Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3733_Библиотеки_им_академика_М_И_Перельмана.pdf
variant that may be a source of unidentified hemorrhage in pelvic
fracture patients. J Trauma. 2011;70(2):366–372.
15. Karadimas EJ, Nicolson T, Kakagia DD, et al. Angiographic
embolisation of pelvic ring injuries. Treatment algorithm and review of
the literature. Int Orthop. 2011;35(9):1381–1390.
16. Bize PE, Duran R, Madoff DC, et al. Embolization for
multicompartmental bleeding in patients in hemodynamically unstable
condition: prognostic factors and outcome. J Vasc Interv Radiol.
2012;23(6):751–760.e4.
17. Travis T, Monsky WL, London J, et al. Evaluation of short-term and
long-term complications after emergent internal iliac artery embolization
in patients with pelvic trauma. J Vasc Interv Radiol. 2008;19(6):840–
847.
18. Sieber PR. Bladder necrosis secondary to pelvic artery embolization:
case report and literature review. J Urol. 1994;151(2):422.
19. Obaro RO, Sniderman KW. Case report: avascular necrosis of the
femoral head as a complication of complex embolization for severe
pelvic haemorrhage. Br J Radiol. 1995;68(812):920–922.
20. Hare WS, Holland CJ. Paresis following internal iliac artery
embolization. Radiology. 1983;146(1):47–51.
21. Hsu WC, Lim KE, Hsu YY. Inadvertent embolization of a persistent
sciatic artery in pelvis trauma. Cardiovasc Intervent Radiol.
2005;28(4):518–520.
22. Palacios-Jaraquemada JM. Buttock necrosis and paraplegia after
bilateral internal iliac artery embolization for postpartum hemorrhage.
Obstet Gynecol. 2012;120(5):1210; author reply 1210.
E
24
Extremity Trauma
Jaime All • John F. Angle
mbolotherapy for extremity trauma is a well-established and essential
tool for the management of hemorrhage and vascular injury with
potential for hemorrhage. Familiarity with clinical presentation,
pretreatment imaging, and angiographic findings are all essential components
to interventionalists providing these services. Embolization technique and the
similarities and important differences between pelvic and extremity injury
will be discussed.
PELVIC TRAUMA
Within the context of a multispecialty approach to the care of the trauma
patient, the transcatheter arterial embolization (TAE) is an essential tool in
the treatment of traumatic pelvic arterial injury.1 Many trauma centers have
developed algorithms based on the nature of the injury, computed
tomography (CT) findings, and other injuries.
2–5
Some trauma scenarios are
best treated with TAE first, others are supplemented with TAE, and many
will not benefit from early pelvic angiography.
2–7
Blunt or penetrating pelvic
trauma may lead to vascular injury, with blunt injuries being much more
common in most geographic areas. Blunt trauma resulting in pelvic fracture
is associated with vascular injury in up to 40% of patients, and hemorrhage is
still the highest cause of mortality (50% to 74% of patients).
8
–10
With blunt
pelvic injury, the source of hemorrhage may be venous, arterial, or from
cancellous bone.
7
,11
TAE is only indicated for the treatment of arterial
hemorrhage and is indicated in approximately 3% to 10% of cases.
2,8,12,13
In
the correct clinical setting, angiography with TAE is effective in controlling
pelvic hemorrhage in 85% to 97% of cases.
6
Patients embolized within 3
hours of arrival have a statistically improved survival rate as compared to
those receiving intervention outside of the initial 3-hour window.
14
Indications for TAE in the setting of pelvic trauma include pelvic
fractures and hemodynamic instability after exclusion of other sources of
hemorrhage outside of the pelvis, active extravasation of contrast on
computed tomography angiography (CTA) in the presence of pelvic fracture
regardless of hemodynamic status, prior TAE for pelvic trauma with ongoing
hemodynamic instability after other sources of hemorrhage have been
excluded, and patients older than 60 years of age with a high-risk pelvic
fracture pattern.
6,12,15,16
Motor vehicle collisions and pedestrians hit by motor vehicles account
for most blunt arterial injury.12 Domestic falls are a less common cause, but
the need for pelvic vascular injury evaluation in this population is well
documented.
7,12,16
This is particularly true for the elderly because age is an
independent predictor of active bleeding and indication for TAE, regardless
of hemodynamic stability.
12,16
Additionally, osteoporosis in elderly women
may result in increased rate of pelvic fracture, even when the mechanism of
injury is less dramatic.17 The prevalence of chronic anticoagulation for
cerebrovascular and cardiovascular disease in this patient population may
also necessitate early intervention.
Types of vascular injury seen with blunt pelvic trauma include complete
or partial transection, arteriovenous fistula, pseudoaneurysm, dissection, and
traumatic thrombosis. The different angiographic appearances of traumatic
vascular injury are listed in Table 24.1.
