Stent graft treatment of an external iliac artery injury associated with pelvic fracture. A case report

Interventional Radiology in Pelvic Trauma

Traumatic pelvic injuries are associated with high injury severity scores and significant morbidity and mortality. As fractures and ligamentous disruption result in increased pelvic volume, retroperitoneal hemorrhage can spiral and progress to hemorrhagic shock. Due to the extensive collateral supply and limitations of surgery for pelvic hematomas, angiographic treatment is at the forefront of pelvic trauma management. This article will discuss typical injuries seen in pelvic trauma, treatment modalities available to the interventional radiologist, and common angiographic treatment strategies and techniques.

Neurological Outcome After Traumatic Transverse Sacral Fractures: A Systematic Review of 521 Patients Reported in the Literature

BACKGROUND

The purpose of this study was to determine the neurological outcome after transverse sacral fractures in patients with neurological impairment.

METHODS

A systematic review of the English, French, German, and Dutch literature was conducted. All study designs, including retrospective cohort studies and case reports, describing transverse sacral fractures were included. Two authors independently extracted the predefined data and scored the neurological impairment according to the Gibbons classification after the trauma and at the time of follow-up. The neurological outcomes were pooled according to the Gibbons classification.

RESULTS

No randomized controlled trials or prospective case series were found. A total of 139 articles were included, consisting of 81 case reports and 58 retrospective case series involving 521 patients. Regardless of the type of management, neurological recovery of at least 1 Gibbons category was reported in 62% of these patients. A comparison of the neurological outcome of nonoperatively treated patients and surgically treated patients showed similar neurological recovery rates. For the surgically treated patients, fixation of the fracture resulted in a better neurological improvement compared with an isolated decompression.

CONCLUSIONS

This review could not provide evidence of improved neurological recovery after surgical treatment compared with nonoperative treatment. When surgical treatment was considered, there was a low level of evidence that fixation of the fracture results in better neurological improvement compared with isolated decompression.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Contemporary Strategies in the Management of Civilian Abdominal Vascular Trauma

The evaluation and management of patients with abdominal vascular trauma or injury requires immediate and effective decision-making in these unfavorable circumstances. The majority of these patients arrive at trauma centers in profound shock, secondary to massive blood loss, which is often unrelenting. Moreover, ischemia, compartment syndrome, thrombosis, and embolization may also be life threatening and require immediate intervention. To minimize the risk of these potentially lethal complications, early understanding of the disease process and emergent therapeutic intervention are necessary. In the literature, the management of acute traumatic vascular injuries is restricted to traditional open surgical techniques. However, in penetrating injuries surgeons often face a potentially contaminated field, which renders the placement of prosthetic grafts inappropriate. Currently, however, there are sparse data on the management of vascular trauma with endovascular techniques. The role of endovascular technique in penetrating abdominal vascular trauma, which is almost always associated with severe active bleeding, is limited. It is worth mentioning that hybrid operating rooms with angiographic radiology capabilities offer more opportunities for the management of this kind of injuries by either temporary control of the devastating bleeding using endovascular balloon tamponade or with embolization and stenting. On the other hand, blunt abdominal injuries are less dangerous and they could be treated at most times by endovascular means. Since surgeons continue to encounter abdominal vascular trauma, open and endovascular techniques will evolve constantly giving us encouraging messages for the near future.

Diagnosis and treatment of rare complications of pelvic fractures

PURPOSE

To enhance the awareness of rare complications of pelvic fracture and describe the correct diagnosis and effective treatment.

METHODS

A total of 188 cases of pelvic fractures were retrospectively reviewed, and four patients who suffered from four types of rare pelvic fracture complications were described, namely ureteral obstruction caused by retroperitoneal hematoma-induced abdominal compartment syndrome (ACS), bowel entrapment, external iliac artery injury, and open scrotal sac injury.

RESULTS

We demonstrated that combined measures should be employed to prevent the occurrence of ACS following major pelvic fractures. Ureteral catheter support may be a good option at an early stage when ACS occurred. Contrasted computed tomography examination and sufficient awareness are keys to a correct diagnosis of bowel entrapment following pelvic fractures. Recognition of risk factors, early diagnosis, and prompt treatment of suspected injury of the external iliac artery are keys to patient survival and to avoid limb loss. Scrotal and/or testicular injury complicated by pelvic fractures should be carefully treated to maintain normal gonad function. Additionally, establishment of a sophisticated trauma care system and multi-disciplinary coordination are important for correct diagnosis and treat- ment of rare complications in pelvic fractures.

CONCLUSIONS

Rare complications of pelvic fractures are difficult to diagnose and negatively impact outcome. Recognition of risk factors and sufficient awareness are essential for correct diagnosis and prompt treatment.

Temporary ex vivo posterior tibial artery bypass for iliofemoral artery injury

BACKGROUND

The objective of this study is to report a temporary, ex vivo, distal extremity revascularization technique providing distal perfusion and allowing for a staged repair of complex iliofemoral injury. In addition, the objective of this report is to provide outcome data after this novel procedure including mortality, limb salvage, and quality of limb assessment.

METHODS

From February 1993 to December 2005, temporary ex vivo posterior tibial artery revascularization from the uninjured (donor) to the injured extremity was performed in 14 patients. All patients had blunt iliofemoral artery injury with class III or IV hemorrhagic shock. An end-to-end anastomosis between the two posterior tibial arteries was performed. Muscle strength of both legs was measured using the Medical Research Council scale and grade 5 means normal strength.

RESULTS

The mean age at surgery was 35 years+/-7.4 years (mean+/-SD). All patients with ipsilateral legs survived. Patency of the bypass was achieved in all cases. At a mean time of 30 days+/-10 days after injury, the injured iliofemoral artery was reconstructed, and the bypass was transected 7 days later. At the final follow-up, the muscle strength of both legs was of grade 5 based on Medical Research Council scale. Static two-point discrimination test scores were similar on both feet.

CONCLUSIONS

Temporary ex vivo revascularization of the posterior tibial artery is a feasible option in selecting patients with blunt iliofemoral artery injury with ischemia and severe physiologic derangements. This unconventional method provides extremity perfusion distal to the injury and maintains neuromuscular viability during an interval period, allowing for a staged, proximal revascularization after improvement in the patient's physiologic condition.