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Chapter 25
Embolization of Hemorrhage Due to Pelvic Fractures
Douglas Coldwell and Clayton Trimmer
Clinical Features
• Due to disruption of the pelvic ring due to blunt trauma.
Types of pelvic fractures are as follows:
• Lateral compression—causes vertical compression fracture in sacrum and
oblique fractures of the pubic rami anteriorly.
• Anterior–posterior—opens the pelvis with rotation of iliac wings outward and
disruption of pubic symphysis and sacral-iliac joints.
• Vertical shear—moves one hemi-pelvis superiorly, tearing the SI joint.
• Combination—mixed features of any of above, usually in much more severe
trauma.
• Extent of vascular damage always greater than plain films would suggest due to
shearing action of the ligaments in the pelvis.
• The more severe the instability of the pelvic fracture, the more likely it is that
life-threatening hemorrhage will occur.
• Bleeding as a result of pelvic injury comes from
1. Arterial injury—hemodynamic instability and needs embolization
immediately.
2. Venous injury—especially the posterior venous plexus; bleeding normally
stops with stabilization of the pelvis with external wrap or external fixators.
3. Fractured cancellous bone edges—stabilized with external fixators.
4. Other injuries, e.g., solid organ injury!! This may be overlooked by orthopedic
surgeons.
Diagnostic Evaluation
Laboratory
• Many of these patients are hemodynamically unstable and require blood products to maintain their blood pressure with decreasing hemoglobin/hematocrit,
Transcatheter Embolization and Therapy,
Techniques in Interventional Radiology, DOI 10.1007/978-1-84800-897-7_25,
C
Springer-Verlag London Limited 2010
241
242 D. Coldwell and C. Trimmer
increasing lactic acidosis (base deficit), and hypothermia. All procedures must
be performed in the most expeditious way possible. Time is of the essence.
Imaging (see also Chapter 10)
Clear protocols need to be in place to ensure rapid and appropriate imaging.
• Stable patients with or without fluid resuscitation should undergo a CT scan
first in order to assess the state of their injuries; splenic or hepatic injury is
common. Additionally, the CT will demonstrate sites of hemorrhage allowing
the interventional radiology team to focus their attention directly to the sites of
hemorrhage.
• Patients who are unstable despite fluid resuscitation should go straight to interventional radiology where their hemorrhage sites can be embolized. Trauma
surgeons may wish to place an external fixator device first so that the pelvic
fracture fragments can be stabilized. A pelvic wrap is preferable to an external
bone fixator, as it simplifies arterial access and angiography.
Indications
• Any bleeding that results in hemodynamic instability or continued loss of blood
over the patient’s hospitalization.
Contraindications
• Relative only. If the patient is unstable despite fluid resuscitation, they need
immediate surgery or embolization. It may be necessary to go to the operating
room to begin the procedure while the surgeon is exploring.
• Not having the interventional radiology team available on a 20-minute call-back
time. This does not usually occur at a Level-1 trauma center.
Complications
• Non-target embolization. This is typically avoided if the embolization is performed under continuous monitoring with frequent checks for stasis.
• Impotence has been suggested as a complication but it is most likely due to
the disruption of the neural plexus. As Dr. Yorum Ben-Menachem, one of the
fathers of trauma angiography, once said, “I would rather have a patient alive and
impotent than dead with a massive erection.”
25 Embolization of Hemorrhage Due to Pelvic Fractures 243
Anatomy
• The vessels of the pelvis are reasonably consistent.
• The common iliac artery bifurcates to the following:
◦ External iliac artery
Inferior epigastric artery—originates at about the level of the inguinal lig-
ament and supplies the anterior abdominal wall, anastomozing with the
internal mammary artery at the level of the diaphragm.
Pubic symphaseal artery—may originate directly from the external iliac
or the inferior epigastric artery.
◦ Internal iliac artery—concentrate here as most of the arteries effected will be
in this distribution. Bifurcates to
Anterior division
• Obturator artery—passing through the obturator foramen.
• Inferior gluteal—supplying the buttocks.
• Umbilical artery/superior vesical artery—feeding the bladder.
• Uterine artery—may also originate vaginal artery.
• Inferior vesical artery—supplying bladder.
• Middle rectal artery.
