Endovascular Management of Pelvic Trauma PDF 2021

123 Endovascular Management of Pelvic Trauma Husameddin El Khudari, MD1 Ahmed Kamel Abdel Aal, MD2 1 Division of Interventional Radiology, Depa...

123 Endovascular Management of Pelvic Trauma Husameddin El Khudari, MD1 Ahmed Kamel Abdel Aal, MD2 1 Division of Interventional Radiology, Department of Radiology, The Address for correspondence Ahmed Kamel Abdel Aal, MD, University of Alabama at Birmingham (UAB), Birmingham, Alabama Department of Diagnostic and Interventional Imaging, The University 2 Department of Diagnostic and Interventional Imaging, The of Texas Health Science Center at Houston (UTHealth), Houston, TX University of Texas Health Science Center at Houston (UTHealth), 77030 (e-mail: [email protected]). Houston, Texas Semin Intervent Radiol 2021;38:123–130 Abstract Major pelvic fractures result from high-energy trauma including traffic accidents and This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. falls, which usually leads to multiple injuries complicating the patient’s management. Keywords Management of these patients requires a coordinated multidisciplinary approach. ► interventional Transcatheter embolization is a minimally invasive and effective technique to control radiology massive hemorrhage and can be performed using a variety of embolic agents. It has ► embolization become an accepted first-line management option for retroperitoneal bleeds in many ► trauma centers. In this article, the indications for endovascular management of hemorrhage ► pelvic from pelvic trauma, the various embolization techniques, and potential complications ► hemorrhage will be discussed. Major pelvic fractures result from high-energy trauma in- centers, and provides detailed information about the type cluding traffic accidents and falls, which usually leads to and location of the hemorrhage; the presence of vascular multiple injuries complicating the patient’s management. injuries such as pseudoaneurysm, arteriovenous fistula, or Pelvic fractures are present in 4 to 9% of patients with blunt complete vascular transection; and the presence of vascular trauma and are associated with significant morbidity and anatomic variants. The development of widely available fast mortality.1,2 Management of these patients require a coor- scanners resulted in a change in the clinical practice, and dinated approach between trauma surgeons, orthopedic currently CT scans are performed even on hemodynamically surgeons and interventional radiologists. Endovascular unstable patients.5 interventions can be lifesaving in patients with hemorrhage In the event the patient was hemodynamically unstable or from pelvic fractures with hemodynamic instability. Such difficult to transport, focused assessment by sonography for interventions have become an accepted first-line manage- trauma (FAST) and diagnostic peritoneal lavage (DPL) can be ment option for pelvic bleeds in many centers. In this article, used to diagnose intraperitoneal bleed in patients not the authors will discuss the indications for endovascular responding to fluid resuscitation, which necessitates opera- management of hemorrhage from pelvic trauma, the various tive intervention. If intraperitoneal and intrathoracic bleeds embolization techniques, and potential complications. are excluded, and the patient is still hemodynamically unstable, a retroperitoneal bleed should be suspected.3 Diagnosis of Pelvic Hemorrhage Management of Pelvic Trauma The diagnosis of pelvic trauma–related hemorrhage can be made clinically, by imaging, or during operative repair of a There are two approaches for the management of patients pelvic fracture.3 The presence of unstable pelvic fracture is a with pelvic trauma–related hemorrhage. The first approach predictor of arterial extravasation.4 Imaging diagnosis is is transcatheter pelvic angiography and embolization as mostly obtained by contrast-enhanced CT scan, especially indicated. The second approach is operative external fixation in stable patients or patients who are responsive to resusci- and preperitoneal pelvic packing. The choice of the approach tation. Contrast-enhanced CT is fast, readily available in most depends on whether the source of hemorrhage is arterial or Issue Theme Seminars in IR Trauma; © 2021. Thieme. All rights reserved. DOI https://doi.org/ Guest Editors, Patrick D. Sutphin, MD, Thieme Medical Publishers, Inc., 10.1055/s-0041-1725112. PhD and Sanjeeva Kalva, MD 333 Seventh Avenue, 18th Floor, ISSN 0739-9529. New York, NY 10001, USA 124 Endovascular Management of Pelvic Trauma Khudari, Aal venous, the availability of resources particularly subspecial- toma into the peritoneum or through a perineal wound. ized physicians, operative experience, the patient’s clinical