- 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.
Percutaneous transcatheter embolization for massive bleeding from pelvic fractures.
Hemorrhage associated with pelvic fractures: causes, diagnosis, and emergent management.