Proposal of standardization of every step of angiographic procedure in bleeding patients from pelvic trauma

Abstract

Trauma accounts for a third of the deaths in Western countries, exceeded only by cardiovascular disease and cancer. The high risk of massive bleeding, which depends not only on the type of fractures, but also on the severity of any associated parenchymal injuries, makes pelvic fractures one of the most life-threatening skeletal injuries, with a high mortality rate. Therefore, pelvic trauma represents an important condition to correctly and early recognize, manage, and treat. For this reason, a multidisciplinary approach involving trauma surgeons, orthopedic surgeons, emergency room physicians and interventional radiologists is needed to promptly manage the resuscitation of pelvic trauma patients and ensure the best outcomes, both in terms of time and costs. Over the years, the role of interventional radiology in the management of patient bleeding due to pelvic trauma has been increasing. However, the current guidelines on the management of these patients do not adequately reflect or address the varied nature of injuries faced by the interventional radiologist. In fact, in the therapeutic algorithm of these patients, after the word "ANGIO", there are no reports on the different possibilities that an interventional radiologist has to face during the procedure. Furthermore, variations exist in the techniques and materials for performing angioembolization in bleeding patients with pelvic trauma. Due to these differences, the outcomes differ among different published series. This article has the aim to review the recent literature on optimal imaging assessment and management of pelvic trauma, defining the role of the interventional radiologist within the multidisciplinary team, suggesting the introduction of common and unequivocal terminology in every step of the angiographic procedure. Moreover, according to these suggestions, the present paper tries to expand the previously drafted algorithm exploring the role of the interventional radiologist in pelvic trauma, especially given the multidisciplinary setting.

Keywords: Angioembolization; Angiography; Bleeding; Interventional radiology; Pelvic trauma.

Fig. 1

Fracture site related to the pelvic artery more likely to be injured by that kind of fracture (modified from [49], artist: Mr Philippe Payet)

Fig. 2

The standard approach for a correct proximal angiographic study in a bleeding pelvic trauma includes studies performed after the insertion of the catheter in the distal abdominal aorta (A), the right common iliac artery (B), the right internal iliac artery (C), the right common femoral artery (D), the left common iliac artery (E), the left internal iliac artery (F), and the left common femoral artery (G). The subsequent digital subtracted images of these studies are shown in the corresponding panels (A′–G′)

Fig. 3

Treatment algorithm for pelvic trauma (modified from [14])

Fig. 4

Axial CT of a stable patient with a fracture of the right pubic ramus (circled in A) presenting with a small focal region of contrast extravasation (circled in B). Proximal angiograms, from the right external iliac artery (C) and from right internal iliac artery (D), showing no signs of contrast extravasation in correspondence of the site of the findings on CT. The selective catheterizations of the suspected injured arteries based on CT findings, for the digital studies, i.e., of the right external obturator artery [non-subtracted (E) and subtracted (F) angiograms] and of the right internal obturator artery [non-subtracted (G) and subtracted (H) angiograms], showing no signs of bleeding. According to the proposed algorithm, the angiographic study was considered completed and the empiric embolization was not performed

Fig. 5

Axial CT of a stable patient with a fracture of the left pubic ramus (circled in A) and pelvic hematoma (circled in B). Proximal non-subtracted angiogram of the left external iliac artery (C) showing no focal “blush”. The subsequent selective study of the left internal obturator artery demonstrating the contrast blush [circled in subtracted image (D)] in correspondence consistent with injury lesions on CT and suitable for superselective embolization; digital subtracted image of the same patient, allowing a more accurate depiction of the arterial extravasation (circled in E). Selective catheterization of the injured artery (F). The arterial branch responsible for the blush was embolized with Glue, a definitive embolic agent (head arrow in G) while the upper obturator branch that supplies external genitalia is closed with Spongel, an absorbable embolic material (arrow in G). Compared to the pre-procedural angiography in which are highlighted the vessel (red points in H) responsible for bleeding (circled in H), the post-embolization angiogram confirms a successful occlusion only of the injured artery (arrow in I) with the regular patency of the remaining vessels