Pelvic packing and angio-embolization after blunt pelvic trauma: a retrospective 18-year analysis

Let us settle the controversy-gelfoam is a safe intravascular embolic agent

OBJECTIVES

A 2021 safety alert restricted endovascular gelfoam use in Australia and resulted in an embargo on gelfoam sales to Interventional Radiology departments. This study aimed to show that gelfoam is safe in a population of trauma patients with pelvic injury, and discuss the basis of the recent controversies.

METHODS

Retrospective cohort study was conducted between 1 January 2010 and 21 May 2021 for the patients who underwent gelfoam embolization for pelvic arterial haemorrhage. Primary outcome was the rate of adverse events related to intravascular gelfoam administration.

RESULTS

Inclusion criteria met in 50 patients, comprising 58% males median age 59.9 years, and median injury severity score 31. There were 0 complications related to gelfoam use and 100% technical success. Thirty-five patients (70%) received a non-targeted embolization approach. All-cause mortality was observed in 5 patients (10%), unrelated to gelfoam.

CONCLUSIONS

Gelfoam is a safe and effective embolic agent in pelvic trauma. Patients are in urgent need of universal on-label registration of endovascular gelfoam products, as it is life-saving in major haemorrhage after trauma.

ADVANCES IN KNOWLEDGE

Endovascular gelfoam is mandatory for a high-quality trauma service, and this study shows that it is safe to use intentionally in the endovascular space. Companies should work with interventional radiologists, sharing and collaborating to ensure positive outcomes for patients.

The effectiveness of palliative middle meningeal artery embolization prior to craniotomy for large acute epidural hematoma: A case report

INTRODUCTION AND IMPORTANCE

Acute epidural hematoma is typically managed with craniotomy. However, there are a few reports on transcatheter arterial embolization (TAE) as an adjunctive therapy.

CASE PRESENTATION

A 70-year-old female with no obvious history of trauma was transported to our hospital. Computed tomography scan revealed an epidural hematoma of approximately 80 ml with a midline shift of 5 mm. We decided to perform an emergency craniotomy. However, the operating room (OR) was already occupied by a scheduled surgery and it would take 30 min to an hour to prepare it. We opted to wait for our OR, considering that, even if the patient was transferred to another hospital, it would take time for the craniotomy to commence.

CLINICAL DISCUSSION

We performed TAE for the middle meningeal artery (MMA) as a palliative measure to prevent hematoma enlargement. The MMA was selectively embolized with 20 % n-butyl-2-cyanoacrylate (NBCA), resulting in no hematoma enlargement or observed complications. The criteria for endovascular treatment of acute epidural hematoma are not yet well-established. This case demonstrates the potential role of endovascular treatment for large acute epidural hematomas in carefully selected patients.

CONCLUSION

If there is a time gap before craniotomy, TAE could be considered a viable option for large acute epidural hematomas as a palliative intervention before craniotomy.

Angioembolization Has Similar Efficacy and Lower Total Charges than Preperitoneal Pelvic Packing in Patients With Pelvic Ring or Acetabulum Fractures

OBJECTIVES

To compare cost, hospital-related outcomes, and mortality between angioembolization (AE) and preperitoneal pelvic packing (PPP) in the setting of pelvic ring or acetabulum fractures.

METHODS

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DESIGN

Retrospective database review.

SETTING

National Inpatient Sample, years 2016-2020.

PATIENT SELECTION CRITERIA

Hospitalized adult patients who underwent AE or PPP in the setting of a pelvic ring or acetabulum fracture.

OUTCOME MEASURES AND COMPARISONS

Mortality and hospital-associated outcomes, including total charges, following AE versus PPP in the setting of pelvic ring or acetabulum fractures.

RESULTS

A total of 3780 patients, 3620 undergoing AE and 160 undergoing PPP, were included. No significant differences in mortality, length of stay, time to procedure, or discharge disposition were found ( P > 0.05); however, PPP was associated with significantly greater charges than AE ( P = 0.04). Patients who underwent AE had a mean total charge of $250,062.88 while those undergoing PPP had a mean total charge of $369,137.16.

