemorrhagic shock with severe pelvic fracture. The propensity matching created 35 pairs of patients. The pair-matched analysis showed no significant differences between the group who received REBOA and the group that did not receive REBOA regarding patients' demography, injury severity, severity of pelvic fractures, lowest blood pressure at initial assessment and laparotomies. There was no significant difference found between REBOA versus no REBOA group in overall in-hospital mortality (34.3% vs. 28.6, P = 0.789). CONCLUSION Our study did not identify any mortality advantage in patients who received REBOA in hemorrhagic shock associated with severe pelvic fracture compared to a similar cohort of patients who did not receive REBOA. A larger sample size prospective study is needed to validate our results. CASE-CONTROL RETROSPECTIVE STUDY Level of Evidence IV.
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Affiliation(s)
- Nasim Ahmed
- Division of Trauma & Surgical Critical Care, Jersey Shore University Medical Center, Neptune, NJ, USA.
- Hackensack Meridian School of Medicine, Nutley, NJ, USA.
| | - Yen-Hong Kuo
- Office of Research Administration, Hackensack Meridian Health Research Institute, Nutley, NJ, USA
- Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, NJ, USA
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Clements W, Lukies M, Zia A, Fitzgerald M, Kavnoudias H. Let us settle the controversy-gelfoam is a safe intravascular embolic agent. Br J Radiol 2024; 97:933-937. [PMID: 38402518 DOI: 10.1093/bjr/tqae047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 02/08/2024] [Accepted: 02/21/2024] [Indexed: 02/26/2024] Open
Abstract
OBJECTIVES A 2021 safety alert restricted endovascular gelfoam use in Australia and resulted in an embargo on gelfoam sales to Interventional Radiology departments. This study aimed to show that gelfoam is safe in a population of trauma patients with pelvic injury, and discuss the basis of the recent controversies. METHODS Retrospective cohort study was conducted between 1 January 2010 and 21 May 2021 for the patients who underwent gelfoam embolization for pelvic arterial haemorrhage. Primary outcome was the rate of adverse events related to intravascular gelfoam administration. RESULTS Inclusion criteria met in 50 patients, comprising 58% males median age 59.9 years, and median injury severity score 31. There were 0 complications related to gelfoam use and 100% technical success. Thirty-five patients (70%) received a non-targeted embolization approach. All-cause mortality was observed in 5 patients (10%), unrelated to gelfoam. CONCLUSIONS Gelfoam is a safe and effective embolic agent in pelvic trauma. Patients are in urgent need of universal on-label registration of endovascular gelfoam products, as it is life-saving in major haemorrhage after trauma. ADVANCES IN KNOWLEDGE Endovascular gelfoam is mandatory for a high-quality trauma service, and this study shows that it is safe to use intentionally in the endovascular space. Companies should work with interventional radiologists, sharing and collaborating to ensure positive outcomes for patients.
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Affiliation(s)
- Warren Clements
- Department of Radiology, Alfred Health, Melbourne 3004, Australia
- Department of Surgery, Central Clinical School, Monash University, Melbourne 3004, Australia
- National Trauma Research Institute, Central Clinical School, Monash University, Melbourne 3004, Australia
| | - Matthew Lukies
- Department of Radiology, Alfred Health, Melbourne 3004, Australia
| | - Adil Zia
- Department of Radiology, Alfred Health, Melbourne 3004, Australia
| | - Mark Fitzgerald
- Department of Surgery, Central Clinical School, Monash University, Melbourne 3004, Australia
- National Trauma Research Institute, Central Clinical School, Monash University, Melbourne 3004, Australia
- Department of Trauma, Alfred Health, Melbourne 3004, Australia
| | - Helen Kavnoudias
- Department of Radiology, Alfred Health, Melbourne 3004, Australia
- Department of Surgery, Central Clinical School, Monash University, Melbourne 3004, Australia
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Lagazzi E, Rafaqat W, Kalva SP, Ly TV, Velmahos GC. The life-over-limb imperative: Damage control angioembolization in pelvic trauma. J Trauma Acute Care Surg 2024; 96:e41-e42. [PMID: 38321604 DOI: 10.1097/ta.0000000000004275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
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Baker JE, Werner NL, Burlew CC. Management of Pelvic Trauma. Surg Clin North Am 2024; 104:367-384. [PMID: 38453308 DOI: 10.1016/j.suc.2023.10.001] [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] [Indexed: 03/09/2024]
Abstract
Pelvic fractures are common after blunt trauma with patients' presentation ranging from stable with insignificant fractures to life-threatening exsanguination from unstable fractures. Often, hemorrhagic shock from a pelvic fracture may go unrecognized and high clinical suspicion for a pelvic source lies with the clinician. A multidisciplinary coordinated effort is required for management of these complex patients. In the exsanguinating patient, hemorrhage control remains the top priority and may be achieved with external stabilization, resuscitative endovascular balloon occlusion of the aorta, preperitoneal pelvic packing, angiographic intervention, or a combination of therapies. These modalities have been shown to reduce mortality in this challenging population.
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Affiliation(s)
- Jennifer E Baker
- Division of GI, Trauma, and Endocrine Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, 12631 East 17th Avenue, Aurora, CO 80045, USA
| | - Nicole L Werner
- Division of Acute Care and Regional General Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue H4/367, Madison, WI 53792, USA
| | - Clay Cothren Burlew
- Division of GI, Trauma, and Endocrine Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, 12631 E 17th Avenue, Box C313, Aurora, CO 80045, USA.
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Lei D, Lei J, Xu H. Biomechanical characteristics of arteries during pelvic fracture reduction and dynamic simulation analysis. Comput Methods Biomech Biomed Engin 2024:1-14. [PMID: 38439667 DOI: 10.1080/10255842.2024.2324880] [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: 12/07/2023] [Accepted: 02/24/2024] [Indexed: 03/06/2024]
Abstract
During robot-assisted reduction of pelvic fracture, blood vessels are susceptible to tensile and shear forces, making them prone to injury. Considering the impact of pelvic reduction on the risk of arterial injury, the biomechanical characteristics of arteries during the pelvic fracture reduction process are studied, and a refined coupled composite model of the damaged pelvic structure is established. Dynamic simulations of pelvic fracture reduction are conducted based on the planned reduction path. The simulation results show that during the reduction process, when the affected side is rotated, the stress and strain of the artery are maximum, particularly at the locations of the iliac common artery, internal iliac artery, and the superior gluteal artery arch endure significant stress and strain. After reduction, the maximum stress is observed in the right superior gluteal artery, and the maximum strain occurs at the intersection of the right iliac common artery. The stretch ratio of both the left and right iliac common arteries is considerable. Therefore, it can be concluded that the superior gluteal artery and the internal iliac artery are prone to injury, particularly the segment from the origin of the superior gluteal artery to its passage around the greater sciatic notch. After reduction, substantial traction on the iliac common artery, which makes it more susceptible to deformation, carries a risk of arterial rupture and aneurysm formation. This study provides a reference for planning the safe reduction path of pelvic fracture surgery and improving safety.
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Affiliation(s)
- Dongwei Lei
- School of Mechatronic Engineering and Automation, Shanghai University, Shanghai, China
| | - Jingtao Lei
- School of Mechatronic Engineering and Automation, Shanghai University, Shanghai, China
| | - Haifei Xu
- School of Mechatronic Engineering and Automation, Shanghai University, Shanghai, China
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Clements W, Dunne T, Clare S, Lukies M, Fitzgerald M, Mathew J, Kavnoudias H, Zia A, Ban EJ, Skelley A, Koukounaras J. A retrospective observational study assessing mortality after pelvic trauma embolisation. J Med Imaging Radiat Oncol 2024. [PMID: 38294148 DOI: 10.1111/1754-9485.13623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 01/17/2024] [Indexed: 02/01/2024]
Abstract
INTRODUCTION Trauma to the pelvic ring and associated haemorrhage represent a management challenge for the multidisciplinary trauma team. In up to 10% of patients, bleeding can be the result of an arterial injury and mortality is reported as high as 89% in this cohort. We aimed to assess the mortality rate after pelvic trauma embolisation and whether earlier embolisation improved mortality. METHODS Retrospective study at single tertiary trauma and referral centre, between 1 January 2009 and 30 June 2022. All adult patients who received embolisation following pelvic trauma were included. Patients were excluded if angiography was performed but no embolisation performed. RESULTS During the 13.5-year time period, 175 patients underwent angiography and 28 were excluded, leaving 147 patients in the study. The all-cause mortality rate at 30-days was 11.6% (17 patients). The median time from injury to embolisation was 6.3 h (range 2.8-418.4). On regression analysis, time from injury to embolisation was not associated with mortality (OR 1.01, 95% CI 0.952-1.061). Increasing age (OR 1.20, 95% CI 1.084-1.333) and increasing injury severity score (OR 1.14, 95% CI 1.049-1.247) were positively associated with all-cause 30-day mortality, while non-selective embolisation (OR 0.11, 95% CI 0.013-0.893) was negatively associated. CONCLUSION The all-cause mortality rate at 30-days in or cohort was very low. In addition, earlier time from injury to embolisation was not positively associated with all-cause 30-day mortality. Nevertheless, minimising this remains a fundamental principle of the management of bleeding in pelvic trauma.
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Affiliation(s)
- Warren Clements
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Talulla Dunne
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Radiology, St James' Hospital, Dublin, Ireland
| | - Steven Clare
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
| | - Matthew Lukies
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Diagnostic and Interventional Imaging, KK Women's and Children's Hospital, Singapore City, Singapore
| | - Mark Fitzgerald
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Trauma, Alfred Health, Melbourne, Victoria, Australia
| | - Joseph Mathew
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Trauma, Alfred Health, Melbourne, Victoria, Australia
| | - Helen Kavnoudias
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Adil Zia
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
| | - Ee Jun Ban
- National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Trauma, Alfred Health, Melbourne, Victoria, Australia
| | - Annabelle Skelley
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
| | - Jim Koukounaras
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
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Mizuno Y, Miyake T, Okada H, Ishihara T, Kanda N, Ichihashi M, Kamidani R, Fukuta T, Yoshida T, Nagata S, Kawada H, Matsuo M, Yoshida S, Ogura S. A short decision time for transcatheter embolization can better associate mortality in patients with pelvic fracture: a retrospective study. Front Med (Lausanne) 2024; 10:1329167. [PMID: 38259838 PMCID: PMC10800860 DOI: 10.3389/fmed.2023.1329167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 12/15/2023] [Indexed: 01/24/2024] Open
Abstract
Background Early use of hemostasis strategies, transcatheter arterial embolization (TAE) is critical in cases of pelvic injury because of the risk of hemorrhagic shock and other fatal injuries. We investigated the influence of delays in TAE administration on mortality. Methods Patients admitted to the Advanced Critical Care Center at Gifu University with pelvic injury between January 2008 and December 2019, and who underwent acute TAE, were retrospectively enrolled. The time from when the doctor decided to administer TAE to the start of TAE (needling time) was defined as "decision-TAE time." Results We included 158 patients, of whom 23 patients died. The median decision-TAE time was 59.5 min. Kaplan-Meier curves for overall survival were compared between patients with decision-TAE time above and below the median cutoff value; survival was significantly better for patients with values below the median cutoff value (p = 0.020). Multivariable Cox proportional hazards regression analysis revealed that the longer the decision-TAE time, the higher the risk of mortality (p = 0.031). TAE duration modified the association between decision-TAE time and overall survival (p = 0.109), as shorter TAE duration (procedure time) was associated with the best survival rate (p for interaction = 0.109). Conclusion Decision-TAE time may play a key role in establishing resuscitation procedures in patients with pelvic fracture, and efforts to shorten this time should be pursued.
