Extravasation and outcomes in computed tomography and angiography in patients with pelvic fractures requiring transcatheter arterial embolization: A single-center observational study

Dynamic changes in bleeding sites: Evaluating contrast extravasation on computed tomography and angiography in pelvic fractures

BACKGROUND

Contrast extravasation ("blush") on contrast-enhanced computed tomography (CECT) indicates active bleeding, but diagnostic angiography (AG) following CECT sometimes differs from the CECT findings in patients with pelvic fractures. This study aimed to evaluate the concordance rate between blush on CECT and AG based on pelvic anatomical location.

METHODS

This retrospective single-center study included patients (18 years or older) with pelvic fractures between 2015 and 2023 who had AG after CECT. Angiography was performed in patients with blush or hematoma on CECT, or unstable hemodynamics due to pelvic fracture. Pelvic bleeding regions were categorized separately into left and right as anterior internal iliac artery and posterior internal iliac artery based on pelvic arterial anatomy. The concordance rate between blush on CECT and AG was assessed using the k statistic.

RESULTS

A total of 87 patients with pelvic fractures were included. Among these, 75 (86%) had blush on CECT, and 12 (14%) had no blush on CECT. The concordance rate was 83% (95% confidence interval, 0.03-0.57; k = 0.30) when assessed on an individual patient basis and 53% (95% confidence interval, 0.24-0.44; k = 0.34) when evaluated by anatomical regions on a unilateral half of the pelvis. The concordance rate for the anatomical hemipelvis evaluation was significantly lower compared with the individual evaluation ( p < 0.001). Thirty-three percent of patients with unilateral blush on CECT showed new contralateral blushes during AG.

CONCLUSION

The location of active bleeding often differs between CECT and AG, indicating that bleeding may change intermittently and at various sites over time. This suggests the importance of evaluating both sides of the pelvic arteries during AG rather than solely relying on CECT findings.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Pelvic fractures in blunt trauma patients: A comparative study

BACKGROUND

Pelvic fractures (PF) with concomitant injuries are on the rise due to an increase of high-energy trauma. Increase of the elderly population with age related comorbidities further complicates the management. Abdominal organ injuries are kindred with PF due to the proximity to pelvic bones. Presence of contrast blush (CB) on computed tomography in patients with PF is considered a sign of active bleeding, however, its clinical significance and association with outcomes is debatable.

AIM

To analyze polytrauma patients with PF with a focus on the geriatric population, co-injuries and the value of contrast blush.

METHODS

This retrospective cohort study included 558 patients with PF admitted to level 1 trauma center (01/2017-01/2023). Analyzed variables included: Age, sex, mechanism of injury (MOI), injury severity score (ISS), Glasgow coma scale (GCS), abbreviated injury scale (AIS), co-injuries, transfusion requirements, pelvic angiography, embolization, laparotomy, orthopedic pelvic surgery, intensive care unit and hospital lengths of stay, discharge disposition and mortality. The study compared geriatric and non-geriatric patients, patients with and without CB and abdominal co-injuries. Propensity score matching was implemented in comparison groups.

RESULTS

PF comprised 4% of all trauma admissions. 89 patients had CB. 286 (52%) patients had concomitant injuries including 93 (17%) patients with abdominal co-injuries. Geriatric patients compared to non-geriatric had more falls as MOI, lower ISS and AIS pelvis, higher GCS, less abdominal co-injuries, similar CB and angio-embolization rates, less orthopedic pelvic surgeries, shorter lengths of stay and higher mortality. After propensity matching, orthopedic pelvic surgery rates remained lower (8% vs 19%, P < 0.001), hospital length of stay shorter, and mortality higher (13% vs 4%, P < 0.001) in geriatric patients. Out of 89 patients with CB, 45 (51%) were embolized. After propensity matching, patients with CB compared to without CB had more pelvic angiography (71% vs 12%, P < 0.001), higher embolization rates (64% vs 22%, P = 0.02) and comparable mortality.

CONCLUSION

Half of the patients with PF had concomitant co-injuries, including abdominal co-injuries in 17%. Similarly injured geriatric patients had higher mortality. Half of the patients with CB required an embolization.

Common and uncommon vascular injuries and endovascular treatment associated with pelvic blunt trauma: a real-world experience

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.