Novel transcatheter arterial embolization method for hemodynamically unstable pelvic fractures to prevent complications of gluteal necrosis

Effects of Prophylactic Coil Embolization of Pelvic Arteries on Surgical Outcomes in Hemodynamically Stable Patients with Complex Acetabular Fractures

PURPOSE

To investigate the effectiveness of prophylactic embolization of the internal iliac artery (IIA) or superior gluteal artery (SGA) before open reduction and internal fixation (ORIF) in reducing intraoperative blood loss (IBL) in hemodynamically stable patients with complex acetabular fractures.

MATERIALS AND METHODS

A total of 136 patients with complex acetabular fractures were retrospectively included and divided into the prophylactic transcatheter arterial embolization (PTAE) group and non-PTAE group, depending on whether ipsilateral IIA or SGA was embolized using coils within 3 days before ORIF. Demographic characteristics, injury severity score, fracture classification, and intraoperative and postoperative data were compared between the 2 groups. Propensity score matching (PSM) was also performed to balance the baseline characteristics of the patients. The determinants of IBL were investigated using multivariate linear regression analysis.

RESULTS

The PTAE and non-PTAE groups consisted of 64 and 72 patients, respectively. PSM yielded 43 matched pairs. After matching, IBL in the PTAE group was less than that in the non-PTAE group (median [interquartile range], 800 [400-1,200] mL vs 1,300 [1,000-1,600] mL; P < .001). Furthermore, the PTAE group showed a shorter ORIF duration and lower intraoperative and 24-hour postoperative blood transfusion requirements (all P < .05). Multivariate analysis revealed that PTAE and the duration of surgery were associated with IBL (PTAE: β = -0.407; P < .001; duration of surgery: β = 0.237; P = .021).

CONCLUSIONS

Prophylactic IIA or SGA embolization may be beneficial in reducing IBL during ORIF in hemodynamically stable patients with complex acetabular fractures.

Managing severe (and open) pelvic disruption

Open pelvic fractures are a rare yet catastrophic injury pattern, often resulting from high-energy trauma such as motor vehicle collisions, motorcycle accidents, and pedestrian impacts. They account for only 2%-4% of all pelvic fractures, but their severity lies in the complex anatomy of the pelvis and its associated structures, including the vasculature, bowel, bladder, and genital organs. Mortality rates range from 15% to 50%, with some studies reporting rates as high as 70% in cases involving severe perineal or rectal injuries. These injuries pose two main risks to survival: hemorrhagic shock in the acute phase and pelvic sepsis during the later phases of recovery. Acute hemorrhage can occur from arterial injury (eg, internal iliac arteries), venous plexuses, or bony sources. Delayed deaths are often caused by sepsis due to fecal contamination of wounds or infected hematomas. Additionally, these fractures are often associated with other life-threatening injuries, including intra-abdominal trauma, genitourinary disruptions, and neurovascular compromise, further complicating their management. Management of these injuries has evolved significantly with advancements in hemorrhage control techniques such as preperitoneal pelvic packing and resuscitative endovascular balloon occlusion of the aorta. A multidisciplinary approach is essential to address the multifaceted challenges posed by these injuries.

Transcatheter Arterial Embolization for Hemorrhagic Pelvic Fracture: Review Article

Pelvic fractures are severe trauma that can cause hemorrhagic shock. The mortality rate is high when patients fall into shock. Therefore, prompt diagnosis and treatment are necessary. Hemostasis for hemorrhage associated with pelvic fractures is achieved through the mechanical stabilization of the fracture site, preperitoneal pelvic packing, and transcatheter arterial embolization. These techniques are frequently employed in hemodynamically unstable patients presenting with pelvic fractures. Among them, transcatheter arterial embolization is often considered the first-line choice: it is a particularly effective hemostatic method for arterial hemorrhage caused by pelvic fracture. An embolization technique and embolic agents should be considered comprehensively while considering the patient's hemodynamics, angiographic findings, and the urgency of the situation. This article describes the indications, techniques, results, and complications of transcatheter arterial embolization for pelvic fractures.

Nonselective versus Selective Angioembolization for Trauma Patients with Pelvic Injuries Accompanied by Hemorrhage: A Meta-Analysis

Background and Objectives: Angioembolization has emerged as an effective therapeutic approach for pelvic hemorrhages; however, its exact effect size concerning the level of embolized artery remains uncertain. Therefore, we conducted this systematic review and meta-analysis to investigate the effect size of embolization-related pelvic complications after nonselective angioembolization compared to that after selective angioembolization in patients with pelvic injury accompanying hemorrhage. Materials and Methods: Relevant articles were collected by searching the PubMed, EMBASE, and Cochrane databases until 24 June 2023. Meta-analyses were conducted using odds ratios (ORs) for binary outcomes. Quality assessment was conducted using the risk of bias tool in non-randomized studies of interventions. Results: Five studies examining 357 patients were included in the meta-analysis. Embolization-related pelvic complications did not significantly differ between patients with nonselective and selective angioembolization (OR 1.581, 95% confidence interval [CI] 0.592 to 4.225, I2 = 0%). However, in-hospital mortality was more likely to be higher in the nonselective group (OR 2.232, 95% CI 1.014 to 4.913, I2 = 0%) than in the selective group. In the quality assessment, two studies were found to have a moderate risk of bias, whereas two studies exhibited a serious risk of bias. Conclusions: Despite the favorable outcomes observed with nonselective angioembolization concerning embolization-related pelvic complications, determining the exact effect sizes was limited owing to the significant risk of bias and heterogeneity. Nonetheless, the low incidence of ischemic pelvic complications appears to be a promising result.

Efficacy of median sacral artery embolization for treating severe pelvic fractures: a retrospective study

Objective

Transcatheter arterial embolization (TAE) of bilateral internal iliac arteries (IIAs) in patients with a hemodynamically unstable pelvic fracture is associated with a low mortality rate. The persistence of unstable hemodynamics after IIA embolization indicates the involvement of other arteries, such as the median sacral artery (MSA). This study aimed to evaluate the efficacy of MSA embolization.

Methods

In this single-center, retrospective, observational study, medical records of patients who underwent MSA angiography or embolization for pelvic fractures (n = 21) between January 2007 and August 2019 were reviewed. The percentage of patients achieving hemodynamic stabilization by MSA embolization was calculated.

Results

Fifteen patients underwent MSA embolization, and the remaining six underwent MSA angiography. The shock index value was significantly higher after MSA embolization than that before MSA embolization in hemodynamically unstable patients who underwent this procedure. The success rate of MSA selection was 100%. One patient presented with urinary retention because of bladder and rectal disorders after MSA embolization. The 30-day survival rate was 85.7%.

Conclusions

Severe pelvic fractures, such as a Dennis Zone III fracture and suicidal jumper’s fracture due to trauma from a fall, may require MSA embolization.

Endovascular Management of Pelvic Trauma

Major pelvic fractures result from high-energy trauma including traffic accidents and falls, which usually leads to multiple injuries complicating the patient's management. Management of these patients requires a coordinated multidisciplinary approach. Transcatheter embolization is a minimally invasive and effective technique to control massive hemorrhage and can be performed using a variety of embolic agents. It has become an accepted first-line management option for retroperitoneal bleeds in many centers. In this article, the indications for endovascular management of hemorrhage from pelvic trauma, the various embolization techniques, and potential complications will be discussed.

Bilateral internal iliac artery embolization for pelvic trauma: Effectiveness and safety

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.