Accuracy of Contrast Extravasation on Computed Tomography for Diagnosing Severe Pelvic Hemorrhage in Pelvic Trauma Patients: A Meta-Analysis

Endovascular management of haemorrhage and vascular lesions in patients with multiple and/or severe injuries: a systematic review and clinical practice guideline update

PURPOSE

Our aim was to update evidence-based and consensus-based recommendations for the inhospital endovascular management of haemorrhage and vascular lesions in patients with multiple and/or severe injuries based on current evidence. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries.

METHODS

MEDLINE and Embase were systematically searched to June 2021. Further literature reports were obtained from clinical experts. Randomised controlled trials, prospective cohort studies, and comparative registry studies were included if they compared endovascular interventions for bleeding control such as embolisation, stent or stent-graft placement, or balloon occlusion against control interventions in patients with polytrauma and/or severe injuries in the hospital setting. The diagnosis of pelvic haemorrhage was added post-hoc as an additional clinical question. We considered patient-relevant clinical outcomes such as mortality, bleeding control, haemodynamic stability, transfusion requirements, complications, and diagnostic test accuracy. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength.

RESULTS

Forty-three new studies were identified. Interventions covered were resuscitative endovascular balloon occlusion of the aorta (REBOA) (n = 20), thoracic endovascular aortic repair (TEVAR) (n = 9 studies), pelvic trauma (n = 6), endovascular aortic repair (EVAR) of abdominal aortic injuries (n = 3), maxillofacial and carotid artery injuries (n = 2), embolisation for abdominal organ injuries (n = 2), and diagnosis of pelvic haemorrhage (n = 1). Five recommendations were modified, and one additional recommendation was developed. All achieved strong consensus.

CONCLUSION

The following key recommendations are made. Whole-body contrast-enhanced computed tomography should be used to detect bleeding and vascular injuries. Blunt thoracic and abdominal aortic injuries should be managed using TEVAR/EVAR. If possible, endovascular treatment should be delayed beyond 24 h after injury. Bleeding from parenchymatous abdominal organs should be controlled using transarterial catheter embolisation. Splenic injuries that require no immediate intervention can be managed with observation.

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.

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.

Flat Inferior Vena Cava on Computed Tomography for Predicting Shock and Mortality in Trauma: A Meta-Analysis

Hypovolemia may be underestimated due to compensatory mechanisms. In this systematic review and meta-analysis, we investigated the diagnostic accuracy of a flat inferior vena cava (IVC) on computed tomography (CT) for predicting the development of shock and mortality in trauma patients. Relevant studies were obtained by searching PubMed, EMBASE, and Cochrane databases (articles up to 16 September 2022). The number of 2-by-2 contingency tables for the index test were collected. We adopted the Bayesian bivariate random-effects meta-analysis model. Twelve studies comprising a total of 1706 patients were included. The flat IVC on CT showed 0.46 pooled sensitivity (95% credible interval [CrI] 0.32-0.63), 0.87 pooled specificity (95% CrI 0.78-0.94), and 0.78 pooled AUC (95% CrI 0.58-0.93) for the development of shock. The flat IVC for mortality showed 0.48 pooled sensitivity (95% CrI 0.21-0.94), 0.70 pooled specificity (95% CrI 0.47-0.88), and 0.60 pooled AUC (95% CrI 0.26-0.89). Regarding the development of shock, flat IVC provided acceptable accuracy with high specificity. Regarding in-hospital mortality, the flat IVC showed poor accuracy. However, these results should be interpreted with caution due to the high risk of bias and substantial heterogeneity in some included studies.

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

BACKGROUND

Extravasation on contrast-enhanced computed tomography (CECT) is a helpful indicator of the need for transcatheter arterial embolization (TAE) for pelvic fractures. However, previous reports were inconsistent on cases in which angiography is necessary, even though there is no extravasation on computed tomography. This study aimed to describe and analyze the contradictory findings in cases where extravasation is observed on angiography but not on CECT, to contribute to improved management of patients with pelvic fractures.

METHODS

This was a retrospective single-center study. Patients with pelvic fractures who underwent CECT and TAE between 2014 and 2020 were included. We classified the patients into three groups: CECT and angiography with extravasation (CT+Angio+), CECT with no extravasation and angiography with extravasation (CT-Angio+), and CECT with extravasation and angiography without extravasation (CT+Angio-).

RESULTS

A total of 113 patients were included in the study: the CT+Angio+ group had 54 patients, CT-Angio+ group, 47; and CT+Angio- group, 12. The CT-Angio+ group had a significantly longer time from arrival to CECT than the CT+Angio+ group (27 minutes vs. 23 minutes, p < 0.05). The CT-Angio+ group had significantly more blood transfusions (fresh frozen plasma, platelets) within 24 hours than the CT+Angio- group did (p < 0.05), and ventilator management days (p < 0.05) and intensive care unit stays (p < 0.05) were significantly longer.

CONCLUSION

There was no significant difference in outcomes among the three groups. There was no difference in severity, transfusion volume, or mortality in patients with pelvic fractures needing TAE, classified as CT-Angio+, compared with that of CT+Angio+ patients. Even in the absence of extravasation in the pelvic region on CECT, angiography or TAE may still be necessary.

LEVEL OF EVIDENCE

Therapeutic/Care Management, Level IV.