Thurs., 10/18/07 Polytrauma, Paper #14, 3:11 pm OTA-2007
CT Angiography for Pelvic Trauma Predicts Angiographically Treatable Arterial Bleeding
Jodi Siegel, MD (n); Paul Tornetta III, MD (n); Peter Burke, MD (n); Neema Kaseje, MD (n); Suresh Agarwal, MD (n); Jorge Soto, MD (n); Stephan Anderson (n);
Boston University Medical Center, Boston, Massachusetts, USA
Introduction: In patients with pelvic trauma, the need to quickly and accurately rule out sources of bleeding is paramount. Many treatment protocols exist, with most utilizing early computed tomography (CT) scanning. The presence of hematoma on standard CT has been correlated with arterial bleeding, as has a positive “blush” sign with contrast-enhanced CT. We sought to determine the predictive value of CT angiography in determining the need for therapeutic angiography in patients who sustained pelvic trauma, and to determine if definable arterial bleeding correlated with anatomic injury.
Methods: Over a 2-year period, 58 patients sustaining pelvic trauma underwent pelvic angiography as part of their initial trauma CT scan. This was performed as a 25-second delayed scan (after contrast introduction) using a GE light-speed VCT64 scanner. CT angiography was performed on all patients with a high-energy mechanism and pelvic trauma if the appropriate personnel were available. This was a nonconsecutive series. The decision to proceed to therapeutic angiography was made on clinical grounds and was later compared with the CT angiographic findings. Additionally, the location of the bleeding seen on CT angiography was compared with the findings of the interventional angiography and with the anatomic location of the pelvic injury.
Results: There were 36 male and 22 female patients, with an average age of 43 years (range, 17-86). The average ISS was 18.6. 18 (31%) of the patients had positive extravasation on CT angiography. These patients had higher initial blood requirements than the group without extravasation. Two of the CT (+) group died after therapeutic angiography was ordered but prior to it being performed. Of the remaining 16, 11 had interventional angiography; 8 had (+) findings, including 7 major vessel injuries treated with coils, and 1 cut-off vessel that was observed. Only one of the 40 patients with negative CT angiography had persistent blood requirements and went on to interventional angiography; this patient had no arterial bleeding. Thus, the negative predictive value of CT angiography for pelvic arterial bleeding requiring therapeutic angiography was 100%. The positive predictive value of CT angiography for angiographically treatable bleeding was 70% (counting the two early deaths). The location of the vessel identified on CT angiography was consistent with the therapeutic angiography in all cases and with displaced fractures or dislocations in 9 of 11 cases. One patient had documented pelvic arterial bleeding that did not correlate with his pelvic injury (a superior gluteal artery in a patient with a sacral fracture). Although fracture pattern was not helpful in predicting arterial bleeding in the specific case, fracture-dislocations of the sacroiliac joint had the highest rate of CT (+) findings. Finally, the CT angiography (+) group had a higher percentage of unstable pelvic injuries (67% vs 40%).
Conclusion: In this pilot study, the use of CT angiography added to the initial trauma scan in patients with pelvic trauma demonstrated a 100% negative predictive value for arterial bleeding that required therapeutic angiography. Positive findings correlated well with the anatomic location of pelvic injury and had a 70% positive predictive value for angiographically treatable bleeding. Further study of this technique is warranted.
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