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Pelvic ring fractures with concomitant large hematomas: diagnostic investigation with arteriography and eventual embolization in 157 trauma patients, with or without contrast extravasation at emergency CT

  • Vascular and Interventional Radiology
  • Published:
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A Correction to this article was published on 11 October 2023

This article has been updated

Abstract

Purpose

This study aims to evaluate the diagnostic value of pelvic arteriography in patients with pelvic ring fractures and associated large hematomas, in both cases of positive or negative findings of contrast agent extravasation at emergency CT; in those patients with positive DSA subsequently treated with embolization, correlations with clinical–radiological parameters were investigated.

Materials and methods

In this single-center retrospective study, patients with acute blunt pelvic trauma showing at CT pelvic ring fractures with associated large (> 3 cm) hematoma, with or without signs of arterial bleeding, were investigated with DSA. Technical success was considered radiographic bleeding control with disappearance of angiographic bleeding; clinical success was defined as clinical bleeding control hemodynamically stable, before applying other surgical maneuvers. Pelvic ring fractures were evaluated according to Tile classification system.

Results

One hundred and fifty-seven patients, mean age 54years, were analyzed. 70.7% had polytrauma; 14.6% patients assumed antiplatelets and/or anticoagulation therapy. False-negative and false-positive rates at CT were 29.6% and 27.1%, respectively. Polytrauma and B3/C1 Tile pattern fractures were significantly associated with bleeding signs at DSA. Seventy-two patients required embolization: 52.8% showed direct signs of DSA bleeding; among these, technical and clinical successes were 88.8% and 81.9%, respectively.

Conclusions

In this study, patients with pelvic ring fractures and concomitant hematomas > 3 cm, with or without contrast extravasation at CT, have been examined in depth with DSA focusing on both direct and indirect angiographic signs of bleeding, finding polytrauma and Tile fracture patterns B3/C1 predictive factors for arterial hemorrhage detection at DSA despite negative CT findings.

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Change history

  • 28 September 2023

    In the original version of this article, the fourth author’s name was published incorrectly as “Edoardo Casciano” instead of “Eduardo Casciano” and has now been corrected.

  • 11 October 2023

    A Correction to this paper has been published: https://doi.org/10.1007/s11547-023-01729-z

References

  1. Ierardi AM, Duka E, Lucchina N et al (2016) The role of interventional radiology in abdominopelvic trauma. Br J Radiol 89(1061):20150866

    Article  PubMed  PubMed Central  Google Scholar 

  2. Ierardi AM, Piacentino F, Fontana F et al (2015) The role of endovascular treatment of pelvic fracture bleeding in emergency settings. Eur Radiol 25(7):1854–64

    Article  PubMed  Google Scholar 

  3. Hoff WS, Holevar M, Nagy KK et al (2002) Eastern asociation for the surgery of Trauma. Practice management guidelines for the evaluation of blunt abdominal trauma: the East practice management guidelines work group. J Trauma 53(3):602–15

    Article  PubMed  Google Scholar 

  4. Huber-Wagner S, Lefering R, Qvick LM et al (2009) Effect of wholebody CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet 373(9673):1455–1461

    Article  PubMed  Google Scholar 

  5. Chidambaram S, Goh EL, Khan MA (2017) A meta-analysis of the efficacy of whole-body computed tomography imaging in the management of trauma and injury. Injury 48(8):1784–1793

    Article  PubMed  Google Scholar 

  6. Raniga SB, Mittal AK, Bernstein M, Skalski MR, Al-Hadidi AM (2019) Multidetector CT in vascular injuries resulting from pelvic fractures: a primer for diagnostic radiologists. Radiographics 39(7):2111–2129

    Article  PubMed  Google Scholar 

  7. Dreizin D, Bodanapally U, Boscak A et al (2018) CT prediction model for major arterial injury after blunt pelvic ring disruption. Radiology 287(3):1061–1069

