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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3733_Библиотеки_им_академика_М_И_Перельмана.pdf
fractures with high risk of vascular lesions. The anteroposterior compression
type and the vertical shear type of pelvic fracture are more often associated
with vascular lesions.13 However, there seems to be no correlation between
the type of fracture and vascular injury. The probability of vascular injury
rather seems to be related to the amount of energy that caused the trauma.
4
The anatomy of the IIA and its branching pattern is highly variable and needs
to be well known. Figure 23.2 displays the classical anatomy of the IIA and
its branches. The most commonly affected vessels are, in descending order of
frequency, the superior gluteal, the lateral sacral, the iliolumbar, the
obturator, and the vesical and inferior gluteal arteries.
5
The aberrant obturator artery from the external iliac artery is a
frequently overlooked source of bleeding in patients with pelvic fracture.
This anatomical variant is thought to be present in 14% to 36% of cases.
14
Figure 23.3 displays the angiographic aspect of the aberrant obturator artery.
The success rate of transcatheter embolization ranges from 59% to
100% and is best assessed by the rapid improvement of the hemodynamic
status in the angiography suite.15 Care should be taken to recontrol the
efficacy of the embolization once the hemodynamic stability has been
restored as arterial spasm might mask adequate management of vascular
injury or bleeding and the embolized vessels might reopen when the
vasoconstriction diminishes.
DEVICE AND MATERIAL DESCRIPTION
Gelatin sponge pledgets is used as the preferred embolic agent, but N-butyl
cyanoacrylate (NBCA) glue can be an efficient alternative in extremely
unstable patients. Particulate agents should not be used in this setting because
of the potential important ischemia that they may induce. Ischemia of the
large muscular territories of the buttocks and thighs have been described.
Coils should be used only in case of superselective occlusion of a single
peripheral vessel. In case of a disrupted vessel, the “front door/back door”
technique should be used to avoid continuous bleeding from collateral
reperfusion. Coils should not be used in the proximal IIA as they will not be
efficient because of the important collateralization in this anatomical region.
TECHNIQUE
Vascular access in patients with pelvic fracture can be challenging in the
presence of soft tissue lesions at or near the usual site of puncture and
because of compression or external fixation devices. Choice of the side of
arterial puncture is usually the opposite of the bone lesions. In case of
nonpalpable femoral pulse, ultrasound guidance should be used promptly. In
these cases, vascular access can also be obtained from the brachial or radial
arteries. The Seldinger technique is used to gain vascular access with a 5-Fr
or 6-Fr introducer sheath. In case of selecting radial or brachial arterial
access, use of introducer sheaths larger than 5-Fr should be avoided. The
contralateral side is embolized first as the contralateral catheterization of the
IIA is usually easier and the rapid control of bleeding will help stabilize the
hemodynamic status of the patient. The contralateral IIA can be easily
catheterized with a Cobra 2 catheter Terumo Europe, Leuven Belgium.
Digital subtraction angiography (DSA) images will allow appreciation of the
vascular anatomy of the IIA. Vascular lesions and active bleeding may be
identified at this point. If the patient’s hemodynamic status allows,
superselective catheterization of the main target vessel should always be
attempted with a microcatheter. It will allow selective embolization with
0.018-in coils. Once the contralateral side is embolized, a Waltman loop may
be formed in the aorta and the catheterization of the ipsilateral IIA is
performed. When the patient is hemodynamically stable, multiple DSAs from
different angles can be obtained to identify the site of active bleeding or
vascular injury (e.g., pseudoaneurysm/sudden cutoff of any branch close to
the bone fracture), which will be then catheterized and embolized
superselectively. But when the patient is hemodynamically unstable, we
recommend to perform just a single DSA in the posteroanterior view to
confirm proper localization of the catheter in the IIA before proximal
embolization is performed. In this setting, both IIAs should be occluded as
rapidly as possible with Gelfoam pledgets (Ethicon, Somerville, New Jersey).