• Internal pudendal artery—supplying genitalia.
Posterior division
• Superior gluteal artery—commonly injured.
• Iliolumbar artery.
• Sacral arteries.
Equipment
Catheters Required
• Non-selective
◦ Pigtail or other flush catheter to be used at the aortic bifurcation.
• Selective catheters
◦ Cobra or Headhunter or Berenstein type—simple curve for selection.
◦ Reverse curve catheters like the Simmons 1 or Sos selective. Usually 5Fr.
• Vascular sheath
◦ 5 or 6Fr
244 D. Coldwell and C. Trimmer
Embolization Agents
• The goal of trauma embolization is to achieve tissue ischemia, not tissue necrosis.
• Gelfoam slurry—the mainstay of trauma embolization. Will dissolve in hours
to days.
• Coils—stainless steel or platinum. Use in larger vessels when permanent occlusion is necessary, e.g., on-going severe hemorrhage. Use gelfoam suspension first,
then place coils in internal iliac or anterior/posterior division of internal iliac
artery (“gelfoam-coil sandwhich” technique). Authors preference is not to use
coils bilaterally unless absolutely necessary.
• Glue—should only be used by those experienced, with it; it is very expensive and
typically requires the use of a microcatheter.
Angiography (See Figs. 25.1 and 25.2)
• Selective or even non-selective arteriography will demonstrate the arterial damage by the following:
◦ Obvious extravasation of contrast into the soft tissues
◦ Blunt ending artery—check for retrograde filling of the more distal arterial
distribution via collaterals.
◦ Spasm in the artery.
• Place sheath in groin, as removing it at end of the procedure will take additional
time and the patient is likely coagulopathic. Suture sheath in place for removal
later.
Fig. 25.1 Arteriogram
demonstrates the classic
appearance of extravasation
due to a very significant
hemorrhage i n the pelvis due
to a complete transaction of
the external iliac artery at the
level of the inguinal ligament
25 Embolization of Hemorrhage Due to Pelvic Fractures 245
a
c
b
d
Fig. 25.2 (a) CT scan of pelvis demonstrates ongoing hemorrhage. (b) Pelvic flush arteriogram
does not demonstrate any ongoing hemorrhage. (c) Selective external iliac arteriogram shows
the extravasating contrast due to the hemorrhage. This originated from the anatomic variant of
a replaced obturator artery to the external iliac artery. (d) Selective embolization of this artery with
coils was performed halting the hemorrhage
• The pelvic aortogram should be performed first to obtain a view of the entire
area. Then more selective arteriograms of the internal iliac arteries bilaterally are performed, even in the absence of vascular injury on the flush pelvic
angiogram.
• The internal iliac anatomy is reasonably predictable but time is of the essence.
A more proximal embolization in the internal iliac artery rather than selective
embolization is preferred if it is going to require extra time and there is ongoing
severe hemorrhage.
• Microcatheters are usually not required, as the selective work necessary can be
performed with a 5Fr catheter. Microcatheters may be required if the bleeding
artery is small and if microcoils are utilized.
• If the bleeding site is not found within the internal iliac distribution, an external
iliac arteriogram should be performed. Branches of the external iliac, e.g., pubic
symphaseal branches, also supply the pelvis.
246 D. Coldwell and C. Trimmer
• Very distal embolization should not be performed bilaterally, as the collateral arteries to the same structure would be eliminated, leading to tissue
necrosis.
• Place the catheter in position for embolization and slowly inject the Gelfoam,
observing under fluoroscopy continuously. Every few milliliters of suspension,
check for stasis with a small contrast injection.
• For the final arteriogram before ending the study, use either an internal iliac run if
the embolization was unilateral or an aortogram at the aortic bifurcation to check
for any untreated sites (Fig. 25.3).
Fig. 25.3 Management of pelvic fractures
Recommendations
Note: Insure that cystography is not performed before the arteriogram. It delays
the study and, more important, if the bladder is torn, the contrast will obscure the
angiographic extravasation of contrast and the study will be compromised.
25 Embolization of Hemorrhage Due to Pelvic Fractures 247
Keypoints
Venous bleeding will usually stop with external compression.
Arterial bleeding will not stop and needs immediate embolization.
Signs of arterial bleeding include extravasation of CM, spasm, and abrupt
arterial cut-off.