CONCLUSIONS

Despite equivalent clinical efficacy in terms of mortality and hospital-related outcomes, PPP was associated with significantly greater charges than AE in the setting of pelvic ring or acetabulum fractures. This data information can inform clinical management of these patients and assist trauma centers in resource allocation.

LEVEL OF EVIDENCE

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

Independent factors of preventable death in a mature trauma center: a propensity-score analysis

INTRODUCTION

The rate of potentially preventable deaths (PPD) and preventable deaths (PD) can reach more than 20% of overall trauma mortality. Bleeding is the leading cause of preventable mortality. The aim of our study is to define the independent factors of preventable or potentially preventable mortality in our mature trauma system.

MATERIALS AND METHODS

We conducted a single-center retrospective study in the Sainte Anne Military Teaching Hospital, Toulon, France, including all severe trauma patients admitted to our trauma center and discharged alive as well as all severe trauma patients who died with a death considered preventable or potentially preventable from January 2013 to December 2020. We matched the two groups using a propensity score and searched for independent factors using a generalized linear model.

RESULTS

846 patients were included and analyzed. After matching, our cohort consisted of 245 patients in the survivor group and 49 patients in the preventable deaths group. Pre-hospital delays (73 min vs 54 min P = 0.003) as well as delays before incision in the operating room (80 min vs 52 min P < 0.001) were significantly longer in the PD group. These delays were independent factors of preventable mortality OR 10.35 (95% CI [3.44-31.11] P < 0.001) and OR 37.53 (95% CI [8.51-165.46] P < 0.001) as well as pelvic trauma OR 6.20 (95% CI [1.53-25.20] P = 0.011).

CONCLUSION

Delays in pre-hospital care, delays in access to the operating room from arrival at the trauma center, and pelvic injuries are independent factors associated with an increased risk of preventable mortality in trauma.

Arterial angioembolisation versus pre-peritoneal pelvic packing in haemodynamically unstable patients with complex pelvic fractures: a meta-analysis

INTRODUCTION

Angioembolisation (AE) and/or pre-peritoneal pelvic packing (PPP) may be necessary for patients with complex pelvic fractures who are haemodynamically unstable. However, it remains unclear whether AE or PPP should be performed as an initial intervention and ongoing debates exist. This meta-analysis aimed to compare AE versus PPP in haemodynamically unstable patients with acute pelvic fractures. The primary outcomes of interest were to compare in-hospital mortality rate and number of blood units transfused. Secondary outcomes included evaluating differences in the time from diagnosis to treatment, as well as the length of stay in the intensive care unit (ICU) and hospital.

METHODS

All clinically relevant studies comparing AE versus PPP in patients with complex pelvic fractures and haemodynamic instability were accessed. The 2020 PRISMA guidelines were followed. In September 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar and Embase, without constraint.

RESULTS

Data from 320 patients were collected (AE: 174; PPP: 146). The mean age on admission was 47.4 ± 7.2 years. The mean Injury Severity Score (ISS) on admission was 43.5 + 5.4 points. Baseline comparability was observed in ISS (P = 0.5, Table 3) and mean age (P = 0.7, Table 3). No difference was reported in mortality rate (P = 0.2) or rate of blood units transfused (P = 0.3). AE had a longer mean time to the procedure of 44.6 min compared to PPP (P = 0.04). The mean length of ICU and hospital stay were similar in both groups.

CONCLUSION

Despite the longer mean time from admission to the procedure, no significant differences were found between AE and PPP in terms of in-hospital mortality, blood units transfused, or length of ICU, and hospital stay. These findings should be interpreted considering the limitations of the present study. High-quality comparative research is strongly warranted.

LEVEL OF EVIDENCE

Level IV, meta-analysis.

Standard practice in the treatment of unstable pelvic ring injuries: an international survey

PURPOSE

Unstable pelvic ring injury can result in a life-threatening situation and lead to long-term disability. Established classification systems, recently emerged resuscitative and treatment options as well as techniques, have facilitated expansion in how these injuries can be studied and managed. This study aims to access practice variation in the management of unstable pelvic injuries around the globe.

