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.
Highlights
In patients with severe pelvic ring injuries, exsanguination still is the leading cause of death in the early post-injury phase
Patients were excluded if they died in the shock room or if they did not receive any type of damage control procedure for their pelvic ring injury
In the present study analyzing a 10-year period, approximately 13% of patients with pelvic ring injuries required emergent mechanical pelvic ring stabilization and direct pre-peritoneal pelvic packing due to hemodynamic instability
Summary
In patients with severe pelvic ring injuries, exsanguination still is the leading cause of death in the early post-injury phase. Many different approaches to effectively manage the hemodynamically unstable patient with pelvic ring injury have been suggested and have been lively and controversially discussed in the contemporary literature [2, 9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25] These controversies have their origin—among other reasons—in different trauma system developments comparing European countries and North America and have resulted in different favored pathways in the treatment of these highly challenging injuries. Two different fundamental treatment modalities have been suggested to manage patients with significant pelvic ring injuries and ongoing hemodynamic instability: Angioembolization addressing arterial bleeding vs. pelvic packing, mainly controlling venous hemorrhage and bleeding from the spongious pelvic fracture site
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