Fri., 10/5/12 Pelvis & Acetabulum, PAPER #63, 3:51 pm OTA-2012
Appropriateness of Angiography and Embolization in the Management of High-Energy Pelvic Ring Injuries
Sean M. Griffin, MD; Kenneth J. Nelson, MD; Bryan J. Loeffler, MD; Brian P. Scannell, MD; Michael J. Bosse, MD; James F. Kellam, MD; Stephen H. Sims, MD; Ronald F. Sing, DO;
Eric A. Wang, MD;
Carolinas Medical Center, Charlotte, North Carolina, USA
Background/Purpose: Patients with pelvic ring injuries may present with hemodynamic instability necessitating pelvic angiography to identify and treat ongoing arterial hemorrhage. Pelvic angiography and embolization has been shown to be effective in controlling hemorrhage but may cause significant complications including renal failure, muscle necrosis, impotence, and the need to alter surgical treatment. Angiography has been made readily available in most trauma centers and the high level of technical skills of angiographers to perform embolizations has led to increased incidences of these patients being treated with pelvic angiography. Given the risk of complications, we reviewed our patients who presented with high-energy pelvic ring injuries to examine the appropriateness of the patient’s referral for pelvic angiography and whether they underwent appropriate embolization procedures. Our hypothesis is that a high rate of disagreement exists between general surgeons, orthopaedic traumatologists, and interventional radiologists at our institution on the appropriateness of referrals for pelvic angiography and subsequent embolizations performed.
Methods: An IRB-approved retrospective study was performed on patients identified by the trauma registry with high-energy pelvic ring injuries presenting to a single Level I trauma center from 2004 to 2008. Of 296 identified patients, 58 (19.6%) underwent pelvic angiography. A detailed chart review was performed to determine the clinician’s indications for referral to angiography, the presence of active extravasation on CT angiography, any other arterial abnormalities encountered, and the specific vessel(s) embolized. A general surgery traumatologist, three different orthopaedic traumatologists, and an interventional radiologist independently reviewed the 58 cases and determined whether they felt referral angiography was appropriate and whether the subsequent embolization performed (or not performed) was appropriate.
Results: There was complete agreement by all five participants in 26 of 58 cases (44.8%) that referral to angiography and the subsequent embolization performed (or not performed) was appropriate. There was disagreement in 32 of 58 cases (55.2%) as to the appropriateness of angiography referral and/or the subsequent embolization. Of these cases, there was complete agreement by all participants in 12 of 32 cases (37.5%) that angiography referral was appropriate; however, variable disagreement existed as to the appropriateness of the subsequent embolization. In 6 of 58 cases (10.3%), no embolization was performed after angiography, and there was complete agreement by all participants in these cases that this was appropriate. There were 7 of 58 cases (12.1%) in which the general surgeon and all orthopaedists disagreed with the interventional radiologist on the appropriateness of the embolization performed. There was complete agreement between the general surgeon and all orthopaedists in 36 of 58 cases (62.1%) that angiography referral was appropriate. Disagreement existed between the general surgeon and at least one of the orthopaedists on angiography referral in 22 of 58 cases (37.9%). The most frequent reasons cited for inappropriate referral to angiography were stable pelvic ring injury and underresuscitated or hemodynamically stable patient. The most frequent reasons cited for inappropriate embolization were that an uninjured vessel was embolized or the embolization performed was too proximal and/or not “selective”.
Conclusion: There was a high rate (37.9%) of disagreement between the general surgeon and at least one of the orthopaedic traumatologists regarding what constitutes appropriate referral to pelvic angiography. There was complete agreement between all surgeons that an inappropriate embolization procedure was performed in 12.1% of cases. These data suggest that the surgeons need to remain active participants in the angiography procedure and critically develop plans with the interventional radiology team. In some cases, unnecessary or overly aggressive embolization of pelvic vessels may be avoided. Elimination of unnecessary interventions may decrease the patient’s dye load and preserve critical pelvic circulation to avoid potential serious complications.
Alphabetical Disclosure Listing (808K PDF)
• 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.