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Affiliation(s)
- Yosuke Mizuno
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takahito Miyake
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hideshi Okada
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
- Center for One Medicine Innovative Translational Research, Gifu University Institute for Advanced Study, Gifu, Japan
| | - Takuma Ishihara
- Innovative and Clinical Research Promotion Center, Gifu University, Gifu, Japan
| | - Norihide Kanda
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Masahiro Ichihashi
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Ryo Kamidani
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Tetsuya Fukuta
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takahiro Yoshida
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Shoma Nagata
- Department of Radiology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hiroshi Kawada
- Department of Radiology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Masayuki Matsuo
- Department of Radiology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Shozo Yoshida
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
- Abuse Prevention Center, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Shinji Ogura
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
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Cacciola G, Desi GL, Masse A. An In Vivo Radiologic Description of Periacetabular Vascularization in a Healthy Subject and a Literature Review of its Clinical Implications. THE ARCHIVES OF BONE AND JOINT SURGERY 2024; 12:423-427. [PMID: 38919742 PMCID: PMC11195040 DOI: 10.22038/abjs.2024.75243.3480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 03/26/2024] [Indexed: 06/27/2024]
Abstract
The aim of this study is to provide a radiologic description of periacetabular vascularization. A computed tomography angiography was used to analyze the vascularization patterns of the periacetabular region, describing for the first time "in vivo" the periacetabular branches of the superior and inferior gluteal artery, obturator artery, and of the medial circumflex femoral artery. The analysis revealed the possibility of visualizing clearly all the previously described vessels of the aforementioned arteries. Both acetabular and supra-acetabular arteries, the rami of the OA directed to the lamina quadrilateral, and the rami of the IGA directed to the posterior wall were identified. In conclusion, understanding the periacetabular vascularization patterns is pivotal for effective clinical decision-making in pelvic trauma, and conservative and reconstructive surgery of the hip. The radiologic description provided in this study, along with the associated literature review, offers valuable insights into the clinical implications of periacetabular vascularization.
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Affiliation(s)
- Giorgio Cacciola
- University of Turin Department of Orthopaedic and Traumatology, Italy
| | - Gian Luca Desi
- University of Turin Department of Orthopaedic and Traumatology, Italy
| | - Alessandro Masse
- University of Turin Department of Orthopaedic and Traumatology, Italy
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Kwon H, Jang JH, Moon NH, Rhee SJ, Ryu DY, Ahn TY. Superior gluteal artery injury in pelvic ring injury and acetabular fracture: Single center observational study. J Orthop Sci 2023:S0949-2658(23)00279-8. [PMID: 37867061 DOI: 10.1016/j.jos.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/04/2023] [Accepted: 10/08/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Intrapelvic hemorrhage following pelvic fractures, including pelvic ring and acetabular fractures, originates from the venous system and the fracture. Arterial injury often causes significant bleeding and hemodynamic instability. The superior gluteal artery (SGA) is a frequently injured artery in patients with pelvic fractures. This study investigated the incidence and pattern of SGA injuries associated with pelvic fractures. METHODS We retrospectively reviewed the medical records of patients with pelvic fractures who visited our institution between January 2016 and April 2022. Patients who underwent angiography for suspected arterial injury and SGA embolization were identified. Furthermore, the demographics and patterns of pelvic fractures were evaluated. RESULTS In total, 2042 patients with pelvic fractures visited our trauma emergency department and 498 patients (24.4%) underwent embolization for arterial injuries. Of these, 30 patients (1.5% of the total and 6.0% of the patients who underwent procedures) received embolization therapy of the main trunk of the SGA. The mean age of patients was 51.2 (23-85 years), and the injury mechanisms were all high-energy injuries. There were 19 pelvic ring injuries, eight acetabular fractures, and three combined injuries. Acetabular fractures involved mostly both columns. The three combined injuries were lateral compression involving both columns, vertical shear involving both columns, and lateral compression with T-type fractures. Twelve (40.0%) occurred through the sciatic notch of different patterns. CONCLUSIONS SGA injury occurred in 1.5% of all pelvic fractures and was identified in 6% of patients receiving embolization. SGA injury occurs through various injury mechanisms and fracture patterns, even in the absence of a fracture in the sciatic notch. However, no conclusions could be drawn in this study on the association between SGA injuries, injury mechanisms, and fracture patterns. Since the prediction of SGA injury by fracture pattern is limited, angiography should be performed regardless of fracture pattern when an injury is suspected.
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Affiliation(s)
- Hoon Kwon
- Department of Radiology, Pusan National University Hospital, Busan, Republic of Korea
| | - Jae Hoon Jang
- Department of Orthopaedic Surgery, Bio-medical Research Institute, Trauma Center, Pusan National University Hospital, Busan, Republic of Korea
| | - Nam Hoon Moon
- Department of Orthopaedic Surgery, Bio-medical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Seung Joon Rhee
- Department of Orthopaedic Surgery, Bio-medical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Dong Yeon Ryu
- Department of Trauma and Surgical Critical Care, Trauma Center, Pusan National University Hospital, Busan, Republic of Korea
| | - Tae Young Ahn
- Department of Orthopaedic Surgery, Bio-medical Research Institute, Pusan National University Hospital, Busan, Republic of Korea.
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Eastman JG, Warner SJ, Saiz AM, Bravin DA, Chip Routt ML. Imaging of Pelvic and Acetabular Trauma: Part 2, Soft-Tissue Findings. J Am Acad Orthop Surg 2023; 31:e706-e720. [PMID: 37450836 DOI: 10.5435/jaaos-d-23-00190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/07/2023] [Indexed: 07/18/2023] Open
Abstract
Pelvic ring injuries and acetabular fractures can be complex and challenging to treat. Orthopaedic trauma surgeons scrutinize pelvic radiographs and accompanying CT images for the osseous details that help create a thorough patient-specific preoperative plan. While the osseous details are incredibly important, the surrounding soft-tissue structures are equally as critical and can have a tremendous effect on both the patient and the surgeon. These findings may change surgery timing, dictate the need for additional surgeons or multidisciplinary teams, and determine the treatment sequence. The structures and potential clinical findings reviewed and demonstrated through example images should be sought out during physical examination and correlative preoperative imaging review. Combining all the available osseous and nonosseous information with a detailed approach helps the surgeon predict potential pitfalls and adjust surgical plans before incision. Maximizing the accuracy of the preoperative planning process can streamline treatment algorithm development and ultimately contribute to the best possible clinical patient outcome.
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Affiliation(s)
- Jonathan G Eastman
- From the Department of Orthopaedic Surgery, space (Dr. Eastman, Dr. Warner, Dr. Chip RouttJr.), University of Texas Health Science Center at Houston, McGovern Medical School and Memorial Hermann Medical Center, Houston, TX (Eastman, Warner, and Chip Routt), the Department of Orthopaedic Surgery, University of California, Davis Medical Center, Sacramento, CA (Saiz), and the Department of Orthopaedic Surgery, University of Missouri, Springfield, MO (Bravin)
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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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13
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Kozak T, Burrows S, Song S, Soares J, Blakeney W. Angioembolisation for arterial haemorrhage related to pelvic ring injury. J Med Imaging Radiat Oncol 2023; 67:656-661. [PMID: 37596932 DOI: 10.1111/1754-9485.13571] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 07/31/2023] [Indexed: 08/21/2023]
Abstract
INTRODUCTION Haemorrhage related to pelvic fractures has been associated with mortality rates of up to 50%. Angioembolisation for the management of pelvic haemorrhage was performed as early as 1972; however, there remains uncertainty over its exact use, timing and priority as a component of modern pelvic management protocols. METHODS We retrospectively analysed cases of angioembolisation for arterial haemorrhage related to pelvic ring fractures at a level 1 trauma centre. Patient demographics were assessed as well as the time taken to reach the interventional radiology (IR) suite from the time of trauma and also arriving at the emergency room (ER). Other factors analysed included the volume of blood products consumed and fracture pattern. RESULTS Fifty-four patients received pelvic angiography for pelvic ring injuries between 2006 and 2021. The average age was 45.1 (20.5) years, with the male to female ratio 2.4:1. Forty (74.1%) of these patients had embolisation to actively bleeding pelvic arterial vessels. Median time to the IR was 4.4 [IQR 3.1-8.1] hours from time of trauma and 2.5 [IQR 2.1-4.2] hours from arrival to ER. The overall mortality rate was 18.5% and the median amount of blood transfused was 4584 mL [IQR 1643.5-8026.5]. In the subset of embolised patients (n = 40), mortality rate was 10% and there was an inverse association between time from ER to IR and volume of blood product consumption (P = 0.024). CONCLUSION Angioembolisation is a life-saving intervention in very severely injured patients and is growing in popularity as a component of modern pelvic trauma management protocols.