    Article  PubMed  Google Scholar 

  8. Miller PR, Moore PS, Mansell E, Meredith JW, Chang MC (2005) External fixation or arteriogram in bleeding pelvic fracture: initial therapy guided by markers of arterial hemorrhage. J Trauma 54(3):437–443

    Article  Google Scholar 

  9. Dreizin D, Liang Y, Dent J, Akhter N, Mascarenhas D, Scalea TM (2020) Diagnostic value of CT contrast extravasation for major arterial injury after pelvic fracture: a meta-analysis. Am J Emerg Med 38(11):2335–2342

    Article  PubMed  Google Scholar 

  10. Hallinan JT, Tan CH, Pua U (2014) Emergency computed tomography for acute pelvic trauma: where is the bleeder? Clin Radiol 69(5):529–37

    Article  CAS  PubMed  Google Scholar 

  11. Coccolini F, Stahel PF, Montori G et al (2017) Pelvic trauma: WSES classification and guidelines. World J Emerg Surg. 18:12–15

    Google Scholar 

  12. Iacobellis F, Scaglione M, Brillantino A et al (2019) The additional value of the arterial phase in the CT assessment of liver vascular injuries after high-energy blunt trauma. Emerg Radiol 26(6):647–654

    Article  PubMed  Google Scholar 

  13. Tile M (1988) Pelvic ring fractures: should they be fixed? J Bone Joint Surg Br 70(1):1–12

    Article  CAS  PubMed  Google Scholar 

  14. Niola R, Pinto A, Sparano A, Ignarra R, Romano L, Maglione F (2012) Arterial bleeding in pelvic trauma: priorities in angiographic embolization. Curr Probl Diagn Radiol 41(3):93–101

    Article  PubMed  Google Scholar 

  15. Filippiadis DK, Binkert C, Pellerin O, Hoffmann RT, Krajina A, Pereira PL (2017) Cirse quality assurance document and standards for classification of complications: the Cirse classification system. Cardiovasc Interv Radiol 40(8):1141–1146

    Article  CAS  Google Scholar 

  16. Salim A, Teixeira PG, DuBose J et al (2008) Predictors of positive angiography in pelvic fractures: a prospective study. J Am Coll Surg 207(5):656–662

    Article  PubMed  Google Scholar 

  17. Kuo L-W, Yang S-J, Fu C-Y, Liao C-H, Wang S-Y, Wu S-C (2016) Relative hypotension increases the probability of the need for angioembolisation in pelvic fracture patients without contrast extravasation on computed tomography scan. Injury 47(1):37–42

    Article  PubMed  Google Scholar 

  18. Brasel KJ, Pham K, Yang H, Christensen R, Weigelt JA (2007) Significance of contrast extravasation in patients with pelvic fracture. J Trauma Acute Care Surg 62(5):1149–1152

    Article  Google Scholar 

  19. Lee HJ, No HK, Choi NJ et al (2020) The size of pelvic hematoma can be a predictive factor for angioembolization in hemodynamically unstable pelvic trauma. Ann Surg Treat Res 98(3):146–152

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Uyeda J, Anderson SW, Kertesz J, Soto JA (2010) Pelvic CT angiography: application to blunt trauma using 64MDCT. Emerg Radiol 17(2):131–7

    Article  PubMed  Google Scholar 

  21. Lindahl J, Handolin L, Söderlund T, Porras M, Hirvensalo E (2013) Angiographic embolization in the treatment of arterial pelvic hemorrhage: evaluation of prognostic mortality-related factors. Eur J Trauma Emerg Surg 39(1):57–63

    Article  CAS  PubMed  Google Scholar 

  22. Hauschild O, Aghayev E, von Heyden J et al (2012) Angioembolization for pelvic hemorrhage control: results from the German pelvic injury register. J Trauma Acute Care Surg 73(3):679–684

