Langenbeck's Archives of Surgery

, Volume 396, Issue 2, pp 243–250 | Cite as

Angioembolization and laparotomy for patients with concomitant pelvic arterial hemorrhage and blunt abdominal trauma

  • Jen-Feng FangEmail author
  • Lih-Yuann Shih
  • Yon-Cheong Wong
  • Being-Chuan Lin
  • Yu-Pao Hsu
Original Article



Treatment of patients with concomitant pelvic arterial hemorrhage and blunt abdominal trauma (BAT) is challenging. Controversies remain over the diagnostic approach and the priority of available treatment resources.


Between 1999 and 2008, 545 patients were admitted due to concomitant BAT and pelvic fracture. Seventy-six patients receiving both angiography and laparotomy were studied. Focused abdominal sonography for trauma (FAST) was used as the primary triage tool in the early 5 years and multi-detector computed tomography (MDCT) in the later 5 years. The clinical courses and results were retrospectively analyzed to determine if the evolution of the clinical pathways for managing these patients resulted in improved outcomes.


Performing laparotomy solely based on FAST during the early 5 years resulted in a high nontherapeutic laparotomy rate (36%). Contrast enhanced MDCT, as the primary triage tool, accurately disclosed active intra-abdominal and pelvic injuries and was helpful in promptly tailoring the subsequent treatment. Additional surgical trauma was avoided in some patients and nontherapeutic laparotomy rate decreased to 16%. Multiple bleeders were found in 70% of positive angiograms; bilateral internal iliac artery embolization for the purpose of damage control showed a lower repeat angioembolization rate for these severely injured patients.


The revised clinical algorithm served well for guiding the treatment pathway. Priority of laparotomy or angiography should be individualized and customized according to the clinical evaluation and CT findings. Angiography can be both diagnostic and therapeutic and simultaneously treat multiple bleeders; thus, it has a higher priority than laparotomy. The primary benefits of our later clinical pathway were in reducing nontherapeutic laparotomy and repeat angioembolization rates.


Pelvic fracture Blunt abdominal trauma (BAT) Angiography Transarterial embolization (TAE) Laparotomy 