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Affiliation(s)
- Thomas Kozak
- Royal Perth Hospital, Perth, Western Australia, Australia
| | - Sally Burrows
- Royal Perth Hospital Research Foundation & School of Medicine, Perth, Western Australia, Australia
| | - Swithin Song
- Royal Perth Hospital, Perth, Western Australia, Australia
| | - Julian Soares
- Royal Perth Hospital, Perth, Western Australia, Australia
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14
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Baker H, Erdman MK, Christiano A, Strelzow JA. Team Approach: The Unstable Trauma Patient. JBJS Rev 2023; 11:01874474-202306000-00001. [PMID: 37276267 DOI: 10.2106/jbjs.rvw.22.00226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
» A multidisciplinary, integrated, and synergistic team approach to the unstable polytrauma patient is critical to optimize outcomes, minimize morbidity, and reduce mortality.» The use of Advanced Trauma Life Support protocols helps standardize the assessment and avoid missing critical injuries» Effective and open dialog with consulting specialists is paramount for effective team-based care.» Orthopaedic surgeons should play an important role in the rapid assessment of potentially life-threatening and/or limb-threatening injuries including pelvic ring disruption, open fractures with substantial blood loss, and dysvascular limbs.
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Affiliation(s)
- Hayden Baker
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, Illinois
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15
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Roszman AD, John DQ, Patch DA, Spitler CA, Johnson JP. Management of open pelvic ring injuries. Injury 2023; 54:1041-1046. [PMID: 36792402 DOI: 10.1016/j.injury.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/18/2023] [Accepted: 02/02/2023] [Indexed: 02/17/2023]
Abstract
Open pelvic ring injuries are rare clinical entities that require multidisciplinary care. Due to the scarcity of this injury, there is no well-defined treatment algorithm. As a result, conflicting evidence surrounding various aspects of care including wound management and fecal diversion remain. Previous studies have shown mortality reaching 50% in open pelvic ring injuries, nearly five times higher than closed pelvic ring injuries. Early mortality is due to exsanguinating hemorrhage, while late mortality is due to wound sepsis and multiorgan system failure. With advancements in trauma care and ATLS protocols, there has been an improved survival rate reported in published case series. Major considerations when treating these injuries include aggressive resuscitation with hemorrhage control, diagnosis of associated injuries, prevention of wound sepsis with early surgical management, and definitive skeletal fixation. Classification systems for categorization and management of bony and soft tissue injury related to pelvic ring injuries have been established. Fecal diversion has been proposed to decrease rates of sepsis and late mortality. While clear indications are lacking due to limited studies, previous studies have reported benefits. Further large-scale studies are necessary for adequate evaluation of treatment protocols of open pelvic ring injuries. Understanding the role of fecal diversion, avoidance of primary closure in open pelvic ring injuries, and importance of well-coordinated care amongst surgical teams can optimize patient outcomes.
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Affiliation(s)
- Alexander D Roszman
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Devin Q John
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - David A Patch
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Clay A Spitler
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Joey P Johnson
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States.
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16
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Current Management of Hemodynamically Unstable Patients with Pelvic Fracture. CURRENT SURGERY REPORTS 2023. [DOI: 10.1007/s40137-023-00348-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
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17
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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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18
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Aoki R, Nakajima K, Kobayashi Y, Sakai Y, Kamide H, Yamamoto T, Furugori S, Sawamura S, Terauchi M, Kamiyama K, Ikeda S, Tsuji G, Koyama S, Yoshigi J, Sekikawa Z, Utsunomiya D. Common and uncommon vascular injuries and endovascular treatment associated with pelvic blunt trauma: a real-world experience. Jpn J Radiol 2023; 41:258-265. [PMID: 36350523 PMCID: PMC9974705 DOI: 10.1007/s11604-022-01355-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022]
Abstract
Pelvic fractures are common in cases of blunt trauma, which is strongly associated with mortality. Transcatheter arterial embolization is a fundamental treatment strategy for fatal arterial injuries caused by blunt pelvic trauma. However, vascular injuries due to blunt pelvic trauma can show various imaging findings other than arterial hemorrhage. We present a pictorial review of common and uncommon vascular injuries, including active arterial bleeding, pseudoaneurysm, arteriovenous fistula, arterial occlusion, vasospasm, and active venous bleeding. Knowledge of these vascular injuries can help clinicians select the appropriate therapeutic strategy and thus save lives.
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Affiliation(s)
- Ryo Aoki
- Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan. .,Department of Diagnostic Radiology, Yokohama City University Medical Center, Yokohama, Japan.
| | - Kento Nakajima
- grid.268441.d0000 0001 1033 6139Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yusuke Kobayashi
- grid.413045.70000 0004 0467 212XDepartment of Diagnostic Radiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Yodo Sakai
- grid.417369.e0000 0004 0641 0318Department of Diagnostic Radiology, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Hiroyuki Kamide
- grid.413045.70000 0004 0467 212XDepartment of Diagnostic Radiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Toh Yamamoto
- grid.417369.e0000 0004 0641 0318Department of Diagnostic Radiology, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Shintaro Furugori
- grid.413045.70000 0004 0467 212XAdvanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Shungo Sawamura
- grid.268441.d0000 0001 1033 6139Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Miki Terauchi
- grid.413045.70000 0004 0467 212XDepartment of Diagnostic Radiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Kazutoshi Kamiyama
- grid.268441.d0000 0001 1033 6139Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Shin Ikeda
- grid.417369.e0000 0004 0641 0318Department of Diagnostic Radiology, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Gengo Tsuji
- grid.417369.e0000 0004 0641 0318Department of Diagnostic Radiology, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Shingo Koyama
- grid.268441.d0000 0001 1033 6139Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Jun Yoshigi
- grid.417369.e0000 0004 0641 0318Department of Diagnostic Radiology, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Zenjiro Sekikawa
- grid.413045.70000 0004 0467 212XDepartment of Diagnostic Radiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Daisuke Utsunomiya
- grid.268441.d0000 0001 1033 6139Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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19
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Wagenpfeil J, Kütting D. [Radiological embolization procedures in acute gastrointestinal, peritoneal and muscular hemorrhage]. RADIOLOGIE (HEIDELBERG, GERMANY) 2023; 63:11-17. [PMID: 36355070 DOI: 10.1007/s00117-022-01086-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/18/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Treatment of acute hemorrhage is particularly challenging due to its sudden onset and the fact that it is often life-threatening. Potential causes include bleeding ulcerations of the gastrointestinal tract or tumor bleeding, but acute bleeding can also occur spontaneously or be traumatic, iatrogenic, or inflammatory. OBJECTIVE To demonstrate the basic principles of catheter embolization, as well as various embolic materials and their properties. RESULTS Today there are a wide range of embolization materials available. Ultimately the duration and extent of the desired occlusion are decisive when selecting an embolic material. Mechanical occlusion devices, particulates, and liquid embolic agents are available. CONCLUSION Irrespective of the wide range of different etiologies, radiological embolization therapy is a very safe treatment option in cases of computed tomographic evidence of active hemorrhage. Ultimately, the interventionalist's comprehensive knowledge of the relevant characteristics is crucial for the success of therapy.
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Affiliation(s)
- J Wagenpfeil
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland.
| | - D Kütting
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland.
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20
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Wang B, Liang KW, Chen CH, Wang CK. Transcatheter Arterial Embolization for Alleviating Chronic Musculoskeletal Pain and Improving Physical Function: A Narrative Review. Diagnostics (Basel) 2022; 13:diagnostics13010134. [PMID: 36611426 PMCID: PMC9818587 DOI: 10.3390/diagnostics13010134] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 12/08/2022] [Accepted: 12/27/2022] [Indexed: 01/03/2023] Open
Abstract
Chronic musculoskeletal pain imposes immense suffering and diminishes the quality of life for millions of patients worldwide; the pain persists despite the use of standard conservative treatments. Increases in our understanding of the pathophysiological mechanisms underlying musculoskeletal disorders indicate the involvement of inappropriate angiogenesis. Accordingly, the resulting neovessels are the target of emerging treatments for chronic musculoskeletal pain, including transarterial embolization. The use of this noninvasive procedure to treat pain refractory to standard therapy in a variety of musculoskeletal conditions is the focus of numerous recent investigations. Here, we describe the pathophysiological indications for the use of transarterial embolization and summarize the findings of studies investigating its use in a variety of histopathological conditions and anatomical sites.
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Affiliation(s)
- Bow Wang
- Department of Medical Imaging, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
| | - Keng-Wei Liang
- Department of Medical Imaging, Chung Shan Medical University Hospital, Taichung 402, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
| | - Chia-Hui Chen
- Department of Medical Imaging and Radiological Sciences, I-Shou University, Kaohsiung City 824, Taiwan
- Correspondence: (C.-H.C.); (C.-K.W.); Tel.: +886-76151100 (C.-H.C.); +886-62766108 (C.-K.W.)
| | - Chien-Kuo Wang
- Department of Medical Imaging, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
- Correspondence: (C.-H.C.); (C.-K.W.); Tel.: +886-76151100 (C.-H.C.); +886-62766108 (C.-K.W.)
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21
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Giannoudis PV. Preperitoneal Pelvic Packing for Hypotension: Should There Be a Real Concern for Increased Risk of Venous Thromboembolism?: Commentary on an article by Joseph T. Patterson, MD, et al.: "Preperitoneal Pelvic Packing for Hypotension Has a Greater Risk of Venous Thromboembolism Than Angioembolization. Management of Refractory Hypotension in Closed Pelvic Ring Injury". J Bone Joint Surg Am 2022; 104:e91. [PMID: 36260051 DOI: 10.2106/jbjs.22.00798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Peter V Giannoudis
- Department of Trauma and Orthopaedics, Leeds General Infirmary, University of Leeds, Leeds, United Kingdom.,NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom
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22
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Effect of angioembolization for isolated complex pelvic injury: A post-hoc analysis of a nationwide multicenter trauma database in Japan. Injury 2022; 53:2133-2138. [PMID: 35300867 DOI: 10.1016/j.injury.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 02/06/2022] [Accepted: 03/05/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND IMPORTANCE Complex pelvic injuries are among the types of trauma with the highest mortality. Treatment strategies should be based on the hemodynamic status, the anatomical type of fracture, and the associated injuries. Combination therapies, including preperitoneal pelvic packing, temporary mechanical stabilization, resuscitative endovascular balloon occlusion of the aorta, and angioembolization, are recommended for pelvic injuries. OBJECTIVE To investigate the effect of urgent angioembolization alone on severe pelvic injury-associated mortality. DESIGN, SETTINGS, AND PARTICIPANTS We used the Japan Trauma Data Bank database, a multicenter observational study, to retrospectively identify adult patients with isolated blunt pelvic injuries (Abbreviated Injury Scale [AIS] score: 3-5) from 2004 to 2018. OUTCOME MEASURES AND ANALYSIS The primary outcome measure was in-hospital mortality. We subdivided patients into two groups, those who underwent urgent angioembolization and non-urgent angioembolization, and compared their mortality rates. We performed multiple imputation and multivariable analyzes to compare the mortality rates between groups after adjusting for known potential confounding factors (age, sex, Glasgow Coma Scale score, systolic blood pressure on hospital arrival, Injury Severity Score, pelvic AIS score, laparotomy, resuscitative endovascular balloon occlusion of the aorta, and external fixation) and for within-hospital clustering using the generalized estimating equation. MAIN RESULTS We analyzed 4207 of 345,932 trauma patients, of whom 799 underwent urgent angioembolization. The in-hospital mortality rate was significantly higher in the urgent embolization group than in the non-urgent embolization group (7.4 vs. 4.0%; p < 0.01). However, logistic regression analysis revealed that the mortality rates of patients with urgent angioembolization significantly decreased after adjusting for factors independently associated with mortality (odds ratio: 0.60; 95% confidence interval: 0.37-0.96; p = 0.03). CONCLUSION Urgent angioembolization may be an effective treatment for severe pelvic injury regardless of the pelvic AIS score and the systolic blood pressure on hospital arrival.
