Pelvic Trauma: Angiography and Embolisation

Reviewed and revised 21 December 2015

OVERVIEW

• In centers with interventional radiology capability immediately available these patients may be taken to the angiography suite for embolization
• This treats arterial bleeding (see Pelvic arterial injury), which though still less common than venous bleeding, occurs more frequently in persistently hypotensive patients
• Either selective embolisation or non-selective embolisation can be performed

INDICATIONS

These patients should have angiography performed (based on the 2011 EAST guidelines):

• haemodynamically unstable patients (probably best to perform pre-peritoneal packing in the operating theatre first)
• patients with a pelvic “blush” on CT with IV contrast usually require selective embolisation even if stable
• ongoing bleeding after angiography should get repeat angiography
• elderly patients (e.g. > 60 years old) with major pelvic fractures should get angio even if stable
• Pelvic hematoma volume > 500 mL predicts the need for angiography

Note that neither fracture pattern nor pelvic hematoma location reliably predicts the need for angiography, and even patients with pubic ramus fractures or isolated acetabular fractures may require angiography.

ADVANTAGES

• can identify and control arterial hemorrhage from pelvic fractures
• 85 to 100% effective in controlling arterial hemorrhage
• embolisation can be performed selectively (just the bleeding vessel) or non-selectively (bilateral internal iliac arteries)
• can be repeated if ongoing bleeding (e.g. a bleeding artery may have been in vasospasm during the initial procedure)
• the procedure is considered safe — reports of gluteal necrosis are likely due to trauma rather than angioembolisation, and rates of sexual dysfunction in men are not increased
• does not require laparotomy for direct retroperitoneal packing
• avoids attempts at direct surgical ligation of bleeding arteries, which results in universally poor outcomes
• may be possible to embolise other bleeding vessels (e.g. splenic or hepatic arteries)

DISADVANTAGES

• not beneficial for venous or bone hemorrhage, which are the sources of most hemorrhage from pelvic trauma (up to 90%)
• limited availability
• frequently delayed even when available… even in Level 1 trauma centers in the US (1-5 hours is typically reported in the literature)
• requires skilled staff and substantial resources
• requires careful communication, coordination, on call rosters and agreed upon hospital protocols
• prolonged procedure (mean 90 minutes)
• arterial bleeding sometimes stops spontaneously, and does not always need angioembolisation
• not suitable for truly unstable patients as not performed in operating theatres where resuscitation and definitive surgery is more easily performed
• risk of complications (e.g. femoral artery injury from venous access, radiation exposure, contrast allergy, contrast induced nephropathy, ischemia from embolisation)
• selective embolisation is associated with increased rates of recurrent or ongoing hemorrhage
• access to the femoral artery may be difficult (e.g. obesity, associated trauma)

References and Links

LITFL

• Weingart on Pelvic Trauma
• Pelvic and Hip injuries in the Emergency Department
• Trauma Tribulation 026 — Trauma! Genitourinary injuries
• CCC — Pelvic arterial injury
• CCC — Pre-peritoneal packing
• CCC — Pelvic Trauma

Journal articles and textbooks

• Cullinane DC, Schiller HJ, Zielinski MD, Bilaniuk JW, Collier BR, Como J, Holevar M, Sabater EA, Sems SA, Vassy WM, Wynne JL. Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture–update and systematic review. J Trauma. 2011 Dec;71(6):1850-68. PMID: 22182895.
• Heetveld MJ, Harris I, Schlaphoff G, Sugrue M. Guidelines for the management of haemodynamically unstable pelvic fracture patients. ANZ J Surg. 2004 Jul;74(7):520-9. PMID: 15230782.
• Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography: competitive or complementary? Injury. 2009 Apr;40(4):343-53. PMID: 19278678.
• White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury. 2009 Oct;40(10):1023-30. PMID:19371871.

FOAM and web resources

• LITFL — Weingart on Pelvic Trauma
• Resus.ME — Exsanguinating pelvis – occlude the aorta
• The Trauma Professional’s Blog — Bleeding And Pelvic Fractures
• The Trauma Professional’s Blog — Predicting Bleeding In Patients With Stable Pelvic Fractures
• The Trauma Professional’s Blog — Pelvic Fractures: OR vs Angio In The Unstable Patient
• Trauma.org — Management of exsanguinating pelvis injuries