    Article  PubMed  Google Scholar 

  23. Gourlay D, Hoffer E, Routt M, Bulger E (2005) Pelvic angiography for recurrent traumatic pelvic arterial hemorrhage. J Trauma 59(5):1168–1174

    Article  PubMed  Google Scholar 

  24. Gurevitz S, Bender B, Tytiun Y, Velkes S, Salai M, Stein M (2005) The role of pelvic fractures in the course of treatment and outcome of trauma patients. Isr Med Assoc J 7(10):623–626

    PubMed  Google Scholar 

  25. Dreizin D, Nascone J, Davis DL et al (2016) Can MDCT unmask instability in binder-stabilized pelvic ring disruptions? AJR Am J Roentgenol 207(6):1244–1251

    Article  PubMed  Google Scholar 

  26. Spanjersberg WR, Knops SP, Schep NW, van Lieshout EM, Patka P, Schipper IB (2009) Effectiveness and complications of pelvic circumferential compression devices in patients with unstable pelvic fractures: a systematic review of literature. Injury 40(10):1031–1035

    Article  PubMed  Google Scholar 

  27. Meinberg E, Agel J, Roberts C, Karam M, Kellam J (2018) Fracture and dislocation classification compendium—2018. J Orthop Trauma 32(1):S1–S10

    Article  PubMed  Google Scholar 

  28. Burgess AR, Eastridge BJ, Young JW et al (1990) Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma 30(7):848–856

    Article  CAS  PubMed  Google Scholar 

  29. Tile M (1996) Acute pelvic fractures. I. Causation and classification. J Am Acad Orthop Surg 4(3):143–151

    Article  CAS  PubMed  Google Scholar 

  30. Bonde A, Velmahos A, Kalva SP, Mendoza AE, Kaafarani HMA, Nederpelt CJ (2020) Bilateral internal iliac artery embolization for pelvic trauma: effectiveness and safety. Am J Surg 220(2):454–458

    Article  PubMed  Google Scholar 

  31. Brohi K, Jasmin S, Heron M, Coats T (2003) Acute traumatic coagulopathy. J Trauma 54:1127–1130

    Article  PubMed  Google Scholar 

  32. Cosgriff N, Moore EE, Sauaia A, Kenny-Moynihan M, Burch JM, Galloway B (1997) Predicting life-threatening coagulopathy in the massively transfused trauma patient: hypothermia and acidoses revisited. J Trauma 42(5):857–861

    Article  CAS  PubMed  Google Scholar 

  33. Awwad A, Dhillon PS, Ramjas G, Habib SB, Al-Obaydi W (2018) Trans-arterial embolisation (TAE) in haemorrhagic pelvic injury: review of management and mid-term outcome of a major trauma centre. CVIR Endovasc 1(1):32

    Article  PubMed  PubMed Central  Google Scholar 

  34. Cullinane DC, Schiller HJ, Zielinski MD, Bilaniuk JW, Collier BR, Como J et al (2011) Eastern association for the surgery of trauma practice management guidelines for hemorrhage in pelvic fracture-update and systematic review. J Trauma 71(6):1850–1868

    PubMed  Google Scholar 

  35. Barentsz MW, Vonken EPA, van Herwaarden JA, Leenen LPH, Mali WPTM, van den Bosch MAAJ (2011) Clinical outcome of intra-arterial embolization for treatment of patients with pelvic trauma. Radiol Res Pract 2011:1–7

    Article  Google Scholar 

  36. Metsemakers WJ, Vanderschot P, Jennes E, Nijs S, Heye S, Maleux G (2013) Transcatheter embolotherapy after external surgical stabilization is a valuable treatment algorithm for patients with persistent haemorrhage from unstable pelvic fractures: outcomes of a single centre experience. Injury 44(7):964–968

    Article  PubMed  Google Scholar 

  37. Brotman S, Soderstrom CA, Oster-Granite M, Cisternino S, Browner B, Cowley RA (1981) Management of severe bleeding in fractures of the pelvis. Surg Gynecol Obstet 153(6):823–826