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23
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Furugori S, Abe T, Funabiki T, Sekikawa Z, Takeuchi I. Arterial embolization for trauma patients with pelvic fractures in emergency settings: A nationwide matched cohort study in Japan. Eur J Vasc Endovasc Surg 2022; 64:234-242. [DOI: 10.1016/j.ejvs.2022.05.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 05/04/2022] [Accepted: 05/29/2022] [Indexed: 11/03/2022]
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24
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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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25
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Forward D, Vaidya R, Buckley R. To infix or not to infix an unstable pelvic injury. Injury 2022; 53:215-217. [PMID: 34986980 DOI: 10.1016/j.injury.2021.12.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Daren Forward
- Orthopedic Trauma Surgeon, Department of Orthopedic Trauma, Nottingham University Hospitals, Nottingham, UK
| | - Rahul Vaidya
- Chief of Orthopedic Trauma, Detroit Medical Center, Professor of Orthopedics, Wayne State University, 9B University Health Center, Detroit Receiving Hospital, 4201 St. Antoine Boulevard, Detroit, MI, 48201 United States
| | - Richard Buckley
- Professor of Orthopedics, 0490 McCaig Tower, Foothills Medical Center 3134 Hospital Dr NW Calgary, Alberta, T2N 5A1 Canada.
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26
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Vasilopoulou A, Mamalis V, Maris S, Antonogiannakis E, Roupinas I, Angelis S, Kyriakopoulos S, Tsanis A, Apostolopoulos A. IS CT-A ALWAYS RELIABLE IN DETECTING ACTIVE BLEEDING IN CLOSED PELVIC FRACTURES? MANAGEMENT OF A CASE WITH MULTIPLE CLOSED PELVIC FRATURES AND INTERNAL ILIAC ARTERY BLEEDING. J Long Term Eff Med Implants 2022; 32:1-6. [DOI: 10.1615/jlongtermeffmedimplants.2022042027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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27
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Darwis P, Putri RN, Elfizri Z. Transarterial endovascular coil embolization in managing intractable bleeding from fibular artery: A case report. Int J Surg Case Rep 2021; 89:106618. [PMID: 34864266 PMCID: PMC8647001 DOI: 10.1016/j.ijscr.2021.106618] [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] [Received: 10/24/2021] [Revised: 11/15/2021] [Accepted: 11/16/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction Pseudoaneurysms of the fibular artery are rare. Recently, endovascular techniques have been preferred over open surgery. Case presentation A 50-year-old male patient complained of recurrent bleeding from surgical wounds that had been present for one month. The patient sustained an open cruris fracture. No source of active bleeding was found at the time of exploration. The patient has then performed angiography with coiling and showed a pseudoaneurysm originating from the left fibular artery branch. Surgical debridement and external fixation were performed one day after the angiography and embolization procedure. The patient was discharged on the third day, and there has been no recurrent bleeding ever since. Case discussion A pseudoaneurysm can be thought of as one of the intractable bleeding causes. Recently, the endovascular technique has been commonly used as an alternative treatment if we did not find the source of bleeding in exploration. Many kinds of the literature showed the success of using non-surgical management, especially the coil embolization as the patient received. Conclusion In the management of pseudoaneurysm following trauma which cannot be found in open surgery, an endovascular technique like coil embolization can be the alternative method.
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Affiliation(s)
- Patrianef Darwis
- Division of Vascular and Endovascular Surgery, Department of Surgery, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | | | - Zatira Elfizri
- Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
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Renzulli M, Ierardi AM, Brandi N, Battisti S, Giampalma E, Marasco G, Spinelli D, Principi T, Catena F, Khan M, Di Saverio S, Carrafiello G, Golfieri R. Proposal of standardization of every step of angiographic procedure in bleeding patients from pelvic trauma. Eur J Med Res 2021; 26:123. [PMID: 34649598 PMCID: PMC8518287 DOI: 10.1186/s40001-021-00594-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 09/27/2021] [Indexed: 12/02/2022] Open
Abstract
Trauma accounts for a third of the deaths in Western countries, exceeded only by cardiovascular disease and cancer. The high risk of massive bleeding, which depends not only on the type of fractures, but also on the severity of any associated parenchymal injuries, makes pelvic fractures one of the most life-threatening skeletal injuries, with a high mortality rate. Therefore, pelvic trauma represents an important condition to correctly and early recognize, manage, and treat. For this reason, a multidisciplinary approach involving trauma surgeons, orthopedic surgeons, emergency room physicians and interventional radiologists is needed to promptly manage the resuscitation of pelvic trauma patients and ensure the best outcomes, both in terms of time and costs. Over the years, the role of interventional radiology in the management of patient bleeding due to pelvic trauma has been increasing. However, the current guidelines on the management of these patients do not adequately reflect or address the varied nature of injuries faced by the interventional radiologist. In fact, in the therapeutic algorithm of these patients, after the word “ANGIO”, there are no reports on the different possibilities that an interventional radiologist has to face during the procedure. Furthermore, variations exist in the techniques and materials for performing angioembolization in bleeding patients with pelvic trauma. Due to these differences, the outcomes differ among different published series. This article has the aim to review the recent literature on optimal imaging assessment and management of pelvic trauma, defining the role of the interventional radiologist within the multidisciplinary team, suggesting the introduction of common and unequivocal terminology in every step of the angiographic procedure. Moreover, according to these suggestions, the present paper tries to expand the previously drafted algorithm exploring the role of the interventional radiologist in pelvic trauma, especially given the multidisciplinary setting.
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Affiliation(s)
- Matteo Renzulli
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy. .,Radiology Unit, Department of Experimental, Diagnostic and Specialized Medicine, Sant'Orsola Hospital, University of Bologna, Bologna, Italy.
| | - Anna Maria Ierardi
- Radiology Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicolò Brandi
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy.,Radiology Unit, Department of Experimental, Diagnostic and Specialized Medicine, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | | | | | - Giovanni Marasco
- Division of Internal Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italia
| | - Daniele Spinelli
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy.,Radiology Unit, Department of Experimental, Diagnostic and Specialized Medicine, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Tiziana Principi
- Intensive Care Unit and Anesthesia, Emergency Department, ASUR MARCHE AV5, San Benedetto del Tronto, Italy
| | - Fausto Catena
- Department of Emergency and Trauma Surgery, Parma University Hospital, Parma, Italy
| | - Mansoor Khan
- Digestive Diseases Department, Brighton and Sussex University Hospitals, Brighton, UK.,Royal College of Surgeons of England, DSTS Faculty, London, UK
| | - Salomone Di Saverio
- Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Varese, Regione Lombardia, Italy
| | - Giampaolo Carrafiello
- Radiology Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Rita Golfieri
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy.,Radiology Unit, Department of Experimental, Diagnostic and Specialized Medicine, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
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Burgade R, Bisson-Patoue A, Rosset P, Bourdais-Sallot A, Le Nail LR. [Anatomical basis of gluteus maximus and application as a pedicled cover flap for pelvic tumor resections]. ANN CHIR PLAST ESTH 2021; 67:35-41. [PMID: 34625300 DOI: 10.1016/j.anplas.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 09/06/2021] [Indexed: 11/01/2022]
Abstract
OBJECTIVES The resection of malignant bone tumors of the pelvis causes significant loss of substances making covering procedures difficult. The gluteus maximus pedicled flap allows some reconstructions, but its use in vascular sacrifice is not clearly established. The objective of our study was to study its vascularization in order to assess the possibility of vascular sacrifice during carcinological resection of a pelvic tumor. METHOD We first performed a vascular mapping of the gluteus maximus muscle using 3-dimensional (3D) models from CT angiography in patients with Leriche syndrome. These models were compared to a cadaveric dissection of 2 injected muscles. A second 3D modeling from postoperative scans was performed in patients who had a gluteus maximus flap after pelvic carcinological surgery. RESULTS Ten patients with Leriche syndrome had a 3D model from their scanners. Three distinct arterial systems were identified. Seven patients had a flap from the gluteus maximus muscle, including 3 cases of an Inverted pedicled Hemi Gluteus maximus flap (HGI). According to the modeling, the richness of the vascular network would allow the sacrifice of the superior gluteal pedicle without compromising the viability of this flap. CONCLUSION Our study made it possible to confirm the richness of the vascular network of the gluteus maximus muscle and to consider the theoretical possibility of sacrificing the superior gluteal pedicle without endangering an HGI pedicled muscle flap.