In case of hemodynamically unstable patients with multiple bleeding
sites, the use of an aortic occlusion balloon catheter (e.g., Equalizer; Boston
Scientific Corporation, Natick, Massachusetts) can be a lifesaver. This type
of balloon can be placed even without any kind of imaging guidance in the
aorta after obtaining common femoral access using Seldinger technique in the
emergency department (ED). The balloon catheter is advanced 30 cm upward
using the umbilicus of the patient as the target level then inflated and pulled
backward until resistance is felt when the balloon reaches the aortic
bifurcation. This will immediately control most bleeding in the lower body
while other procedures can take place.
TAE of upper abdominal organs can be performed while an occlusion
balloon is inflated by inserting a 5-Fr catheter between the balloon and the
aortic wall (Fig. 23.4
). Once the other bleeding sources are controlled, the
balloon can be deflated and the IIA embolized.
Particular attention should be paid to “missing arteries.” One example is
the truncated superior gluteal artery in case of anteroposterior compression
type fracture. This artery must be embolized using the front door and back
door technique with coils.
One must know that some arteries are at more risk of complications: the
inferior gluteal artery feeds the sciatic nerve roots and the inferior and median
rectal arteries are the feeding vessels of the rectal lower third and anal canal.
CLINICAL APPLICATIONS
Scenario 1
Hemodynamically stable patient with localized source of bleeding on CT
scan. This patient should benefit from selective TAE of the injured vessel
first. TAE is a quick procedure that will prevent occurrence of secondary
hemodynamic instability and allow the patient to undergo surgical internal
stabilization of the pelvis, which can be a long and complex procedure.
Scenario 2
Patient with marginal hemodynamic stability (transiently responding to fluid
resuscitation) with localized source of bleeding on CT scan. This patient
should benefit from both external pelvic fixation and nonselective
embolization of both IIAs. Which should be performed first remains debated,
but external fixation is a quick procedure that can be performed in the ED and
in our opinion, should be performed first.9 Because external fixation only
takes care of venous and osseous bleeding and arterial bleeding is the main
cause of hemodynamic instability, TAE should be performed as soon as
possible after external fixation.
Scenario 3
Polytrauma patient with marginal hemodynamic stability with multiple pelvic
and extrapelvic sources of bleeding on CT scan and no indication for
emergent laparotomy. This patient should benefit from external fixation and
TAE or laparotomy for bleeding control. It has been demonstrated that in this
particular setting, TAE can be efficient in controlling multiple bleeding
sources and has the advantage of avoiding the physiologic insult of
laparotomy in fragile patients.16 Figure 23.5 displays the case of a patient
with hemodynamic instability and clinically evident pelvic fracture that was
treated by TAE of both IIAs with Gelfoam pledgets before being scanned.
POTENTIAL COMPLICATIONS
In the setting of polytraumatized patients with complex pelvic ring fractures,
it is difficult to establish with certainty if the observed complication was
caused by the trauma itself or by the embolization. Major complications
related to TAE in the pelvic territory are observed in less than 5%.5 These
complications mostly consist of puncture-related hematomas, skin necrosis,
rhabdomyolysis, pelvic or perineal infections, and nerve injuries. Travis et
al.17 found no significant differences in the complication rates between
embolized and nonembolized patients within 30 days from injury as well as
during the 18.4-month follow-up. Nevertheless, a significantly higher rate of
moderate complications such as buttock, thigh, and perineal paresthesia in the
embolized patients group was observed. There was no significant difference
between patients who underwent superselective embolization or nonselective
embolization of the IIA. Ischemic complications such as rhabdomyolysis and
skin necrosis are probably more frequent in patients with poor collateral
supply, such as patient with extensive atherosclerosis. Rare complications
reported in the literature include bladder necrosis,18 necrosis of the femoral
head,19 paresis in the territory of the sciatic nerve,20 and nontarget
embolization. Inadvertent embolization of a persistent sciatic artery has also
been described.21 A few cases of paraplegia have been reported.
15,22
TIPS AND TRICKS
CONCLUSION
TAE should be integrated in the multidisciplinary management of patients
with pelvic trauma. The indication for TAE should be based on the
hemodynamic status of the patient above all. TAE has many advantages in
this particular setting: it can quickly control hemorrhage in a difficult-toreach anatomical compartment and it can be associated with embolization of
other bleeding sites without exposing the patient to the risk of an emergency
surgical procedure.
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