Transcatheter embolization in the treatment of hemorrhage in pelvic trauma

Abstract

Massive hemorrhage related to pelvic trauma is relatively rare, but when it occurs rapid triage to therapeutic intervention is essential for survival. Traditional surgical repairs had limited success. Anatomic and clinical studies indicate that arterial hemorrhage is often identified in patients with hemodynamic instability that do not respond to initial resuscitation. Transcatheter angiography directly identifies arterial injury, and embolization can control retroperitoneal arterial hemorrhage. Stent-graft technology extends the scope of interventional therapy to include rapid and definitive repair of nonexpendable artery injury. Successful management requires coordination between multiple services and the continuation of resuscitative procedures in the angiography suite.

Keywords: Angiography; embolization; hemorrhage; pelvic fracture; trauma.

Figure 1

A 74-year-old woman passenger in a motor vehicle crash remained hypotensive despite initial fluid resuscitation. (A) Pelvic radiograph shows acetabular fracture (arrow) and large pelvic hematoma compressing bladder (arrowheads). (B) Computed tomography (CT) scan depicts caudal extent of the hematoma with active extravasation within (arrow). (C) Early and (D) late flush angiographic images of pelvis is shown. Note contrast extravasation (arrow) over left symphysis pubis. (E) Selective left internal iliac angiogram shows focus of extravasation from internal pudendal (arrow). (F) Late image from selective left internal iliac injection was taken after internal iliac Gelfoam embolization. There is stasis in the anterior division arteries (arrow). However, reflux into external iliac artery and opacification of the inferior epigastric and deep femoral branches were noted with subsequent extravasation at the area of injury (arrowhead). (G) Selective arteriogram shows symphyseal branch of inferior epigastric artery (arrow) with extravasation. (H) Unsubtracted image was taken after microcoil embolization (arrow) of inferior epigastric artery branch. Residual contrast is seen in multiple areas of extravasation (arrowheads). (I) Subtracted image of left iliac artcriogram shows occluded symphyseal branch (arrow at microcoil).

Figure 2

A 20-year-old man, after motor vehicle crash and after open repair of abdominal injury in the operating room, was transferred to vascular and interventional radiology (VIR) due to large retroperitoneal hematoma seen intraoperatively and continued blood requirements. Selective right internal iliac artery digital-subtracted angiogram shows multiple foci of extravasation from visceral and internal pudendal artery branches (arrowheads). These were successfully occluded with Gelfoam slurry.

Figure 3

After an automobile crash, this 62-year-old woman was referred to vascular and interventional radiology (VIR) for recurrent hypotension despite initial fluid and blood product administration. (A) Low abdominal aortic angiogram shows large area of extravasation from inferior gluteal transection (arrow). (B) Selective left internal iliac angiogram identifies superior gluteal artery (short arrow) and precisely localizes the lesion in the inferior gluteal (long arrow). (C) Transcatheter coil embolization shows coils deployed proximally (arrow) and distally (arrowhead) to the injury. (D) After embolization, internal iliac angiogram shows no flow into the inferior gluteal artery.

Figure 4

This inebriated 42-year-old man presented hypotensively with falling hematocrit after he fell down a couple flights of stairs. (A) Computed tomography image shows fracture in right iliac (arrow) and adjacent hematoma with active extravasation (arrowhead). (B) Selective right internal iliac angiogram shows extravasation at level of fracture from iliolumbar branch (arrow). (C) Selective right fourth lumbar angiogram shows collateral supply to the injury at the fracture site (arrow), as well as a more distal lumbar injury with extravasation (arrowhead).