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Affiliation(s)
- R Burgade
- Service de chirurgie orthopédique et traumatologique, CHRU de Tours, université François-Rabelais de Tours, Centre-Val de Loire Université, avenue de la république, 37170 Chambray-lès-Tours, France; Inserm U957, faculté de médecine, Laboratoire de physiopathologie de la résorption osseuse et thérapie des tumeurs osseuses primitives (LPRO), université de Nantes, France.
| | - A Bisson-Patoue
- Service de chirurgie plastique, CHU de Tours, université François-Rabelais de Tours, Centre-Val de Loire Université, Tours, France
| | - P Rosset
- Service de chirurgie orthopédique et traumatologique, CHRU de Tours, université François-Rabelais de Tours, Centre-Val de Loire Université, avenue de la république, 37170 Chambray-lès-Tours, France; Inserm U957, faculté de médecine, Laboratoire de physiopathologie de la résorption osseuse et thérapie des tumeurs osseuses primitives (LPRO), université de Nantes, France
| | - A Bourdais-Sallot
- Service de chirurgie plastique, CHU de Tours, université François-Rabelais de Tours, Centre-Val de Loire Université, Tours, France
| | - L R Le Nail
- Service de chirurgie orthopédique et traumatologique, CHRU de Tours, université François-Rabelais de Tours, Centre-Val de Loire Université, avenue de la république, 37170 Chambray-lès-Tours, France; Inserm U957, faculté de médecine, Laboratoire de physiopathologie de la résorption osseuse et thérapie des tumeurs osseuses primitives (LPRO), université de Nantes, France
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Copp J, Eastman JG. Novel resuscitation strategies in patients with a pelvic fracture. Injury 2021; 52:2697-2701. [PMID: 32044116 DOI: 10.1016/j.injury.2020.01.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/23/2020] [Accepted: 01/28/2020] [Indexed: 02/02/2023]
Abstract
Patients with a pelvic ring injury and hemodynamic instability can be challenging to manage with high rates of morbidity and mortality rates. Protocol-based resuscitation strategies are critical to successfully manage these potentially severely injured patients in a well-coordinated manner. While some aspects of treatment may vary slightly from institution to institution, it is critical to identify pelvic injuries and their associated injuries expediently. The first step at the scene of injury or in the trauma resuscitation bay should be the immediate application of a circumferential pelvic sheet or binder, initiation of physiologically optimal fluid resuscitation in the form 1:1:1 (pRBC:FFP:platelets) or whole blood, and to consider TXA as a safe adjunct to treat coagulopathy. Providers should have a very low threshold for emergent operative intervention in the form of pelvic external fixation and/or pelvic packing. This occurs in addition to simultaneous interventions addressing the other possible sources of bleeding in patients demonstrating signs of hemorrhagic shock and failure to respond to early resuscitation and external pelvic tamponade. Finally, while arterial injury is only present in a small percentage of patients with a pelvic ring injury, percutaneous vascular intervention with selective angiography and REBOA have been shown to be efficacious for patients with clinical indicators of arterial injury or who remain hemodynamically unstable despite external pelvic tamponade and packing to address venous bleeding. They should be performed when as early as possible for patients in true extremis limit further hemorrhage and allow resuscitation efforts to continue.
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Affiliation(s)
- Jonathan Copp
- Department of Orthopaedic Surgery, University of California, Davis Medical Center, Sacramento, CA, United States
| | - Jonathan G Eastman
- Department of Orthopaedic Surgery, University of California, Davis Medical Center, Sacramento, CA, United States.
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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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Weir A, Kennedy P, Joyce S, Ryan D, Spence L, McEntee M, Maher M, O'Connor O. Endovascular management of pelvic trauma. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1196. [PMID: 34430637 PMCID: PMC8350659 DOI: 10.21037/atm-20-4591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 12/18/2020] [Indexed: 11/06/2022]
Abstract
Traumatic pelvic injuries are an important group of acquired pathologies given their frequent association with significant vascular compromise. Potentially fatal as a consequence of rapid hemorrhage, achievement of early hemostasis is a priority; endovascular management of traumatic pelvic arterial injuries is an important potential option for treatment. Precipitated by any number of mechanisms of trauma, pelvic vascular injury necessitates timely patient assessment. Variable patterns of arterial injury may result from blunt, penetrating or iatrogenic trauma. Selection of the most appropriate imaging modality is a priority, ensuring streamlined access to treatment. In the case of CT, this is complemented by acquisition of the most appropriate phase of imaging; review of both arterial and delayed phase imaging improves the accuracy of detection of low-flow hemorrhage. In cases where surgical intervention is not deemed appropriate, endovascular treatment provides an alternative means for cessation of hemorrhage associated with pelvic injuries. This may be achieved in a selective or nonselective manner depending on the patient's clinical status and time constraints. Consequently, a detailed understanding of vascular anatomy is essential, including an appreciation of the normal variant anatomy between males and females. Additional consideration must be given to variant anatomy which may co-exist in both sexes. This review article aims to provide a synopsis of endovascular management of pelvic vascular injury. Through case examples, available treatment options will be discussed, including thrombin injection and transcatheter arterial embolization. Furthermore, potential adverse complications of pelvic arterial embolization will be highlighted. Finally, in view of the potential severity of these injuries, a brief overview of initial management of the hemodynamically unstable patient is provided.
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Affiliation(s)
- Arlene Weir
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland.,Department of Radiology, Mercy University Hospital, Grenville Place, Cork, Ireland
| | - Padraic Kennedy
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland.,Department of Radiology, Mercy University Hospital, Grenville Place, Cork, Ireland
| | - Stella Joyce
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland.,Department of Radiology, Mercy University Hospital, Grenville Place, Cork, Ireland.,School of Medicine, University College Cork, Cork, Ireland
| | - David Ryan
- School of Medicine, University College Cork, Cork, Ireland
| | - Liam Spence
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland
| | - Mark McEntee
- School of Medicine, University College Cork, Cork, Ireland
| | - Michael Maher
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland.,Department of Radiology, Mercy University Hospital, Grenville Place, Cork, Ireland.,School of Medicine, University College Cork, Cork, Ireland
| | - Owen O'Connor
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland.,Department of Radiology, Mercy University Hospital, Grenville Place, Cork, Ireland.,School of Medicine, University College Cork, Cork, Ireland
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Kazley JM, Potenza MA, Marthy AG, Arain AR, O'Connor CM, Czajka CM. Team Approach: Evaluation and Management of Pelvic Ring Injuries. JBJS Rev 2021; 8:e0149. [PMID: 33006457 DOI: 10.2106/jbjs.rvw.19.00149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
A multidisciplinary approach to the management of pelvic ring injuries has been shown to decrease mortality rates. The primary goals within the emergency room are to assess, resuscitate, and stabilize the patient. The Advanced Trauma Life Support protocol guides the initial assessment of the patient. A pelvic binder or sheet should be applied to help to provide reduction of the fracture and temporary stabilization. The trauma team becomes the primary service for the patient as he or she transitions away from the emergency department. The trauma team must effectively communicate with and serve as the liaison between other specialists as injuries are identified. emodynamic stability should be closely monitored in patients with pelvic ring injuries, involving the assessment of vital signs, imaging findings, and clinical judgment. Angioembolization and peritoneal packing may play a role in helping to control hemorrhage. Urologists should be consulted if a Foley catheter cannot be passed or there is concern for urethral or bladder injury. Further imaging or urologic intervention may be necessary. Orthopaedic surgeons can help to assess the patient, classify the injury, and assist in temporary stabilization while planning definitive fixation.
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Affiliation(s)
- Jillian M Kazley
- 1Divisions of Orthopaedic Surgery (J.M.K., A.R.A., C.M.O., and C.M.C.), Emergency Medicine (M.A.P.), and General Surgery (A.G.M.), Albany Medical Center, Albany, New York
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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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Al-Thani H, Abdelrahman H, Barah A, Asim M, El-Menyar A. Utility of Angioembolization in Patients with Abdominal and Pelvic Traumatic Bleeding: Descriptive Observational Analysis from a Level 1 Trauma Center. Ther Clin Risk Manag 2021; 17:333-343. [PMID: 33907407 PMCID: PMC8064722 DOI: 10.2147/tcrm.s303518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 03/29/2021] [Indexed: 12/03/2022] Open
Abstract
Background Massive bleeding is a major preventable cause of early death in trauma. It often requires surgical and/or endovascular intervention. We aimed to describe the utilization of angioembolization in patients with abdominal and pelvic traumatic bleeding at a level 1 trauma center. Methods We conducted a retrospective analysis for all trauma patients who underwent angioembolization post-traumatic bleeding between January 2012 and April 2018. Patients’ data and details of injuries, angiography procedures and outcomes were extracted from the Qatar national trauma registry. Results A total of 175 trauma patients underwent angioembolization during the study period (103 for solid organ injury, 51 for pelvic injury and 21 for other injuries). The majority were young males. The main cause of injury was blunt trauma in 95.4% of the patients. The most common indication of angioembolization was evident active bleeding on the initial CT scan (contrast pool or blushes). Blood transfusion was needed in two-third of patients. The hepatic injury cases had higher ISS, higher shock index and more blood transfusion. Absorbable particles (Gelfoam) were the most commonly used embolic material. The overall technical and clinical success rate was 93.7% and 95%, respectively, with low rebleeding and complication rates. The hospital and ICU length of stay were 13 and 6 days, respectively. The median injury to intervention time was 320 min while hospital arrival to intervention time was 274 min. The median follow-up time was 215 days. The overall cohort mortality was 15%. Conclusion Angioembolization is an effective intervention to stop bleeding and support nonoperative management for both solid organ injuries and pelvic trauma. It has a high success rate with a careful selection and proper implementation.
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Affiliation(s)
- Hassan Al-Thani
- Department of Surgery, Trauma&Vascular Surgery, Hamad General Hospital, Doha, Qatar
| | - Husham Abdelrahman
- Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar
| | - Ali Barah
- Department of Radiology, Hamad General Hospital, Doha, Qatar
| | - Mohammad Asim
- Department of Surgery, Clinical Research, Trauma & Vascular Surgery, Hamad General Hospital, Doha, Qatar
| | - Ayman El-Menyar
- Department of Surgery, Clinical Research, Trauma & Vascular Surgery, Hamad General Hospital, Doha, Qatar.,Department of Clinical Medicine, Weill Cornell Medical School, Doha, Qatar
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Angiography in patients with pelvic fractures and contrast extravasation on CT following high-energy trauma. Eur J Trauma Emerg Surg 2021; 48:1939-1944. [PMID: 33665753 DOI: 10.1007/s00068-021-01628-w] [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: 12/20/2020] [Accepted: 02/21/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Pelvic fracture may be accompanied by severe bleeding. Computed tomography (CT) is a gold standard diagnostic tool in stable trauma patients. Contrast extravasation detected on CT of pelvis is a sign of hemorrhage, but its significance is not clear. We aimed to evaluate the need for angiography in patients with pelvic fracture and CT revealed contrast extravasation. We tried to identify parameters that might help to choose patients who will benefit from therapeutic angiography. METHODS Electronic medical records of patients with pelvic fracture admitted to Level II Trauma Center during 10 years were retrospectively reviewed. Patients who had contrast extravasation on CT were included. Data base consisted of demographics, injury severity, initial physiologic parameters, laboratory data, results of CT and angiography. RESULTS Forty out of 396 patients had contrast extravasation detected by CT. Twelve patients underwent angiography and 4 of them benefited from embolization. The sensitivity of contrast extravasation in evaluating the need for embolization was 1.0 (95% CI 0.398, 1.0), positive predictive value was 0.1 (95% CI 0.028, 0.237), and the negative predictive value was 1.0 (95% CI 0.990, 1.0). CONCLUSION The role of angiography in stable patients with pelvic fracture and CT identified contrast extravasation remains questionable. Most of these patients are not in need of angioembolization.