Intraoperative packing to provide temporary control and condition, and the presence of associated injuries such as subsequent transfer to the angiographic suite for transcath- intraperitoneal hemorrhage. Despite that, it should be em- eter embolization may be the best approach to stop bleeding phasized that most of the patients who undergo preperito- from pelvic arteries that are difficult to control neal pelvic packing end up requiring transcatheter surgically.12,13 embolization. Survival outcomes are documented to be better in Angiographic Technique patients who undergo angiography and transcatheter embo- lization first followed by operative intervention even in the The use of ultrasound guidance to obtain vascular access is presence of hemoperitoneum.6 The timing of angiography very helpful, especially in patients with hypotension, col- and embolization is very critical in these patients. Delayed lapsed vessels, weak pulses, or groin hematoma/edema. pelvic angiography and transcatheter embolization in these Using ultrasound guidance, percutaneous femoral access is patients may be associated with poor outcomes and in- obtained on the side with less involvement by the fracture or This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. creased in-hospital mortality.7 Tesoriero et al reported a the hematoma. If the hematoma involves the groin or there is median time to angiography of 286 minutes in a cohort of severe edema secondary to aggressive fluid resuscitation, 344 patients with pelvic fractures who underwent pelvic with difficulty obtaining femoral access, radial access can be angiography. Most of the delays were due to time spent considered. Other possible access sites are the brachial or awaiting mobilization of resources needed to perform angi- axillary arteries. The procedure can be performed with only ography which allows ongoing hemorrhage. Nearly 80% of moderate sedation, with continuous monitoring of vital the deaths in their study could be attributed to early uncon- signs. General anesthesia is not required, unless indicated trolled hemorrhage. They suggested that early surgical inter- by other clinical conditions. Anesthesia support is helpful in vention like preperitoneal packing and resuscitative most patients with hemodynamic instability and allows the endovascular balloon occlusion of the aorta (REBOA) and interventional radiologist to focus more on the endovascular the use of hybrid operative suites may improve the outcome.8 technique. Bladder catheterization using a Foley catheter is A recent study found that preperitoneal pelvic packing alone helpful to avoid obscuring pelvic hemorrhage by contrast is not effective for arterial hemorrhage control.4 The decision filled bladder. Both un-subtracted and subtracted images to proceed with preperitoneal pelvic packing or angiography should be reviewed to eliminate bowel movement artifacts. and embolization should be tailored to individual patient Imaging at two to three frames per second is usually ade- and based on availability of resources and experience. For quate. The imaging should continue into the venous phase to these reasons, the current practice of most level 1 trauma distinguish extravasation from early draining vein. institutions is to have interventional radiology services An aorto-bi-iliac angiography (pelvic angiography) is available to perform angiography and possible embolization performed using a standard pigtail catheter in the antero- within 30 minutes of the activation of a trauma code requir- posterior projection, followed by selective internal iliac ing endovascular intervention. Having a trauma interven- catheterization and angiography in the ipsilateral oblique tional radiology hybrid operating room angiography suite is projection using a 4- or 5-Fr diagnostic catheter. This projec- also gaining acceptance in most level 1 trauma hospitals, as it tion helps separate the internal iliac artery branches. Both provides not only a shorter time to hemorrhage control but internal iliac arteries should be evaluated, as bleeding can be also a cohesive collaborative management of trauma patients bilateral and from multiple sites. Review of available imaging by members of the trauma and interventional radiology studies to recognize the fracture type and location and other teams. CT findings can be helpful predict the injured vessels, and minimize unnecessary radiation exposure and contrast use.1 If angiographic signs of hemorrhage or vascular injury are Indications and Contraindications for Pelvic noted, further superselective catheterization and angiogra- Angiography phies of the injured or bleeding vessel are then performed, Clinical indications for pelvic angiography in a patient with usually using a microcatheter. These angiographic