Gelfoam slurry is the preferred agent.
Suggested Reading
1. Ben-Menachem Y, Coldwell DM, Young J, Burgess A: Hemorrhage Associated with Pelvic
Fractures: Causes, Diagnosis, and Emergency Management. AJR 157:1005, 1991.
Chapter 26
Embolization of Extremity Trauma
Tanya Tivorsak and Catherine Vu
Clinical Features
Management Goals
• Life-saving and resuscitation: direct application of pressure on bleeding site or
proximal tourniquet remains first step in control of hemorrhage.
• Limb salvage.
• Preservation of limb function.
• Clinical urgency depends on the presentation.
Mechanisms of Extremity Vascular Injury
• Penetrating injury: shooting, stabbing (more common)—causes transection,
pseudoaneurysm, or arteriovenous fistula.
• Blunt injury: in the setting of fractures and joint dislocation—causes dissection or
spasm. Some injuries such as knee dislocation are particularly prone to associated
vascular injury.
Clinical Manifestations of Extremity Vascular Trauma
• Hemorrhage
• Ischemia
• Compartment syndromes
Role of Intervention
• Rapid control of hemorrhage
• Definitive therapy
• Pre-operative intervention to temporize bleeding prior to surgery
• Post-operative intervention to control non-operative vascular bleeding
Transcatheter Embolization and Therapy,
Techniques in Interventional Radiology, DOI 10.1007/978-1-84800-897-7_26,
C
Springer-Verlag London Limited 2010
249
250 T. Tivorsak and C. Vu
Diagnostic Evaluation
This includes clinical and imaging.
Clinical Evaluation
Physical Signs of Vascular Injury
These can be misleading; remember that injuries proximal to the shoulder girdle and
hips have variable signs on physical examination. Consider the mechanism of the
injury and the possibility of co-existing remote problem, e.g., aortic injury, organ
damage.
Hard Signs—Indicate increased likelihood of vascular injury requiring
intervention.
• Diminished or absent peripheral pulses or asymmetric limb blood pressures
• Expanding hematoma
• Vascular thrill or bruit
• Active or pulsatile arterial hemorrhage
• Limb ischemia (5Ps = pain, pallor, paresthesias, pulse deficit, paralysis)
Soft Signs—Less useful in predicting vascular injury requiring intervention.
• Hypotension or shock: remember that this may be a manifestation of another
more serious injury!
• Adjacent nerve injury
• Adjacent fracture
• Stable/non-pulsatile hematoma
• Delayed capillary refill
• Soft tissue injury
Laboratory: Decreasing hematocrit and hemoglobin are usually present.
Coagulopathy may be present in the setting of large volume transfusion.
Imaging
Radiographs
• Initial evaluation in extremity trauma—assess for displaced fractures but do not
give information on the blood vessels.
26 Embolization of Extremity Trauma 251
Computed tomography angiography (CTA): CTA is becoming a crucial
investigation in trauma.
• Demonstrates signs of arterial injuries including active extravasation of contrast,
pseudoaneurysm, occlusion/stenosis/narrowing of an artery, early draining vein
in arteriovenous fistula (AVF).
• Identifies collaterals and variant anatomy.
• Identifies other injuries.
Catheter Angiography
• Usually performed in association with intervention to control bleeding or restore
flow.
• May be required to demonstrate distal circulation.
Ultrasound with Doppler/Duplex
• Promising but not widely used
• Operator dependent
Magnetic resonance angiography—not commonly used in the acute setting.
Indications
• Bleeding
◦ In areas that are difficult to access surgically
◦ Control of bleeding prior to surgical repair
◦ Ongoing bleeding after surgical operation
◦ In poor operative candidates
• Pseudoaneurysm Formation
• Arteriovenous Fistula Formation
• Hemodynamic Instability
Alternative Therapies
• Direct compression and tourniquet first aid. Compression may be therapeutic in
minor injury (just like post-angiography).
• Endovascular: balloon tamponade, stent graft.
• Emergent exploration and surgical correction—especially when arterial injury is
associated with ischemia of the extremity.
• Ultrasound-guided compression closure and ultrasound-guided thrombin injection for pseudoaneurysms. Seldom used in the context of acute trauma.