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Dilogo IH, Prabowo I. The role of angioembolization and C-clamp fixation: Damaged control orthopaedic in haemodynamically unstable pelvic fracture. Ann Med Surg (Lond) 2021; 63:102157. [PMID: 33664945 PMCID: PMC7903064 DOI: 10.1016/j.amsu.2021.02.003] [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] [Received: 11/27/2020] [Revised: 01/31/2021] [Accepted: 02/02/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Unstable pelvic fracture may emerge to major bleeding complication. Angioembolization is one of method to stop the bleeding effectively. This case series aims to analyze whether the bleeding of unstable pelvic fracture is managed by angioembolization to achieve the better functional outcome. PRESENTATION OF CASE Three cases of haemodynamically unstable pelvic fracture were studied retrospectively and prospectively. A staged approach using damage control orthopaedic surgery was performed. Initial resuscitation began from fluid resuscitation, pelvic wrapping using binder. All patients followed with pelvic external fixation, while 2 patients immediately replaced binder to C-Clamp, and 1 patient with anterior frame. Angioembolization was done to all patients. All patients required definitive internal fixation, while only 2 patients reach the definitive surgery. Finally, we measured the functional outcome of all patients using Hannover Pelvic score, Majeed pelvic score, and Iowa Pelvic score. DISCUSSION We review some literatures regarding pelvic angioembolization. The previous study suggested to resuscitate patients when the hemodynamic is unstable, the angioembolization procedure is still preferred. The indication and successful definition of this procedure is still unclear, yet it shows decrease of mortality rate of pelvic injury if this procedure starts ahead a schedule. CONCLUSION Angioembolization as a part of damaged control orthopaedic has been shown a favorable result in managing unstable pelvic injury.
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Affiliation(s)
- Ismail Hadisoebroto Dilogo
- Department of Orthopaedic and Traumatology, Faculty of Medicine Universitas Indonesia, Dr Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Ido Prabowo
- Resident of Department of Orthopaedic and Traumatology, Faculty of Medicine Universitas Indonesia, Dr Cipto Mangunkusumo Hospital, Jakarta, Indonesia
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Luckhurst CM, Mendoza AE. The Current Role of Interventional Radiology in the Management of Acute Trauma Patient. Semin Intervent Radiol 2021; 38:34-39. [PMID: 33883799 PMCID: PMC8049765 DOI: 10.1055/s-0041-1725113] [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
Trauma is one of the most common causes of death, particularly in younger individuals. The development of specialized trauma centers, trauma-specific intensive care units, and trauma-focused medical subspecialties has led to the formation of comprehensive multidisciplinary teams and an ever-growing body of research and innovation. The field of interventional radiology provides a unique set of minimally invasive, endovascular techniques that has largely changed the way that many trauma patients are managed. This article discusses the role of interventional radiology in the care of this complex patient population, and in particular how the specialty fits into the overall team management of these patients.
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Affiliation(s)
- Casey M. Luckhurst
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - April E. Mendoza
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
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Bernhard Z, Myers D, Passias BJ, Taylor BC, Castaneda J. Testicular Dislocation After Unstable Pelvic Ring Injury. Cureus 2021; 13:e13119. [PMID: 33728137 PMCID: PMC7935200 DOI: 10.7759/cureus.13119] [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: 11/17/2022] Open
Abstract
Reproductive and genitourinary complications following pelvic ring injuries have been described; however, testicular dislocation is rare and can cause significant morbidity if not managed appropriately. We describe a case of testicular dislocation after pelvic ring injury and outline the subsequent management and outcome, and seek to identify areas of improvement to ensure expedient and appropriate care in the setting of these injuries. Our case describes a 29-year-old male who presented to a level-one trauma center following a motorcycle collision. An anteroposterior compression type II rotationally unstable pelvic ring was identified on imaging. He was hemodynamically unstable and computed tomography (CT) with angiography was ordered. Arterial extravasation was noted from the bilateral anterior internal iliac arteries, which were subsequently embolized by interventional radiology. However, no concomitant genitourinary injury was identified at the time of CT. After resuscitation, the pelvis was stabilized with an anterior symphyseal plate and bilateral sacroiliac screws. During the anterior pelvic approach, the patient’s dislocated testicle was surprisingly discovered inferior to the pubis. Urology was consulted intra-operatively, and the testicle was successfully relocated. At the final follow-up, the pelvic ring was healed without any noticeable urogenital complication. While testicular dislocation has been reported in the setting of pelvic ring injury, a paucity of information exists regarding management, implications, and areas for improvement in the identification of these injuries. Therefore, in cases of pelvic ring injury with significant trauma, radiologists, traumatologists, and orthopedic surgeons should adopt a multi-disciplinary approach in diligently attempting to rule out testicular dislocation pre-operatively. Intra-operatively, examination under anesthesia and careful operative technique are important in preventing iatrogenic injury.
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Affiliation(s)
- Zachary Bernhard
- Medical Education, West Virginia School of Osteopathic Medicine, Lewisburg, USA
| | - Devon Myers
- Orthopedic Surgery, OhioHealth, Columbus, USA
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Relationship between door-to-embolization time and clinical outcomes after transarterial embolization in trauma patients with complex pelvic fracture. Eur J Trauma Emerg Surg 2021; 48:1929-1938. [PMID: 33523237 PMCID: PMC9192384 DOI: 10.1007/s00068-021-01601-7] [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] [Received: 06/03/2020] [Accepted: 01/02/2021] [Indexed: 11/05/2022]
Abstract
Background While transarterial embolization (TAE) is an effective way to control arterial bleeding associated with pelvic fracture, the clinical outcomes according to door-to-embolization (DTE) time are unclear. This study investigated how DTE time affects outcomes in patients with severe pelvic fracture. Methods Using a trauma database between November 1, 2015 and December 31, 2019, trauma patients undergoing TAE were retrospectively reviewed. The final study population included 192 patients treated with TAE. The relationships between DTE time and patients’ outcomes were evaluated. Multiple binomial logistic regression analyses, multiple linear regression analyses, and Cox hazard proportional regression analyses were performed to estimate the impacts of DTE time on clinical outcomes. Results The median DTE time was 150 min (interquartile range, 121–184). The mortality rates in the first 24 h and overall were 3.7% and 14.6%, respectively. DTE time served as an independent risk factor for mortality in the first 24 h (adjusted odds ratio = 2.00, 95% confidence interval [CI] = 1.20–3.34, p = 0.008). In Cox proportional hazards regression analyses, the adjusted hazard ratio of DTE time for mortality at 28 days was 1.24 (95% CI = 1.04–1.47, p = 0.014). In addition, there was a positive relationship between DTE time and requirement for packed red blood cell transfusion during the initial 24 h and a negative relationship between DTE time and ICU-free days to day 28. Conclusion Shorter DTE time was associated with better survival in the first 24 h, as well as other clinical outcomes, in patients with complex pelvic fracture who underwent TAE. Efforts to minimize DTE time are recommended to improve the clinical outcomes in patients with pelvic fracture treated with TAE. Supplementary Information The online version contains supplementary material available at 10.1007/s00068-021-01601-7.
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Cho HS, Kim Y, Lee J, Yi KS, Choi CH. Use of N-butyl cyanoacrylate in the successful transcatheter arterial embolization of an arteriovenous fistula caused by blunt pelvic fracture: A case report and review of literature. Medicine (Baltimore) 2021; 100:e24215. [PMID: 33429814 PMCID: PMC7793380 DOI: 10.1097/md.0000000000024215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 12/16/2020] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Traumatic arteriovenous fistulas (AVFs) of the pelvis are uncommon and present with a variety of clinical manifestations; their detection may be difficult. An endovascular approach is usually the first choice of treatment, because surgical intervention is complicated due to the location of the lesions. PATIENT CONCERNS A 68-year-old man was admitted with severe pelvic pain following a fall. DIAGNOSIS A pelvic bone fracture (Young and Burgess Classification, lateral compression type II) was revealed on pelvic computed tomography (CT), while a pelvic sidewall hematoma, unaccompanied by any vascular injury, was detected on multidetector CT. INTERVENTIONS Pelvic angiography revealed an AVF between the internal iliac artery and vein, which was undetected by MDCT. The AVF was successfully treated using transcatheter arterial embolization (TAE) with n-butyl cyanoacrylate (NBCA). OUTCOMES The patient recovered well and was discharged 4 weeks later. No complications were noted at the 8-month follow-up. LESSONS AVF may occur as a complication of blunt pelvic bone fracture. A high index of suspicion, angiography, and prompt diagnosis resulted in the successful management of our patient who presented with risk factors. Furthermore, TAE using NBCA enables a minimally invasive and effective treatment of traumatic pelvic AVF.
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Perumal R, S DCR, P SS, Jayaramaraju D, Sen RK, Trikha V. Management of pelvic injuries in hemodynamically unstable polytrauma patients - Challenges and current updates. J Clin Orthop Trauma 2021; 12:101-112. [PMID: 33716435 PMCID: PMC7920327 DOI: 10.1016/j.jcot.2020.09.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/26/2020] [Accepted: 09/28/2020] [Indexed: 12/30/2022] Open
Abstract
Pelvic injuries are notorious for causing rapid exsanguination, and also due to concomitant injuries and complications, they have a relatively higher mortality rate. Management of pelvic fractures in hemodynamically unstable patients is a challenging task and has been variably approached. Over the years, various concepts have evolved, and different guidelines and protocols were established in regional trauma care centers based mainly on their previous experience, outcomes, and availability of resources. More recently, damage control resuscitation, pelvic angioembolization, and acute definitive internal fixation are being employed in the management of these unstable injuries, without clear consensus or guidelines. In this background, we have performed a computerized search using the Cochrane Database of Systematic Reviews, Scopus, Embase, Web of Science, and PubMed databases on studies published over the past 30 years. This comprehensive review aims to consolidate available literature on the current epidemiology, diagnostics, resuscitation, and management options of pelvic fractures in polytraumatized patients with hemodynamic instability with particular focus on damage control resuscitation, pelvic angioembolization, and acute definitive internal fixation.