1,18–20
Vascular injury typically occurs
in relationship to adjacent osseous fractures or shearing forces against the
ligamentous structures of the pelvis.19 It is important to note that disruption
of the osseous pelvis significantly enlarges what is normally a confined
space. This allows for a larger volume of hemorrhage to accumulate rapidly,
and thus early intervention is necessary to prevent exsanguination.7 It is
worth repeating that pelvic hemorrhage is usually from venous or fractured
cancellous bone, and this type of low-pressure hemorrhage is best controlled
with external fixation or compression with pelvic binding. The goal of these
methods is to reestablish the normal tamponading effect of the
retroperitoneum, although some recent studies call into question the overall
efficacy with this approach.
6,19,21
Peritoneal pelvic packing has been
introduced as an additional method of treating pelvic hemorrhage. Some
centers have questioned; whether pelvic packing should replace TAE, most
use TAE as an adjunctive treatment, and others suggest TAE first with
fixation secondarily.
2–7,21
From a practical standpoint, we push for
angiography first if active extravasation is seen on CT and suggest deferring
the fixation, which can make angiography very difficult to perform.
Regardless of the algorithm or combinations of treatment employed, early
control of pelvic arterial hemorrhage has a strong association with improved
outcome, and TAE continues to occupy a central role in the treatment of
traumatic pelvic hemorrhage.
1–6,14
As many as 50% of patients with pelvic fracture have additional injuries,
so pelvic fracture should be treated as an indicator of polytrauma (Fig.
24.1).21 An algorithm approach to the care of the trauma patient, although
institution-dependent, must weigh the severity of multiple injuries and
therefore mandates a multidisciplinary approach. Most would prioritize an
intra-abdominal source of hemorrhage over intrapelvic bleeding, although a
few have argued to the contrary.
4,6,22
However, it is accepted that exploratory
laparotomy in the setting of unaddressed pelvic hemorrhage can lead to rapid
expansion of the pelvic hematoma.9 Additionally, some solid organ injury
within the abdomen may be treated at the time of pelvic embolization, such as
a splenic or renal laceration. Regardless of when TAE is performed,
consideration must be given to the possibility of additional organ injury, and
this should guide the goal of the procedure in terms of the degree of vessel
selectivity. Failure of hemodynamic status to correct following embolization
should prompt search for additional sources of bleeding.
Historically, fracture patterns were felt to be important diagnostic
indicators in pelvic trauma.
9,19
More recent studies have shown that arterial
hemorrhage can occur with any of the fracture patterns, as well as in the less
severe subtypes, and may occur in the absence of fracture.22 Those most
worrisome (and those which are considered high-grade at our institution) are
vertical shear and types II and III lateral compressions and anterior posterior
compressions.
9,19,23
It is still important for the interventionalist to recognize
these patterns because they may suggest which vessel is the culprit, even in
the absence of active extravasation at angiography. At the most basic level,
anterior fracture patterns are associated with injury to the anterior division of
the internal iliac artery, and posterior fractures are associated with injuries to
the posterior division.
1,23
The importance of fracture pattern recognition has
been largely supplanted by CT, which has superior diagnostic sensitivity, and
adds a wealth of additional data over conventional radiography.
24,25
Advances in technology have allowed for rapid image acquisition and
processing, thereby allowing for the imaging of patients whose status may be
tenuous and, in some centers, even those who are unstable.
Examples of penetrating pelvic injuries include gunshot wounds, stab
wounds, or iatrogenic injury (such as with percutaneous drainage tube
placement and placement of orthopedic hardware).26 Penetrating injuries are
more likely to result in transection or pseudoaneurysm formation, with or
without arteriovenous fistula.27 Traumatic pseudoaneurysms are at high risk
for rupture and should all be treated, preferably with endovascular methods
when possible.
18
EXTREMITY INJURY
Traumatic vascular injury to the extremity may also cause life-threatening
hemorrhage, but, more commonly than in the pelvis, it may result in vessel
occlusion with signs of acute limb ischemia. Iatrogenic injury accounts for
74% of embolization procedures performed in the extremity.28 Many of these
are associated with orthopedic procedures, which are likely to increase as our
aging population requires an increasing number of major joint procedures.
Arterial injury associated with orthopedic procedures typically involves a
branch vessel in the pelvis or lower extremities, rather than a major artery,
and is thus ideally suited to treatment via endovascular methods.
28
Traumatic arterial injury of the extremity is divided into penetrating or
blunt trauma. The distinction between the two has important clinical
implications. Penetrating injury (more common) results in pseudoaneurysm,
arteriovenous fistula, and partial or complete transection.29 Outside of
iatrogenic causes, glass is the most common source of penetrating injury
followed by gunshot wounds and stab wounds.30 Blunt injury is often seen
with associated orthopedic trauma such as fracture and dislocation. The
vascular injury seen with blunt trauma is typically dissection,
pseudoaneurysm, or occlusion secondary to intramural hematoma or
traumatic thrombosis.31 Diagnosis of arterial injury in the setting of a
penetrating mechanism is usually more straightforward as there is obvious
external evidence of injury. Hard signs of injury are more likely to be present,
such as active external hemorrhage, enlarging hematoma, or obvious
indicators of limb ischemia.27 Signs of limb ischemia include pallor,
abnormal peripheral pulses, unequivocal neurologic defects, and a thrill or
bruit.