Conflicts of interest



  1. 1.
    Demetriades D, Karaiskakis M, Toutouzas K et al (2002) Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes. J Am Coll Surg 195:1–10CrossRefPubMedGoogle Scholar
  2. 2.
    Grotz MR, Gummerson NW, Gansslen A et al (2006) Staged management and outcome of combined pelvic and liver trauma—an international experience of the deadly duo. Injury 37:642–651CrossRefPubMedGoogle Scholar
  3. 3.
    Biffl WL, Smith WR, Moore EE et al (2001) Evolution of a multidisciplinary clinical pathway for the management of unstable patients with pelvic fractures. Ann Surg 233:843–850CrossRefPubMedGoogle Scholar
  4. 4.
    Heetveld MJ, Harris I, Schlaphoff G et al (2004) Hemodynamically unstable pelvic fractures: recent care and new guidelines. World J Surg 28:904–909CrossRefPubMedGoogle Scholar
  5. 5.
    Davis JW, Moore FA, McIntyre RC Jr et al (2008) Western trauma association critical decisions in trauma: management of pelvic fracture with hemodynamic instability. J Trauma 65:1012–1015CrossRefPubMedGoogle Scholar
  6. 6.
    Bassam D, Cephas GA, Ferguson KA et al (1998) A protocol for the initial management of unstable pelvic fracture. Am Surg 64:862–867PubMedGoogle Scholar
  7. 7.
    Eastridge BJ, Starr A, Minei JP et al (2002) The importance of fracture pattern in guiding therapeutic decision-making in patients with hemorrhagic shock and pelvic ring disruptions. J Trauma 53:446–451CrossRefPubMedGoogle Scholar
  8. 8.
    Durkin A, Sagi HC, Durham R et al (2006) Contemporary management of pelvic fractures. Am J Surg 192:211–223CrossRefPubMedGoogle Scholar
  9. 9.
    Gansslen A, Giannoudis P, Pape HC (2003) Hemorrhage in pelvic fracture: who needs angiography? Curr Opin Crit Care 9:515–523CrossRefPubMedGoogle Scholar
  10. 10.
    Osborn PM, Smith WR, Moore EE et al (2009) Direct retroperitoneal pelvic packing versus pelvic angiography: a comparison of two management protocols for hemodynamically unstable pelvic fractures. Injury 40:54–60CrossRefPubMedGoogle Scholar
  11. 11.
    Verbeek D, Sugrue M, Balogh Z et al (2008) Acute management of hemodynamically unstable pelvic trauma patients: time for a change? Multicenter review of recent practice. World J Surg 32:1874–1882CrossRefPubMedGoogle Scholar
  12. 12.
    Foley WD (2002) Special focus session: multidetector CT: abdominal visceral imaging. Radiographics 22:701–719PubMedGoogle Scholar
  13. 13.
    Dondelinger RF, Trotteur G, Ghaye B et al (2002) Traumatic injuries: radiological hemostatic intervention at admission. Eur Radiol 12:979–993CrossRefPubMedGoogle Scholar
  14. 14.
    Fang JF, Wong YC, Lin BC et al (2006) Usefulness of multidetector computed tomography for the initial assessment of blunt abdominal trauma patients. World J Surg 20:176–182CrossRefGoogle Scholar
  15. 15.
    Velmahos GC, Toutouzas KG, Vassiliu P et al (2002) A prospective study on the safety and efficacy of angiographic embolization for pelvic and visceral injuries. J Trauma 52:303–308CrossRefGoogle Scholar
  16. 16.
    Margolies MN, Ring EJ, Waltman AC et al (1972) Arteriography in the management of hemorrhage from pelvic fractures. N Engl J Med 287:317–321CrossRefPubMedGoogle Scholar
  17. 17.
    Miller PR, Moore PS, Mansell E et al (2003) External fixation or arteriogram in bleeding pelvic fracture: initial therapy guided by markers of arterial hemorrhage. J Trauma 54:437–443CrossRefPubMedGoogle Scholar
  18. 18.
    Agolini SF, Shah K, Jaffe J et al (1997) Arterial embolization is a rapid and effective technique for controlling pelvic fracture hemorrhage. J Trauma 43:395–399CrossRefPubMedGoogle Scholar
  19. 19.
    Bryceland JK, Keating JF (2008) Laparotomy and unstable pelvic fractures. Injury 39:853–857CrossRefPubMedGoogle Scholar
  20. 20.
    Hagiwara A, Minakawa K, Fukushima H et al (2003) Predictors of death in patients with life-threatening pelvic hemorrhage after successful transcatheter arterial embolization. J Trauma 55:696–703CrossRefPubMedGoogle Scholar
  21. 21.
    American College of Surgeons Committee on Trauma (1997) Advanced trauma life support, 6th ednGoogle Scholar
  22. 22.
    Fang JF, Shih LY, Wong YC et al (2009) Repeat transcatheter arterial embolization for the management of recurrent pelvic arterial hemorrhage. J Trauma 66:429–435CrossRefPubMedGoogle Scholar
  23. 23.
    Stengel D, Bauwens K, Rademacher G et al (2005) Association between compliance with methodological standards of diagnostic research and reported test accuracy: meta-analysis of focused assessment of US for trauma. Radiology 236:102–111CrossRefPubMedGoogle Scholar
  24. 24.
    Becker A, Lin G, McKenney MG et al (2010) Is the FAST exam reliable in severely injured patients? Injury 41:479–483CrossRefPubMedGoogle Scholar
  25. 25.
    Friese RS, Malekzadeh S, Shafi S et al (2007) Abdominal ultrasound is an unreliable modality for the detection of hemoperitoneum in patients with pelvic fracture. J Trauma 63:97–102CrossRefPubMedGoogle Scholar
  26. 26.
    Shanmuganathan K, Mirvis SE, Sherbourne CD et al (1999) Hemoperitoneum as the sole indicator of abdominal visceral injuries: a potential limitation of screening abdominal US for trauma. Radiology 212:423–430PubMedGoogle Scholar
  27. 27.
    Bansal V, Fortlage D, Lee J et al (2009) Hemorrhage is more prevalent than brain injury in early trauma deaths: the golden six hours. Eur J Trauma Emerg Surg 35:26–30CrossRefGoogle Scholar
  28. 28.
    Soreide K, Krüger AJ, Vårdal AL et al (2007) Epidemiology and contemporary patterns of trauma death: changing place, similar place, old faces. World J Surg 31:2092–2103CrossRefPubMedGoogle Scholar
  29. 29.
    Huber-Wagner S, Lefering R, Qvick LM et al (2009) Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet 373:1455–1461CrossRefPubMedGoogle Scholar
  30. 30.
    Shapiro M, McDonald AA, Knight D et al (2005) The role of repeat angiography in the management of pelvic fractures. J Trauma 58:227–231CrossRefPubMedGoogle Scholar
  31. 31.
    Gourlay D, Hoffer E, Routt M et al (2005) Pelvic angiography for recurrent traumatic pelvic arterial hemorrhage. J Trauma 59:1168–1174CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  • Jen-Feng Fang
    • 1
    Email author
  • Lih-Yuann Shih
    • 2
  • Yon-Cheong Wong
    • 3
  • Being-Chuan Lin
    • 1
  • Yu-Pao Hsu
    • 1
  1. 1.Trauma and Critical Care Center, Department of SurgeryChang-Gung Memorial Hospital, Chang-Gung UniversityTaoyuanTaiwan
  2. 2.Department of OrthopedicsChang-Gung Memorial Hospital, Chang-Gung UniversityTaoyuanTaiwan
  3. 3.Department of Radiology, Chang-Gung Memorial HospitalChang-Gung UniversityTaoyuanTaiwan

Personalised recommendations