signs pelvic traumatic fracture include (1) persistent hypotension include free contrast extravasation, pseudoaneurysm forma- after 2 L of fluid challenge with exclusion of intraperitoneal tion, vascular occlusion, vascular narrowing, transection or hemorrhage, (2) transfusion requirement exceeding four cutoff, intimal flaps, filling defects, or arteriovenous fistula. units of blood within 24 hours or six units within 48 hours, Contrast extravasation should persist into the venous phase (3) a pelvic hematoma greater than 600 mL or active extrav- (►Fig. 1). asation seen on CT, and (4) a large or expanding pelvic Arteries may appear narrowed secondary to hypovolemic hematoma found on laparotomy.3,9,10 Recent studies have shock or vasopressors use. Absence of contrast extravasation suggested that angiography and transcatheter embolization may be related to transient vasospasm, inadequate blood should be guided by the hematoma volume, rather than by flow due to hypotension or vasopressors, or temporary the presence or absence of contrast extravasation alone.11 clotting, which can limit the angiographic evaluation.14 Contraindications for pelvic angiography are relative and In these cases, a selective hand injection of the suspected include rapidly expanding hematoma, and ruptured hema- vessel can help overcome these issues (►Fig. 2). Occluded Seminars in Interventional Radiology Vol. 38 No. 1/2021 © 2021. Thieme. All rights reserved.  Endovascular Management of Pelvic Trauma Khudari, Aal 125 Fig. 1 A 16-year-old-male patient with history of motor vehicle accident and pelvic trauma. (a) CT of the pelvis revealed left obturator ring and pubic bone fracture with adjacent hematoma and a focus of contrast extravasation suggesting active bleeding (white arrow). (b) Selective left internal iliac angiography showing a tiny focus of contrast extravasation from a branch of the left internal pudendal artery (arrow). (c) Selective left internal pudendal angiography confirming the presence of contrast extravasation (arrow). (d) Superselective distal left internal pudendal angiography showing small pseudoaneurysm (white arrow) and free contrast extravasation (black arrow). (e) Left distal internal pudendal angiography following coil embolization (arrow) showing no flow in the embolized vessel. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. Fig. 2 A 51-year-old man with history of pelvic trauma from a tree falling on him. (a) CT of the pelvis showing active extravasation in the left anterior pelvis (arrow). (b) Selective left internal iliac angiography showing a truncated left internal pudendal artery (arrow). (c) Superselective distal left internal pudendal angiography showing disruption of the formed clot resulting in contrast extravasation indicating active bleeding. (d) Left distal internal pudendal angiography following coil embolization (arrow) showing no flow in the embolized vessel. pelvic vessels, narrowed vessels, or vessels with filling urgent but not emergent, we recommend a selective or defects suggesting a local thrombus should preferably be superselective embolization of the focal bleeding site. This treated by embolization if they can be sacrificed.3 requires the use of microcatheter system which takes longer Evaluation of the lumbar, external iliac, and femoral time to perform and is more technically demanding arteries can be performed based on the CT findings (►Fig. 5). Nonselective embolization of unilateral or bilateral (►Fig. 3). Unusual cases of bleeding from variant obturator internal iliac arteries or their anterior or posterior divisions artery originating from the inferior epigastric branch of the is less time consuming and is preferred in patients with external iliac artery (corona mortis) or the external iliac hemodynamic instability, ongoing hemorrhage, and the artery itself have been reported.15–17 It is advisable that both presence of multiple vascular injuries (►Fig. 6). The presence external iliac arteries should be evaluated in patients with of extensive collateral circulation between the internal iliac pubic bone fractures/hemorrhage (►Fig. 4). artery branches minimizes the risk of infarction following Whether to perform a selective or nonselective emboli- transcatheter embolization of the internal iliac artery. If zation is still debatable, but depends largely on the patient’s selective internal iliac angiographies were negative for arte- hemodynamic status, urgency to stop the bleeding, and rial bleeding, theoretically performing transcatheter embo- operator preference and experience. If bleeding control is lization can decrease venous bleeding by decreasing the Fig. 3 A 59-year-old woman with history of motor vehicle accident. (a) CT scan showing right pectineus muscle hematoma with contrast blush concerning for active bleeding (white arrow). (b) Right external iliac angiography showing a tiny focus of contrast extravasation from a branch of the right profunda femoris artery (arrow). (c) Superselective catheterization and angiography of the right medial circumflex femoral showing contrast extravasation from a small branch (arrow) corresponding to the contrast blush seen on CT image. (d) Right medial circumflex femoral angiography following coil embolization (arrow) showing occlusion of the targeted vessels with no residual contrast extravasation. Seminars in Interventional Radiology Vol. 38 No. 1/2021 © 2021. Thieme. All rights reserved. 