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Bleeding from Pelvic Frx: Angiography and Embolization

- Discussion:
    - embolization in pts who have sustained vascular injures from pelvic frx is the most direct means for controling of hemorrhage;
          - when bleeding originates from major arteries only effective technique is direct approach to the vessels;
    - embolization avoids the retroperitoneal contamination that is assoc w/ laparotomy and ligation of bleeding vessels;
         - it preserves tamponade effect present in retroperitoneal space;
         - it avoids problems inherent in entering hematoma;
    - indications:
         - control of arterial bleeding following pelvic fracture;
                - major blood loss usually occurs from injury to superior gluteal artery or anterior branches of the internal iliac artery;
                       - this can be alleviated by a variety of embolization techniques;
         - pts who are early operative candidates for fixation of pelvic frx
                - should have angiogram to r/o retroperitoneal arterial bleeding;
                - if bleeding is present, it can be controlled by transcatheter embolization;
         - to assess patency of superior gluteal artery,
                - this vessel maintains the muscle flaps that are raised during pelvic surgical exposures, such as extended iliofemoral and triradiate  approach to the acetabulum; 

         - disadvantages & complications:
                - source of arterial bleeding is identified on pelvic arteriography in only 10-15% of pts who have severe pelvic disruption;
                - when embolization failure occurs, it is almost always in assoc w/ severe secondary coagulopathy;
         - complications include:
                - necrosis of the buttocks after occlusion of entire internal iliac artery;
                - sciatic or femoral nerve paresis;
                - necrosis of bladder wall;
                - emboli to normal vessels;
                - high mortality rate (due to associated abdominal injuries)

- Technical Points:
    - some embolize vessels w/ clotted blood, coils, or Gelfoam (gelatin sponge);
    - others have advocated embolization of the entire hypogastric artery, to decrease time and over-all loss of blood;
         - procedure reportedly is not as successful in pts who have brisk multifocal bleeding;
    - cystourethrography must not be perfomed before Angiography;
         - if positive, extravasated contrast medium will prevent later diagnosis of arterial hemorrhage;
        - cystourethrography &, if needed, insertion of supra-pubic catheter into bladder, can all follow angiography & embolization on same table, aided by fluoroscopy and digital imaging

Pelvic fractures: diagnostic and therapeutic angiography.

Preoperative angiographic assessment of the superior gluteal artery in acetabular fractures requiring extensile surgical exposures.

Percutaneous transcatheter embolization for massive bleeding from pelvic fractures.

Hemorrhage associated with pelvic fractures: causes, diagnosis, and emergent management

A Prospective Study on the Safety and Efficacy of Angiographic Embolization for Pelvic and Visceral Injuries.

Control of severe hemorrhage using C-clamp and arterial embolization in hemodynamically unstable patients with pelvic ring disruption.

Clinical characteristics of pelvic fracture patients with gluteal necrosis resulting from transcatheter arterial embolization.