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Affiliation(s)
- Ramesh Perumal
- Department of Orthopedics and Trauma, Ganga Hospital, Coimbatore, 641043, India
| | | | - Sivakumar S. P
- Department of Orthopedics and Trauma, Ganga Hospital, Coimbatore, 641043, India
| | | | - Ramesh Kumar Sen
- Institute of Orthopedic Surgery, Max Super Specialty Hospital, Mohali, 160055, India
| | - Vivek Trikha
- Department of Orthopedics, All India Institute of Medical Science, New Delhi, 110029, India
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Lustenberger T, Störmann P, Eichler K, Nau C, Janko M, Marzi I. Secondary Angio-Embolization After Emergent Pelvic Stabilization and Pelvic Packing Is a Safe Option for Patients With Persistent Hemorrhage From Unstable Pelvic Ring Injuries. Front Surg 2020; 7:601140. [PMID: 33392246 PMCID: PMC7773821 DOI: 10.3389/fsurg.2020.601140] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/30/2020] [Indexed: 12/30/2022] Open
Abstract
Introduction: In patients with severe pelvic ring injuries, exsanguination still is the leading cause of death in the early post-injury phase. While mechanical pelvic ring stabilization and pre-peritoneal pelvic packing are mainly addressing venous bleeding, angio-embolization aims to control arterial bleeding. The goal of the present study was to evaluate the rate of postoperative angio-embolization after mechanical pelvic ring injury stabilization and pre-peritoneal pelvic packing. Bleeding sources detected in the angiography and the patient's outcome were investigated. Patients and Methods: Retrospective observational cohort study at a single academic level I trauma center, reviewing all patients with pelvic ring injuries admitted from 01/2010 to 12/2019. Patients with emergent mechanical pelvic ring stabilization (supraacetabular external fixator and/or pelvic C-clamp) and direct pre-peritoneal pelvic packing were further analyzed. Patients that underwent postoperative angio-embolization were compared with those that did not. All postoperative angio-embolizations were evaluated with regards to bleeding sources and type of embolization. Results: During the study period, a total of 39 patients required immediate mechanical pelvic stabilization and direct pre-peritoneal pelvic packing. Of these, 12 patients (30.8%) underwent a postoperative angio-embolization. The following vessels were identified as bleeding sources: superior gluteal artery (n = 6), obturator artery (n = 2), internal pudendal artery (n = 2), unnamed branches of the internal iliac artery (n = 3). A selective embolization was successful in 11 patients; in 1 patient, an unilateral complete occlusion of the internal iliac artery was performed to control the bleeding. Mean time from hospital admission to the surgical procedure was 52.8 ± 14.7 min and the mean time from admission to angio-embolization was 189.1 ± 55.5 min. The in-hospital mortality rate of patients with angio-embolization was 25.0% (n = 3). Of these, 2 patients died due to multiple organ failure and 1 patient due to severe head injury. Conclusion: Secondary angio-embolization after external pelvic fixation and pre-peritoneal pelvic packing was effective in controlling ongoing bleeding. The most frequently detected bleeding vessel was the superior gluteal artery, which is difficult to surgically address, further highlighting the importance of angio-embolization in the management algorithm.
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Affiliation(s)
- Thomas Lustenberger
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt am Main, Frankfurt, Germany
| | - Philipp Störmann
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt am Main, Frankfurt, Germany
| | - Kathrin Eichler
- Institute for Diagnostic and Interventional Radiology, Hospital of the Goethe University Frankfurt am Main, Frankfurt, Germany
| | - Christoph Nau
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt am Main, Frankfurt, Germany
| | - Maren Janko
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt am Main, Frankfurt, Germany
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt am Main, Frankfurt, Germany
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Marmor M, El Naga AN, Barker J, Matz J, Stergiadou S, Miclau T. Management of Pelvic Ring Injury Patients With Hemodynamic Instability. Front Surg 2020; 7:588845. [PMID: 33282907 PMCID: PMC7688898 DOI: 10.3389/fsurg.2020.588845] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 10/12/2020] [Indexed: 12/28/2022] Open
Abstract
Pelvic ring injuries (PRI) are among the most difficult injuries to deal with in orthopedic trauma. When these injuries are accompanied by hemodynamic instability their management becomes significantly more complex. A methodical assessment and expeditious triage are required for these patients followed by adequate resuscitation. A major triage decision is whether these patients should undergo arterial embolization in the angiography suit or prompt packing and pelvic stabilization in the operating room. Patient characteristics, fracture type and injury characteristics are taken into consideration in the decision-making process. In this review we discuss the acute evaluation, triage and management of PRIs associated with hemodynamic instability. An evidence based and protocol driven approach is necessary in order to achieve optimal outcomes in these patients.
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Affiliation(s)
- Meir Marmor
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Ashraf N El Naga
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Jordan Barker
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Jacob Matz
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, CA, United States
| | | | - Theodore Miclau
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, CA, United States
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Abstract
EPIDEMIOLOGY Traumatic fractures of the pelvic ring are relatively rare, but are associated with increased risk of mortality. Depending on injury mechanism and main vector of energy impact, a distinction is made between anteroposterior compression, lateral compression, and vertical shear (Young and Burgess classification), while the stability-related classification according to Tile distinguishes between type A (stable), type B (rotationally unstable) and type C (completely unstable). A comprehensive modern classification is given by the AO/OTA. RADIOLOGICAL FRACTURE DIAGNOSIS Plain pelvis x‑rays lack sufficient sensitivity but are still used to detect highly unstable pelvic fractures. CT has superior sensitivity and specificity. In addition to fracture classification, CT allows reliable assessment of associated vascular and bladder/urethral injuries and large soft tissue hemorrhage. MRI is unparalleled in showing bone marrow edema, cauda and plexus complications, and peripelvic soft tissue damage. MRI may also prove to be a valuable diagnostic tool for pelvic ring injuries in children, adolescents and young women, provided they are hemodynamically stable. Angiography, ultrasonography and bone scintigraphy are additional important diagnostic and therapeutic options. PRACTICAL RECOMMENDATIONS Knowledge of basic pelvic trauma mechanisms is important to understand the potential severity of traumatic pelvic fractures and to classify them correctly in terms of stability. Being familiar with typical concomitant injuries in pelvic ring fractures allows reliable diagnosis and their communication with the clinician. CT remains the "diagnostic workhorse". In fragile pelvic fractures, the often prolonged course with fracture progression must be taken into account, which is why MRI is of particular importance herein.
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Affiliation(s)
- Thomas Grieser
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
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Raniga SB, Mittal AK, Bernstein M, Skalski MR, Al-Hadidi AM. Multidetector CT in Vascular Injuries Resulting from Pelvic Fractures: A Primer for Diagnostic Radiologists. Radiographics 2020; 39:2111-2129. [PMID: 31697619 DOI: 10.1148/rg.2019190062] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pelvic vascular injuries are typically caused by high-energy trauma. The majority of these injuries are caused by motor vehicle collisions, and the rest are caused by falls and industrial or crush injuries. Pelvic vascular injuries are frequently associated with pelvic ring disruption and have a high mortality rate due to shock as a result of pelvic bleeding. Morbidity and mortality resulting from pelvic vascular injury are due to pelvic hemorrhage and resultant exsanguination, which is potentially treatable and reversible if it is diagnosed early with multidetector CT and treated promptly. The pelvic bleeding source can be arterial, venous, or osseous, and differentiating an arterial (high-pressure) bleed from a venous-osseous (low-pressure) bleed is of paramount importance in stratification for treatment. Low-pressure venous and osseous bleeds are initially treated with a pelvic binder or external fixation, while high-pressure arterial bleeds require angioembolization or surgical pelvic packing. Definitive treatment of the pelvic ring disruption includes open or closed reduction and internal fixation. Multidetector CT is important in the trauma setting to assess and characterize pelvic vascular injuries with multiphasic acquisition in the arterial and venous phases, which allows differentiation of the common vascular injury patterns. This article reviews the anatomy of the pelvic vessels and the pelvic vascular territory; discusses the multidetector CT protocols used in diagnosis and characterization of pelvic vascular injury; and describes the spectrum of pelvic vascular injuries, the differentiation of common injury patterns, mimics, and imaging pitfalls. Online supplemental material is available for this article. ©RSNA, 2019 See discussion on this article by Dreizin.
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Affiliation(s)
- Sameer B Raniga
- From the Departments of Radiology and Molecular Imaging, Sultan Qaboos University Hospital, Muscat, PO Box 38, PC 123, Al Khoud, Oman (S.B.R., A.K.M.); Department of Radiology, New York University Langone Health Medical Centers/Bellevue Hospital, New York, NY (M.B.); Department of Radiology, Palmer College of Chiropractic West, San Jose, Calif (M.R.S.); and Department of Radiology, Royal Hospital, Ministry of Health, Muscat, Oman (A.M.A.)
| | - Alok K Mittal
- From the Departments of Radiology and Molecular Imaging, Sultan Qaboos University Hospital, Muscat, PO Box 38, PC 123, Al Khoud, Oman (S.B.R., A.K.M.); Department of Radiology, New York University Langone Health Medical Centers/Bellevue Hospital, New York, NY (M.B.); Department of Radiology, Palmer College of Chiropractic West, San Jose, Calif (M.R.S.); and Department of Radiology, Royal Hospital, Ministry of Health, Muscat, Oman (A.M.A.)
| | - Mark Bernstein
- From the Departments of Radiology and Molecular Imaging, Sultan Qaboos University Hospital, Muscat, PO Box 38, PC 123, Al Khoud, Oman (S.B.R., A.K.M.); Department of Radiology, New York University Langone Health Medical Centers/Bellevue Hospital, New York, NY (M.B.); Department of Radiology, Palmer College of Chiropractic West, San Jose, Calif (M.R.S.); and Department of Radiology, Royal Hospital, Ministry of Health, Muscat, Oman (A.M.A.)
| | - Matthew R Skalski
- From the Departments of Radiology and Molecular Imaging, Sultan Qaboos University Hospital, Muscat, PO Box 38, PC 123, Al Khoud, Oman (S.B.R., A.K.M.); Department of Radiology, New York University Langone Health Medical Centers/Bellevue Hospital, New York, NY (M.B.); Department of Radiology, Palmer College of Chiropractic West, San Jose, Calif (M.R.S.); and Department of Radiology, Royal Hospital, Ministry of Health, Muscat, Oman (A.M.A.)
| | - Aymen M Al-Hadidi
- From the Departments of Radiology and Molecular Imaging, Sultan Qaboos University Hospital, Muscat, PO Box 38, PC 123, Al Khoud, Oman (S.B.R., A.K.M.); Department of Radiology, New York University Langone Health Medical Centers/Bellevue Hospital, New York, NY (M.B.); Department of Radiology, Palmer College of Chiropractic West, San Jose, Calif (M.R.S.); and Department of Radiology, Royal Hospital, Ministry of Health, Muscat, Oman (A.M.A.)