126 Endovascular Management of Pelvic Trauma Khudari, Aal Fig. 4 Young patient with motor vehicle accident undergoing pelvic angiography for the evaluation of pelvic hematoma. (a) Initial CT scan revealed bilateral obturator ring fractures, small left obturator hematoma, and tiny contrast blush suggesting active bleeding (white arrow). (b) Aorto-bi-iliac angiography showing irregularity in the right superior gluteal artery (arrowhead) without definite extravasation. Note that bilateral obturator arteries (black arrows) are arising from the inferior epigastric arteries (white arrows). (c) Following Gelfoam embolization of bilateral internal iliac arteries, a selective left external iliac angiography demonstrates an irregular left obturator artery (black arrow) arising from the inferior epigastric artery (white arrow), without definite extravasation. (d) Superselective left obturator angiography confirming vessel caliber irregularity without extravasation. (e) Superselective left inferior epigastric angiography following Gelfoam embolization of the left obturator This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. artery showing patent left inferior epigastric artery and occluded left obturator artery (arrow). arterial pressure head. A recent study showed that perform- Young-Burgess classification is the most widely used classi- ing embolization in the presence of a negative angiogram did fication system of pelvic ring fractures (►Fig. 7). It is based not change the need for transfusion. However, it may aid in on the predominant force vectors during trauma: lateral hemorrhage control as evidenced by decreased amount of compression, anteroposterior compression, vertical shear, products transfused.18 and combined injuries. The type of pelvic fracture may help Understanding the mechanism of injury and type of predict the injured vessel. The lateral compression (side fracture can help guide the angiographic evaluation. impact) fractures are associated with hemorrhage from the Fig. 5 Young patient with gunshot wound and initial CT (not shown) revealing a large right pelvic hematoma and pseudoaneurysm. (a and b) Aorto-bi-iliac angiography showing occlusion of the right internal iliac artery with reconstitution of the branches of the posterior trunk through collaterals between the right lumbar and ilio-lumbar arteries (arrowhead). Arterial injury and pseudoaneurysm are seen in the proximal portion of the right superior gluteal artery and are seen more prominently in the late arterial phase (arrow). (c) Angiography of the common trunk of the fifth lumbar arteries demonstrates the collateral flow to the branches of the posterior trunk of the right internal iliac artery. The pseudoaneurysm of the proximal right superior gluteal artery is again seen (arrow). Note the bullet fragment (arrowhead). (d and e) Catheterization of the right superior gluteal artery through ilio-lumbar collaterals using a microcatheter (arrowheads) and deployment of coils in the pseudoaneurysm as well as the proximal and distal portions to the arterial injury (arrows) to prevent back door bleeding through collaterals. (f) Postembolization angiography showing occlusion of the pseudoaneurysm and the injured artery with collateral flow to the distal right superior gluteal artery through the right fifth lumbar artery (arrow). Seminars in Interventional Radiology Vol. 38 No. 1/2021 © 2021. Thieme. All rights reserved.  Endovascular Management of Pelvic Trauma Khudari, Aal 127 Fig. 6 A 23-year-old patient with history of motor vehicle accident resulting in pelvic fractures. The patient is status post internal fixation with persistent transfusion requirement. (a) CT scan showing left sidewall pelvic hematoma with small foci of extravasation (white arrow). (b) Aorto- bi-iliac angiography showing no definite extravasation or vascular abnormality. (c) Selective left internal iliac angiogram showing multiple small foci of extravasation (arrows). (d) Delayed images showing persistence of contrast at these sites of suspected small extravasation. (e) Left internal iliac angiography following nonselective embolization of the left internal iliac artery using Gelfoam slurry showing occlusion of all the arterial branches. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. Fig. 7 Illustration of Young-Burgess classification. The arrow indicates the predominant force vector during trauma. (Illustration by Dr. Husameddin El Khudari). Seminars in Interventional Radiology Vol. 38 No. 1/2021 © 2021. Thieme. All rights reserved. 128 Endovascular Management of Pelvic Trauma Khudari, Aal anterior division of the internal iliac artery, most commonly aliquots can be injected using a 1-mL syringe. Constant the internal pudendal and the obturator artery.19 The ante- remixing and agitation prior to injection is required to rior posterior compression (open book) fractures are mostly prevent particle aggregation. associated with injury of the posterior division of the internal Metallic (stainless steel or platinum) coils and vascular iliac artery, with the superior gluteal and lateral sacral occlusion plugs can be used for more focal injuries, pseu- arteries being the most commonly injured arteries. The doaneurysm, or transected vessels. Coil embolization of focal superior gluteal artery is particularly at risk of injury with bleeding point requires arterial occlusion both proximal and fractures of the greater sciatic notch.20 distal to the site of injury to prevent persistent bleeding through collateral circulation, known as back door bleeding. This requires crossing the area of injury, which is feasible Embolic Agents when dealing with a pseudoaneurysm but may be challeng- If embolization is indicated, the choice of embolic agent ing in cases of vessel transection. Both pushable and detach- depends on the type of injury, the vessel involved, the extent able, macro and micro, fibered coils can be used. The fibers of injury, collateral supply, and the clinical condition of the attached to these coils increase their thrombogenicity and This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. patient. Gelatin sponge (Gelfoam; Upjohn, Kalamazoo, MO) is improve their performance. Coils need intact coagulation a temporary embolic agent derived from a biologic substance system to produce thrombus at the site of embolization. made of purified skin gelatin. Gelatin sponge is the embolic Patients with coagulopathy may require reinforcement of the agent of choice in most of the cases, as it is widely available, coils by Gelfoam slurry injection. In general, coils should be inexpensive, easy to use, and produce mechanical occlusion sized according to the target vessel size, and softer coils can providing rapid control of hemorrhage in unstable patients. be oversized by 20 to 30%. Vascular plugs should be oversized It is particularly useful in patients with multiple bleeding by 30 to 50% of the vessel diameter.23 The use of vascular vessels and in patients with coagulopathy, as its mechanism plugs requires a guiding catheter or sheath be placed in the is independent on the patient’s own coagulation. Addition- target artery, and the plug is deployed by unsheathing it. ally, being a temporary agent, Gelfoam allows the body to Because of the relatively large delivery system, vascular plugs heal injured vessels and maintain normal blood flow, once are mainly used for transected large vessels such as the these vessels recanalize after several days or weeks.21,22 internal iliac artery. Microvascular plugs are now available The most commonly used form is the sheet or block of and can be delivered through microcatheters, which allows Gelfoam, which is cut with scissors into small 1- to 2-mm their use in distal territories to minimize nontarget cubes. Gelfoam slurry is produced by rapidly mixing these embolization. Gelfoam cubes with 10 to 20 mL of contrast through a three- Liquid embolic agents are rarely used in trauma and way stopcock between two 20-mL syringes. When the Gel- include N-butyl cyanoacrylate (Trufill NBCA; Cordis Neuro- foam is pumped forcefully through the stopcock, a signifi- vascular, Miami Lakes, FL) and ethylene vinyl alcohol copol- cantly higher number of less than 500-μm particles is ymer (Onyx; Micro Therapeutics, Inc., Irvine, CA), which are created.23 Small aliquots of this slurry can be injected using mixed with ethiodized oil and dimethyl sulfoxide (DMSO), 1- to 3-mL syringe under fluoroscopic guidance. The Gelfoam respectively. They produce fast occlusion which is dependent slurry can be administered through a 4- or 5-Fr catheter on the concentration of the active agent in the mixture. when embolizing the internal iliac artery or its anterior or Occlusion of the vessel is independent of the patient’s posterior divisions; however, it can also be injected through a coagulation system. Despite these advantages, their use is 2- to 3-Fr