32
Blunt peripheral arterial injury is more likely to be occult with delayed
diagnosis and concomitant traumatic injuries to the head and body, which
may take precedence over the extremity.31 Diagnosis of blunt arterial injury
requires a higher index of suspicion and recognition of soft signs of vascular
injury. These include (1) discrepancies in the ankle–brachial index performed
with Doppler ultrasound and (2) adjacent injury, including fracture, nerve
injury, or stable hematoma.18 Duplex ultrasonography may be beneficial for
characterization of some specific vascular injuries, but CTA provides
clinically important additional information about extremity osseous and soft
tissue structures.
27,33
Additionally, newer CT scanners can acquire arterial
phase imaging of the extremities during the concomitant CTA evaluation of
the chest, abdomen, and pelvis. Conventional angiography for diagnostic
evaluation of acute arterial injury has largely been replaced by CTA, given
the excellent sensitivity of CTA.
33
Vascular injury is more common in the lower extremity than the upper
extremity, and the femoral and popliteal arteries are the most common sites
of vascular traumatic injury.34 Knee dislocation is a common cause of occult
lower extremity arterial injury.32 In the upper extremity, the brachial artery is
the most commonly injured vessel followed by the radial and ulnar arteries.
30
The arteries of the forearm typically do not require intervention for occlusive
traumatic injury secondary to collateral flow at the palmar arch.30 Blunt
brachial artery injury is most commonly seen in children in the setting of
elbow dislocation or displaced supracondylar fractures.35 Injury to the
axillary artery is less common but can be seen with severe anterior
dislocation of the glenohumeral joint.31 Additional damage to the branch
vessels of the axillary artery can also be seen with this mechanism of injury.
With respect to extremity treatment, embolotherapy is predominantly
indicated for hemorrhage originating from branch vessels that do not provide
distal perfusion.
18,29
Pseudoaneurysms and arteriovenous fistulas, even those
without active extravasation, are often appropriate indications for
embolization as well.
18,29
Acute injury of the larger vessels is more often
treated surgically, although endovascular treatment with stent graft placement
is increasing.36 Branches of the profunda femoral artery are an ideal site for
endovascular treatment of acute traumatic hemorrhage because these do not
provide direct perfusion to the distal extremity and are traditionally difficult
to access via a surgical approach.19 The branches surrounding the shoulder
and the profunda brachial artery are similarly potential candidates for TAE in
the upper extremity.
28,37
TECHNIQUE
Preprocedural Planning
Familiarity with the trauma history and all available medical information
including prior imaging is essential to assisting the trauma team in assessing
the appropriateness and timing of angiography. The local algorithm for the
treatment of the trauma patient should also be clearly understood. The
interventionalist should be familiar with Advanced Trauma Life Support
(ATLS) protocol and have an appropriate level of critical care support in the
angiography suite.
Embolic materials used in trauma are almost always coils, microcoils, or
Gelfoam (Pfizer Inc., New York, New York). Alternative large vessel
occlusion devices such as the Amplatzer 4 Vascular Plug (St. Jude Medical,
Inc., St. Paul, Minnesota) have seen increasing usage. Some authors have
described the use of liquid embolic agents such as Onyx (Covidien, Irvine,
California) and N-butyl cyanoacrylate (Trufill; Codman & Shurtleff, Inc.,
Raynham, Massachusetts), with the potential advantages of achieving vessel
occlusion in the setting of coagulopathy and providing distal control when
distal catheterization is not possible.
38,39
Cost, a steep learning curve, and a
potentially narrow safety profile are noteworthy considerations in the use of
liquid embolic agents. Catheter-directed thrombin has also been described for
the treatment of traumatic pseudoaneurysms of branches of the internal iliac
artery.40 We feel that the efficacy and safety profile of autologous clot, Onyx,
or glue are better choices when distal control cannot be achieved. Small
particles, including Gelfoam particles, have little or no role in the treatment
of acute trauma, and the use of alcohol in the trauma patient is
contraindicated.
18,19
Additional embolic agents that are mostly of historical
interest include clipped pieces of silk suture and segments of the outer
winding of a 0.035-in Bentson guidewire (Cook Medical, Inc., Bloomington,
Indiana).
Periprocedural considerations should include anticipating the impact of
CTA contrast within the urinary bladder. If there is suspicion for urethral
injury, pelvic angiography should not be delayed and consideration should be
given to delaying cystography until after the embolization procedure to avoid
extravasation of contrast.
19
Examination of the extremity color, temperature, and pedal pulses
(radial and ulnar pulses if upper extremity access is planned) should be
assessed by the interventionalist performing the procedure. Any
postprocedure change should prompt query into a potential complication,
such as reflux of embolic agents into the extremity vessels or access site
vascular injury.
SITE OF ACCESS AND DIAGNOSTIC IMAGING
Pelvic binders vary among institutions. Some are made of fabric, and a hole