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Boonsinsukh T, Maroongroge P. Effectiveness of transcatheter arterial embolization for patients with shock from abdominopelvic trauma: A retrospective cohort study. Ann Med Surg (Lond) 2020; 55:97-100. [PMID: 32477504 PMCID: PMC7248579 DOI: 10.1016/j.amsu.2020.04.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 04/23/2020] [Accepted: 04/28/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Transcatheter arterial embolization (TAE) is a useful endovascular technique for controlling hemorrhage in blunt abdominopelvic trauma without shock. However, several studies have reported that TAE is safe and effective for controlling hemorrhage in hypovolemic shock. OBJECTIVE To evaluate the effectiveness of TAE for patients with shock from abdominopelvic trauma. METHOD The medical records of patients with abdominopelvic trauma at Her Royal Highness Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot University from January 2014 to January 2019 were retrospectively reviewed. We enrolled patients with shock caused by injury to solid organs or pelvic fractures who underwent TAE. RESULT Of the 320 patients, 14 patients with shock underwent TAE. A total of 78.6% were male. The mean age was 37.5 years. The average injury severity score was 31.3. The most common mechanism of injury was traffic accidents (85.7%). Embolization was performed for 8 liver injuries, 5 pelvic fractures and 1 splenic injury. The treatment time for TAE was approximately 47.9 ± 33.2 min. The mean length of hospital stay was 21.3 ± 15.9 days. Two patients died (14.3%). There were no embolization-related complications. A significant improvement in systolic blood pressure (p = 0.028) and a decrease in heart rate (p = 0.001), lactate concentration (p = 0.011), and crystalloid fluid (p = 0.001) and blood transfusion requirements (p = 0.002) were observed after TAE. CONCLUSIONS TAE is a safe and effective method for treating shock patients with a rapid or transient response to resuscitation. For patients who are nonresponsive to resuscitation, TAE is an additional useful option for arterial hemorrhage control in abdominopelvic trauma.
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Affiliation(s)
- Thana Boonsinsukh
- Department of Surgery, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhon Nayok, 26120, Thailand
| | - Panitpong Maroongroge
- Department of Radiology, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhon Nayok, 26120, Thailand
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Qiu S, Wei X, Hu H, Zhao X, Wen X, Zhong LM. Superselective Arterial Embolization of Arteriovenous Malformation of Internal Pudendal Artery, a Rare Cause of Hematuria: A Case Report. Am J Mens Health 2020; 14:1557988320923913. [PMID: 32865100 PMCID: PMC7466900 DOI: 10.1177/1557988320923913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Arteriovenous malformation (AVM) is a common form of vascular malformation, an abnormal direct communication between an artery and a vein without passing through the capillaries. AVM may just present as hematuria without plain or other symptoms. The article presents a case of a 52-year-old male with gross hematuria diagnosed as AVM of internal pudendal artery, which was successfully managed with superselective arterial embolization using temporary embolization materials.
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Affiliation(s)
- Shixiang Qiu
- School of Medical Imaging, North Sichuan Medical College, Nanchong, Sichuan Province, P.R. China
| | - Xin Wei
- Department of Interventional Radiology, Central Hospital of Nanchong, The Second Clinical School of North Sichuan Medical College, Nanchong, Sichuan Province, P.R. China
| | - Hong Hu
- Department of Interventional Radiology, Central Hospital of Nanchong, The Second Clinical School of North Sichuan Medical College, Nanchong, Sichuan Province, P.R. China
| | - Xiaowei Zhao
- Department of Interventional Radiology, Central Hospital of Nanchong, The Second Clinical School of North Sichuan Medical College, Nanchong, Sichuan Province, P.R. China
| | - Xiaoxia Wen
- Department of Interventional Radiology, Central Hospital of Nanchong, The Second Clinical School of North Sichuan Medical College, Nanchong, Sichuan Province, P.R. China
| | - Li-Ming Zhong
- Department of Interventional Radiology, Central Hospital of Nanchong, The Second Clinical School of North Sichuan Medical College, Nanchong, Sichuan Province, P.R. China
- Li-Ming Zhong, Professor, Chief Physician, Department of Interventional Radiology, Central Hospital of Nanchong, The Second Clinical School of North Sichuan Medical College, 97 Renmin South Road, Central Hospital of Nanchong, Nanchong, Sichuan Province 637000, P.R. China.
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Yang Q, Wang T, Ai L, Jiang K, Tao X, Gong D, Chen N, Fu Y, Pan F. Clinical outcomes of blood transfusion to patients with pelvic fracture in the initial 6 h from injury. Exp Ther Med 2020; 19:2252-2258. [PMID: 32104291 PMCID: PMC7027319 DOI: 10.3892/etm.2020.8445] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 12/02/2019] [Indexed: 11/06/2022] Open
Abstract
As part of the treatment of pelvic fracture, major hemorrhage poses a challenge for trauma surgeons. The aim of the present study was to evaluate the clinical outcomes of blood transfusion in the initial 6 h after pelvic fracture, and to define the blood transfusion volume required for each pelvic fracture type. A retrospective cohort study was performed on patients with pelvic fracture at a single Level I Trauma Centre over a 3-year period. A total of 1,297 patients were transported to our trauma centre within 2 h of injury and blood transfusion was administered in the initial 6 h after pelvic fracture. Review of the patients' medical records provided the initial pelvic radiographs and data from emergency department care. Clinical outcomes, including frequency of blood transfusion, blood transfusion volume, injury severity scores and mortality, were evaluated. All pelvic fractures were defined as closed fractures and patients were categorized according to the Arbeit fuer Osteosynthese (AO) classification system. Statistical methods were used to identify trends to provide guidance for clinical prediction. Complete data were available for 497 patients with pelvic fracture, 104 (20.9%) of which received blood transfusion. The blood transfusion volume in the initial 6 h ranged from 0 to 10,000 ml, with a mean of 1,213.94±1354.11 ml. The total mortality rate was 1.8%. Among the patients with C-type pelvic fractures, the frequency of blood transfusion was 59.0% and the mean volume was 2,191.30±1,740.93 ml. The mortality rate for C-type pelvic fractures was 11.43%. The B3 subtype of pelvic fractures had the highest transfusion frequency (53.6%), while the C3 subtype had the largest blood transfusion volume (5,700.00±4,666.90 ml). Patients with type A-C pelvic fractures had a progressively larger mean transfusion volume, transfusion frequency and mortality in the initial 6 h after pelvic fracture. The AO classification system was demonstrated to be a useful tool for the identification of pelvic fracture risk in the present study.
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Affiliation(s)
- Qing Yang
- Department of Orthopedics, QingPu Branch of Zhongshan Hospital Affiliated to Fudan University, Qingpu District Central Hospital of Shanghai, Shanghai 201700, P.R. China
| | - Ting Wang
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai 201600, P.R. China
| | - Lei Ai
- Department of Laboratory, Taishan Coal Sanatorium, Taian, Shangdong 201700, P.R. China
| | - Kai Jiang
- Department of Orthopedics, QingPu Branch of Zhongshan Hospital Affiliated to Fudan University, Qingpu District Central Hospital of Shanghai, Shanghai 201700, P.R. China
| | - Xingguang Tao
- Department of Orthopedics, QingPu Branch of Zhongshan Hospital Affiliated to Fudan University, Qingpu District Central Hospital of Shanghai, Shanghai 201700, P.R. China
| | - Dongliang Gong
- Department of Orthopedics, QingPu Branch of Zhongshan Hospital Affiliated to Fudan University, Qingpu District Central Hospital of Shanghai, Shanghai 201700, P.R. China
| | - Nong Chen
- Department of Orthopedics, QingPu Branch of Zhongshan Hospital Affiliated to Fudan University, Qingpu District Central Hospital of Shanghai, Shanghai 201700, P.R. China
| | - Yang Fu
- Department of Orthopedics, QingPu Branch of Zhongshan Hospital Affiliated to Fudan University, Qingpu District Central Hospital of Shanghai, Shanghai 201700, P.R. China
| | - Fugen Pan
- Department of Orthopedics, QingPu Branch of Zhongshan Hospital Affiliated to Fudan University, Qingpu District Central Hospital of Shanghai, Shanghai 201700, P.R. China
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Bonde A, Velmahos A, Kalva SP, Mendoza AE, Kaafarani HMA, Nederpelt CJ. Bilateral internal iliac artery embolization for pelvic trauma: Effectiveness and safety. Am J Surg 2019; 220:454-458. [PMID: 31902526 DOI: 10.1016/j.amjsurg.2019.12.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 12/01/2019] [Accepted: 12/09/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Bilateral internal iliac artery embolization (BIIAE) with temporary embolic materials epitomizes damage-control principles in the treatment of exsanguinating hemorrhage from pelvic trauma. However, instances of ischemic complications have been reported. The aim of our study was to assess safety and effectiveness of BIIAE. METHODS All patients who received BIIAE for pelvic trauma at a Level I Trauma Center between 1998 and 2018 were reviewed. Effectiveness was assessed by radiographic bleeding control and clinical bleeding control, i.e. stabilization of vital signs and reduction in blood transfusion. Safety was assessed by any evidence for ischemic damage of pelvic organs or tissues. RESULTS Of 61 patients undergoing BIIAE, bleeding control was confirmed radiographically in 60 (98%) and clinically in 55 (90%), including 4 (7%) patients who required repeat embolization. Six (10%) patients died due to insufficient pelvic bleeding control. No BIIAE-related complications were identified. CONCLUSION The overall clinical effectiveness and safety rates of BIIAE for pelvic bleeding control, when combined with other methods of hemostasis, were 90% and 100% respectively.
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Affiliation(s)
- Alexander Bonde
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts, General Hospital, Harvard Medical School, Boston, United States; Department of Anesthesia, Center of Head and Orthopedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Andriana Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts, General Hospital, Harvard Medical School, Boston, United States
| | - Sanjeeva P Kalva
- Division of Interventional Radiology, Massachusetts General Hospital, Harvard Medical, School, Boston, United States
| | - April E Mendoza
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts, General Hospital, Harvard Medical School, Boston, United States
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts, General Hospital, Harvard Medical School, Boston, United States
| | - Charlie J Nederpelt
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts, General Hospital, Harvard Medical School, Boston, United States.
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