microcatheter when distal selective embolization limited by the high cost of these embolic agents, and the need is performed to avoid occlusion of the main artery by the for an experienced interventionist to avoid reflux and non- larger catheter which limits particles flow. Additionally, the target embolization.5,23 use of microcatheter to perform selective embolization into Other liquid embolic agents such as absolute alcohol and the targeted vessel minimizes nontarget embolization. The other sclerosing agents are not used in trauma, due to the risk main disadvantage of Gelfoam is that the sizes of the of tissue necrosis. When large nonexpendable vessels are particles are not uniform. Additionally, clot disruption with injured such as the abdominal aorta, common iliac, external rebleeding is possible. Gelfoam powder with particle size of iliac, or femoral arteries, surgical repair or stent graft place- 40 to 60 µm should be avoided, as they can occlude the ment should be considered. arterioles and provide distal capillary occlusion that might lead to skin necrosis. Complications Alternative embolic agents include particles. Particles are more uniform in size and produce permanent embolization Failure to control the hemorrhage is a major complication of by mechanical occlusion and by producing inflammatory pelvic angiography and embolization. This may be the result changes in the vessel wall. Particles include polyvinyl alco- of extensive injuries in a poly trauma patient, or, rarely, due hol, tris-acryl gelatin microspheres, and hydrogel particles. to the inability to safely perform the embolization if the They are usually produced with calibrated sizes that span a targeted bleeding vessel was not adequately accessed. 200-µm range, for example, 100 to 300 µm. The embolization Recurrent hemorrhage requiring a repeat intervention is mixture is prepared by mixing these particles with contrast the most common complication. These may be due to a new according to the manufacturer’s recommendation. Small bleeding site that was not seen on initial intervention, Seminars in Interventional Radiology Vol. 38 No. 1/2021 © 2021. Thieme. All rights reserved.  Endovascular Management of Pelvic Trauma Khudari, Aal 129 rebleed from early recanalization of an embolized artery, the transcatheter embolization. Those patients, who are respon- use of temporary embolic agent such as Gelfoam, or persis- sive to resuscitative efforts and are hemodynamically stable, tent bleeding from a missed injury. Repeat embolization is should be offered transcatheter embolization first. The deci- reported in 7 to 11% of the patients.5,14,24 sion to perform selective or nonselective embolization Less commonly reported complications include ischemic depends on the level of urgency and the type of vascular necrosis of the gluteal and perineal muscles or skin and injury, and management should be tailored to individual necrosis of the rectum. Rare cases of bladder ischemia, and patients. Early percutaneous endovascular intervention is avascular necrosis of the femoral head, have also been very critical to minimize morbidity and mortality. reported.25,26 However, in most of the reported cases of ischemic necrosis attributed to bilateral internal iliac artery embolization, the effect of the embolization cannot be References separated from the original injury and the operative inter- 1 van der Vlies CH, Saltzherr TP, Reekers JA, Ponsen KJ, van Delden ventions which affect tissue viability. A recent study of 61 OM, Goslings JC. Failure rate and complications of angiography and embolization for abdominal and pelvic trauma. J Trauma patients who underwent bilateral internal iliac artery em- Acute Care Surg 2012;73(05):1208–1212 This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. bolization for pelvic trauma using Gelfoam slurry with 2 Sathy AK, Starr AJ, Smith WR, et al. The effect of pelvic fracture on additional coil embolization in selected patients, at a level mortality after trauma: an analysis of 63,000 trauma patients. J 1 trauma center over a 20-year period, reported no ischemic Bone Joint Surg Am 2009;91(12):2803–2810 complication related to bilateral internal iliac artery emboli- 3 Hoffer EK. Transcatheter embolization in the treatment of hemor- zation.14 An earlier study reported similar results with no rhage in pelvic trauma. Semin Intervent Radiol 2008;25(03):281–292 4 Sandhu J, Abrahams R, Miller Z, Bhatia S, Zakrison TL, Mohan P. ischemic complication in a cohort of 70 patients who under- Pelvic trauma: factors predicting arterial hemorrhage and the role went bilateral internal iliac artery embolization using Gel- of angiography and preperitoneal pelvic packing. Eur Radiol 2020; foam slurry. 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