Fri., 10/17/08 Pelvis/Injury Prevention, Paper #24, 11:08 am OTA-2008
Indications and Complications of Angiography and Embolization in the Management of High-Energy Pelvic Ring Injuries
Bryan J. Loeffler, MD1 (a-Synthes, Zimmer); Brian P. Scannell, MD1 (n);
Michael J. Bosse, MD1 (a-OREF, Synthes, Zimmer; e-KCI, Medtronic);
James F. Kellam, MD1 (a-Synthes, Zimmer); Stephen H. Sims, MD1 (a-Synthes, Zimmer);
Chris Wise, MD1 (n); John White, MS2 (n);
1Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA;
2Dickson Institute of Health Studies, Carolinas Medical Center, Charlotte, North Carolina, USA
Purpose: High-energy pelvic ring injuries often produce patients with hemodynamic instability. Embolization of bleeding pelvic vessels may aid in restoring hemodynamic stability, but is not without its own complications that may compromise the ideal treatment plan. The primary purposes of this study were to characterize the patients in our institution undergoing pelvic angiography and to determine: (1) the efficacy of CT scans in identifying patients with active arterial extravasation and (2) the rate of complications associated with the procedure.
Methods: An IRB-approved retrospective review was performed on patients with high-energy pelvic ring injuries from 2004 to 2006. A total of 263 patients were identified, of whom 45 (17%) underwent pelvic angiography (group A). Patients were classified according to the Advanced Trauma Life Support (ATLS) classification of hemorrhagic shock. Angiography was indicated if the initial CT scan demonstrated an intravenous (IV) contrast “blush” (n = 33) or if other sources of bleeding were ruled out and the patient remained hemodynamically unstable (n = 12). Complications of angiography such as renal failure, failed embolization, gluteal muscle necrosis, and postoperative wound infection were also recorded. Standard statistical analysis was performed to compare the outcomes between the group undergoing angiography and the group not sent for angiography (group NA).
Results: In group A there were 30 males and 15 females with a mean age of 45 years. The mean Injury Severity Score (ISS) was 27, and there were 2 type A, 24 type B, and 19 type C fractures. According to the ATLS classification of hemorrhagic shock, there were 3 patients in grade I, 13 in grade II, 18 in grade III, and 11 in grade IV shock. The sensitivity of a blush on pelvic CT for detecting active extravasation visualized during angiography was 82.4% (28 of 34), positive predictive value was 84.8% (28 of 33), and specificity was 44.4% (4 of 9). Embolization was performed on 41 patients (91.1%)—35 out of 35 patients with active extravasation (100%) and 6 out of 10 without extravasation (60%). Patients received a mean of 214 cm3 of IV contrast at angiography in addition to the 120 cm3 of IV contrast given during the initial CT scans. Acute renal failure requiring hemodialysis during initial admission occurred more frequently in group A than group NA (8.9% vs 0.5%, P = 0.0038). In group A, gluteal muscle necrosis was observed during surgery in two cases (8.7%), and there were two acute, deep postoperative wound infections (8.7%). Neither was observed in group NA. Embolization failed in one patient (2.4%), who required repeat embolization due to recanalization.
Conclusions and Significance: The presence or absence of a blush on admission CT scan alone is unreliable in predicting the presence of active extravasation during angiography. Significant complications such as acute renal failure, gluteal muscle necrosis, and postsurgical wound infection may result following this procedure.
If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options; e-consultant or employee; n-no conflicts disclosed, and *disclosure not available at time of printing.
• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.