Interventional Radiology in Pelvic Trauma

Abstract

Traumatic pelvic injuries are associated with high injury severity scores and significant morbidity and mortality. As fractures and ligamentous disruption result in increased pelvic volume, retroperitoneal hemorrhage can spiral and progress to hemorrhagic shock. Due to the extensive collateral supply and limitations of surgery for pelvic hematomas, angiographic treatment is at the forefront of pelvic trauma management. This article will discuss typical injuries seen in pelvic trauma, treatment modalities available to the interventional radiologist, and common angiographic treatment strategies and techniques.

Keywords: angiography; embolization; hemorrhage; interventional radiology; pelvic trauma.

Fig. 1

Axial ( a ) and coronal ( b ) CTA of a patient with corona mortis variant, demonstrating the typical course over the anterior lip of the left acetabulum ( arrows ).

Fig. 2

Patient who fell four stories and suffered from multiple pelvic fractures. Axial CTA shows active extravasation, in the territory of the right inferior gluteal artery ( arrow ; a ) and left internal pudendal artery ( arrowhead ; b ). The specific arteries involved could not be identified on CTA; however, the predicted arteries based on these vascular territories proved to be correct on subsequent angiography. Additionally seen is a fracture of the left pubic ramus closely associated with the internal pudendal territory extravasation.

Fig. 3

Left internal iliac artery angiography ( a ) of the same patient from Fig. 2 demonstrating contrast blush ( arrow ) arising from the left internal pudendal artery consistent with injury pattern on CTA. There is early venous filling consistent with a traumatic arteriovenous fistula. The left internal pudendal artery was embolized using Nester coils ( arrow ; Cook Medical, Bloomington, IN) until stasis was achieved ( b ).

Fig. 4

The same patient from Figs. 2 and 3 , with right internal iliac artery angiography showing contrast blush arising off the right inferior gluteal artery (not shown). Subsequent selective angiography of the right inferior gluteal artery again showed contrast blush arising from the right inferior gluteal artery with a small pseudoaneurysm ( arrow ; a ). Using a microcatheter, the pseudoaneurysm and tear in the artery was selected ( b ). Micro-Nester coils were used to embolize the pseudoaneurysm and the front and back door of the right inferior gluteal artery. This was followed by Gelfoam slurry. Repeat angiography showed no continued hemorrhage ( c ).

Fig. 5

Patient with a gunshot wound to the abdomen. Thoracic/abdominal aortogram showing frank extravasation of contrast arising from the distal abdominal aorta ( arrow ) with visualized ballistic fragment just to the left of the aorta ( arrowhead ; a ). Over an Amplatz wire (Boston Scientific, Marlborough, MA) a 12-mm compliant occlusion balloon was inflated over the site of active hemorrhage ( arrow ; b ). A 12 × 40 mm covered stent graft was then deployed ( c ). Postdeployment angiography showed no evidence of endoleak or arterial extravasation. A final flush aortogram confirmed these findings ( d ).

Fig. 6

Patient with coagulopathy and iatrogenic penetrating trauma following attempted line catheter placement. Axial CTAs ( a and b ) show a right retroperitoneal hematoma with active extravasation ( arrow ) from the right external iliac artery. Right common iliac angiography demonstrated focal extravasation ( arrow ) from the right external iliac artery ∼2 cm proximal to the inferior epigastric artery, consistent with findings on CTA ( c ). An 8-mm Viabahn stent (Gore & Associates, Inc, Flagstaff, AZ) was placed in the right external iliac artery ( arrow ) across the area of extravasation ( d ). The stent was balloon expanded to 9 mm and repeat angiography of the right common iliac artery did not demonstrate extravasation ( e ).

Fig. 7

Patient involved in a motor vehicle collision found to have a left pubis fracture seen on pelvis radiograph ( a ). On subsequent CTA, the fracture was again visualized as a left parasymphyseal pubic fracture ( arrow ; b ) with a hematoma adjacent to the urinary bladder and partially extending into the left internal canal ( arrows ) on axial ( c ) and coronal ( d ). No evidence of active extravasation was seen. Pelvic angiography demonstrated a paucity of distal arterial branches near the left pubic rim fractures, specifically vessel cutoff signs noted arising from the left obturator arterial branches (not shown). Subselective left obturator artery angiography showed vessel irregularity and irregularity from a medial branch of the left obturator artery ( e ). Following this, a solitary 3 × 50 mm Nester coil was deployed within the left obturator artery and post embolization left obturator artery angiography showed significant reduction of flow within the left obturator artery ( f ).

Fig. 8

Patient involved in motor vehicle collision found to have multiple pelvic fractures including the left acetabulum ( black arrow ), left iliac wing ( arrowhead ), and pubic body/superior pubic ramus ( white arrow ) among others ( a ). Subsequent CTA again showed the left acetabular fracture with a corona mortis variant ( arrow ) seen traversing in its classic location over the anterior lip of the acetabulum ( b ). Pelvic angiography (not shown) again demonstrated the aberrant left obturator artery arising from the left external iliac artery and sharing a short common trunk with the left inferior epigastric artery. The common trunk of the left inferior epigastric and left obturator was catheterized and angiography of both vessels showed no active hemorrhage or pseudoaneurysm ( c ). Given the irregularity of the vessel on CTA, the left obturator artery was embolized using two 4 mm × 7 cm Nester coils ( arrows ). The postembolization angiography confirmed occlusion of the left obturator corona mortis variant ( d ).