    CAS  PubMed  Google Scholar 

  38. Morozumi J, Homma H, Ohta S et al (2010) Impact of mobile angiography in the emergency department for controlling pelvic fracture hemorrhage with hemodynamic instability. J Trauma 68(1):90–95

    PubMed  Google Scholar 

  39. Stassen NA, Bhullar I, Cheng JD, Crandall ML, Friese RS, Guillamondegui OD et al (2012) Eastern association for the surgery of Trauma. Selective nonoperative management of blunt splenic injury: an Eastern association for the surgery of Trauma practice management guideline. J Trauma Acute Care Surg 73(5):S294–S300

    Article  PubMed  Google Scholar 

  40. Chakraverty S, Flood K, Kessel D et al (2012) CIRSE guidelines: quality improvement guidelines for endovascular treatment of traumatic hemorrhage. Cardiovasc Interv Radiol 35(3):472–82

    Article  Google Scholar 

  41. Yoshikawa S, Shiraishi A, Kishino M et al (2018) Predictive ability and interobserver reliability of computed tomography findings for angioembolization in patients with pelvic fracture. J Trauma Acute Care Surg 84(2):319–324

    Article  PubMed  Google Scholar 

  42. Verbeek DO, Zijlstra IA, van der Leij C, Ponsen KJ, van Delden OM, Goslings JC (2014) Management of pelvic ring fracture patients with a pelvic ‘‘blush” on early computed tomography. J Trauma Acute Care Surg 76(2):374–379

    Article  PubMed  Google Scholar 

  43. Agolini SF, Shah K, Jaffe J, Newcomb J, Rhodes M, Reed JF (1997) Arterial embolization is a rapid and effective technique for controlling pelvic fracture hemorrhage. J Trauma 43(3):395–399

    Article  CAS  PubMed  Google Scholar 

  44. Tanizaki S, Maeda S, Matano H, Sera M, Nagai H, Ishida H (2014) Time to pelvic embolization for hemodynamically unstable pelvic fractures may affect the survival for delays up to 60 min. Injury 45(4):738–741

    Article  PubMed  Google Scholar 

  45. Blackmore CC, Jurkovich GJ, Linnau KF, Cummings P, Hoffer EK, Rivara FP (2003) Assessment of volume of hemorrhage and outcome from pelvic fracture. Arch Surg 138(5):504–508

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Vascular and Interventional Radiology Department, Cardarelli Hospital, Via Antonio Cardarelli 9, Naples, 80131, Italy

    Francesco Giurazza, Francesco Pane, Fabio Corvino & Raffaella Niola

  2. Department of Precision Medicine, University of Campania “L. Vanvitelli”, Naples, 80138, Italy

    Pietro Roccatagliata & Salvatore Cappabianca

  3. Orthopedic and Trauma Unit, Department of Surgery, Cardarelli Hospital, Via Antonio Cardarelli 9, Naples, 80131, Italy

    Eduardo Casciano

  4. Trauma Center Department, Cardarelli Hospital, Via Antonio Cardarelli 9, Naples, 80131, Italy

    Patrizio Festa

  5. Radiology Department, Cardarelli Hospital, Via A. Cardarelli 9, Naples, 80131, Italy

    Gianluca Ponticiello & Luigia Romano

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  1. Francesco Giurazza
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Correspondence to Francesco Giurazza.

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In the original version of this article, the fourth author’s name was published incorrectly as “Edoardo Casciano” instead of “Eduardo Casciano” and has now been corrected.

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Giurazza, F., Pane, F., Roccatagliata, P. et al. Pelvic ring fractures with concomitant large hematomas: diagnostic investigation with arteriography and eventual embolization in 157 trauma patients, with or without contrast extravasation at emergency CT. Radiol med 128, 1429–1439 (2023). https://doi.org/10.1007/s11547-023-01714-6

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