METHODS

A standardized questionnaire including 15 questions was developed by experts from the SICOT trauma committee (Société Internationale de Chirurgie Orthopédique et de Traumatologie) and then distributed among members. The survey was conducted online for one month in 2022 with 358 trauma surgeons, encompassing responses from 80 countries (experience > 5 years = 79%). Topics in the questionnaire included surgical and interventional treatment strategies, classification, staging/reconstruction procedures, and preoperative imaging. Answer options for treatment strategies were ranked on a 4-point rating scale with following options: (1) always (A), (2) often (O), (3) seldom (S), and (4) never (N). Stratification was performed according to geographic regions (continents).

RESULTS

The Young and Burgess (52%) and Tile/AO (47%) classification systems were commonly used. Preoperative three-dimensional (3D) computed tomography (CT) scans were utilized by 93% of respondents. Rescue screws (RS), C-clamps (CC), angioembolization (AE), and pelvic packing (PP) were observed to be rarely implemented in practice (A + O: RS = 24%, CC = 25%, AE = 21%, PP = 25%). External fixation was the most common method temporized fixation (A + O = 71%). Percutaneous screw fixation was the most common definitive fixation technique (A + O = 57%). In contrast, 3D navigation techniques were rarely utilized (A + O = 15%). Most standards in treatment of unstable pelvic ring injuries are implemented equally across the globe. The greatest differences were observed in augmented techniques to bleeding control, such as angioembolization and REBOA, more commonly used in Europe (both), North America (both), and Oceania (only angioembolization).

CONCLUSION

The Young-Burgess and Tile/AO classifications are used approximately equally across the world. Initial non-invasive stabilization with binders and temporary external fixation are commonly utilized, while specific haemorrhage control techniques such as pelvic packing and angioembolization are rarely and REBOA almost never considered. The substantial regional differences' impact on outcomes needs to be further explored.

Preperitoneal Pelvic Packing versus Angioembolization for Patients with Hemodynamically Unstable Pelvic Fractures with Pelvic Bleeding: A Single-Centered Retrospective Study

The aim of this study was to compare the outcomes of preperitoneal pelvic packing (PPP) and angioembolization (AE) for patients with equivocal vital signs after initial resuscitation. This single-centered retrospective study included information from the database of a regional trauma center from April 2014 to December 2022 for patients with pelvic fractures with a systolic blood pressure of 80-100 mmHg after initial fluid resuscitation. The patients' characteristics, outcomes, and details of AE after resuscitative endovascular balloon occlusion of the aorta (REBOA) placed in zone III were collected. The follow-up duration was from hospital admission to discharge. A total of 65 patients were enrolled in this study. Their mean age was 59.2 ± 18.1 years, and 40 were males. We divided the enrolled patients into PPP (n = 43) and AE (n = 22) groups. The median time from emergency department (ED) to procedure and the median duration of ED stay were significantly longer in the AE group than in the PPP group (p ≤ 0.001 for both). The median mechanical ventilation (MV) duration was significantly shorter (p = 0.046) in the AE group. The number of patients with complications, overall mortality, and mortality due to hemorrhage did not differ between the two groups. Three patients (13.6%) were successfully treated with AE after REBOA. AE may be beneficial for patients with hemodynamically unstable pelvic fractures who show equivocal vital signs after initial fluid resuscitation in terms of reducing the MV duration and incidence of infectious complications.

Complications Following Temporary Bilateral Internal Iliac Artery Ligation for Pelvic Hemorrhage Control in Trauma

Background: Temporary bilateral internal iliac artery ligation (TBIIAL) is an option for surgical control of pelvic hemorrhage after trauma. Concerns persist that complications, particularly gluteal necrosis, following TBIIAL should preclude its use, despite a lack of formal research on TBIIAL complications. This study aimed to define complications following TBIIAL for emergent control of traumatic pelvic bleeding.Study Design: Patients undergoing TBIIAL after blunt trauma (2008-2020) at our level 1 trauma center were included without exclusions. Demographics, clinical/injury data, and outcomes were collected. Descriptive statistics summarized study variables. Multivariable analysis of factors independently associated with mortality after TBIIAL was performed.Results: In total, 77 patients undergoing emergent TBIIAL after blunt trauma were identified. Median age was 46 [IQR 29-63] years. Most patients (n = 70, 91%) were severely injured (ISS ≥16), with 43% undergoing resuscitative thoracotomy prior to TBIIAL. No local complications (gluteal necrosis, iatrogenic injury, fascial dehiscence, surgical site infection) after TBIIAL occurred over the 13-year study period. In the first 28 days after injury, median hospital-, ICU-, and ventilator-free days were 0. Mortality was 70% (n = 54). On multivariable analysis, older age was the only variable independently associated with in-hospital mortality (OR 1.081, P = .028).Conclusion: Zero cases of gluteal necrosis, iatrogenic injury to surrounding structures, or surgical site infection/fascial dehiscence of the exploratory laparotomy occurred over the study period. High concern for gluteal necrosis after TBIIAL in severely injured trauma patients is unfounded and should not prevent a surgeon from obtaining prompt pelvic hemorrhage control with this technique among patients in extremis.

Posterior hinge fixation for the treatment of unstable traumatic sacroiliac joint injuries

INTRODUCTION

Posterior hinge fixation (PHF) is a sacroiliac joint fixation method indicated for the surgical treatment of unstable pelvic ring fractures (tile C).

HYPOTHESIS

PHF yields good functional outcomes based on the Majeed score at more than 1 year of follow-up.

METHODS

A single-center, retrospective study of patients who had a Tile C pelvic ring fracture, who were operated by PHF and who were evaluated at a minimum follow-up of 1 year. The functional outcome was determined using the Majeed score and pain was evaluated by the patients using a visual analog scale (VAS). The preoperative, intraoperative and postoperative data, complications and sequelae were documented. A CT-scan was done at least 1 year after the surgical treatment to determine the SI joint's reduction and fusion.

RESULTS

Included were 22 patients (59% men) who had a mean age of 37.3±11.9 years; 21 of these patients were reviewed at a mean of 4.8±4 years. The mean Majeed score at the final assessment was 76.4 points±15.3, with 24% of patients having excellent results (n=5), 53% having good results (n=11), 19% having average results (n=4) and 5% having poor results (n=1). The mean pain level on VAS was 28±23mm. Of the eight surgical site infections, seven occurred in the PHF (88%). CT-scans taken at 1 year postoperative were compared to the preoperative scans. The pelvic opening was reduced by -9±6 (p<0.01), SI diastasis by -11mm±9 (p<0.001), vertical displacement by-7mm±8 (p<0.001), symphysis opening by -15mm±15 (p<0.001), median transverse diameter by -10mm±9 (p<0.001) and bispinal diameter by -5mm±7 (p<0.001). SI fusion was confirmed in 43% of patients (n=9).

CONCLUSION

PHF is a surgical instrumentation method that provides satisfactory long-term reduction of Tile C pelvic ring fractures. The clinical outcomes are good or excellent in 77% of cases. The perioperative morbidity is marked by surgical site infections, all of which healed.

LEVEL OF EVIDENCE

IV; retrospective, non-comparative cohort study.

[Interventional radiology as emergency treatment for pelvic injuries]

CLINICAL ISSUE

Pelvic arterial bleeding constitutes a potentially life-threatening event, which can be difficult to control with surgical procedures alone, especially in the case of ligamentous ruptures and a subsequently increased pelvic volume.

STANDARD RADIOLOGICAL PROCEDURES

Using angiography and embolization (AE) with resorbable gelatine-based particles or permanent coils, plugs, liquid embolic systems or by vascular stenting, in most cases traumatic pelvic arterial bleeding can be stopped and can also be used to close pseudoaneurysms, arteriovenous fistulas or dissections.

METHODOLOGICAL INNOVATION AND EVALUATION

The AE has become established as a fast and effective minimally invasive procedure in the treatment of traumatic pelvic vascular injuries with an advantageous risk-benefit ratio.

PRACTICAL RECOMMENDATIONS

An interdisciplinary approach should be used in the indications for AE; which can be used as definitive treatment as well as in combination with surgical procedures. To improve the clinical outcome any delay between establishing the indications and the start of the intervention must be avoided.