AJR 2001; 176:796
© American Roentgen Ray Society
Trauma Cases from the Harborview Medical Center |
Successful Resuscitative Sacral Artery Embolization After Traumatic Unstable Pelvic Fracture
Bradley L. Nicholson1 and
John Borsa2
1
Department of Emergency Medicine, Harborview Medical Center, University of
Washington School of Medicine, Seattle, WA 98104-2499.
2
Department of Radiology, Harborview Medical Center, University of Washington
School of Medicine, 325 Ninth Ave., Box 359728, Seattle, WA 98104-2499.
This is another in the continuing series on radiology in trauma cases from
the Harborview Medical Center. Editors: Fred A. Mann, Eric J. Stern, and
Alexander B. Baxter.
Address correspondence to F. A. Mann.
Introduction
A 30-year-old man fell 40 ft (12 m) after coming in contact with
approximately 14,400 V while working on a billboard. At the initial
examination of the patient, we found severe circumferential burns to his upper
extremities bilaterally and to his left thigh, an open fracture of his left
leg and ankle, and a grossly unstable pelvis. An anteroposterior radiograph
(Fig. 1A) showed a vertical
shear-type fracture with marked diastasis of the public symphysis and
bilateral sacral fractures. The patient's vital signs remained unstable
despite the fact that he had received more than 9.0 L of resuscitative fluid.
A catheter-type diagnostic peritoneal lavage revealed grossly negative
findings. Pelvic angiography showed isolated brisk bleeding from the right
lateral sacral artery (Fig.
1A,1B,1C).
The sacral artery was embolized with a gelatin sponge (Gelfoam; Upjohn,
Kalamazoo, MI) followed by placement of coils both distally and proximally to
the artery's origin, resulting in hemostasis.
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Fig. 1A. —30-year-old man with unstable pelvic fracture and hypotension
caused by extraperitoneal hemorrhage. Anteroposterior radiograph of pelvis
shows widened symphysis (thick black arrow), vertical misalignment
(thick white arrow), and foramina disruption (thin white
arrows).
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Fig. 1B. —30-year-old man with unstable pelvic fracture and hypotension
caused by extraperitoneal hemorrhage. Anteroposterior angiogram of iliac and
pelvic vessels reveals bleeding from right sacral artery (arrow).
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Fig. 1C. —30-year-old man with unstable pelvic fracture and hypotension
caused by extraperitoneal hemorrhage. Anteroposterior angiogram of right
internal iliac artery after gelatin sponge (Gelfoam; Upjohn, Kalamazoo, Ml)
and coil embolization (thick arrow) shows evident vasospasm (thin
arrows).
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Pelvic ring disruptions are caused by highenergy forces and may result in
significant morbidity and mortality with death rates ranging from 5% to 50%
[1,2,3,4,5].
Those patients with the highest mortality present with hemodynamic instability
and have concurrent central nervous system or abdominal injuries
[1,
4]. Care of such
polytraumatized patients requires an integrated multispecialty approach and an
aggressive search for other injuries.
Life-threatening hemorrhage is among the most serious complications in
patients with unstable pelvic fractures and often requires massive blood
products and fluid resuscitation (15-30 units of blood products)
[1,2,3,4].
Most retroperitoneal bleeding arises from low-pressure sources within the
pelvis, such as the posterior venous plexus, major pelvic veins, or exposed
bone surface
[1,2,3,4].
Theoretically, stabilization of pelvic volume through either external
("sheeting," pneumatic antishock garments, or external fixation)
or internal (open reduction with internal fixation) manipulation may limit
this bleeding through earlier tamponade
[4]. Arterial sources account
for only 5-10% of massive pelvic bleeding—most commonly, the pudendal
and obturator for anterior fractures and the superior gluteal, internal iliac,
and sacrolumbar for posterior fractures
[1,
3]. Arterial bleeding may not
be limited by pelvic volume because blood may divide along properitoneal
fascial planes. Hemorrhage is frequently multifocal (in up to 70% of
patients), including coincidental posterior, anterior, and bilateral arterial
disruption [1,
3]. Although the correlation
among fracture type, specific arterial injury, or transfusion requirement has
not been well established, it is generally believed that vertical shear
fractures have a greater propensity for significant arterial bleeding
[1,
4].
Embolization with either a gelatin sponge (Gelfoam) or coils can be
effective (up to 100%) for resolving active bleeding of both anterior and
posterior branches of the internal iliac artery
[1,2,3,4].
Even though embolization may significantly decrease blood replacement
requirements, this tool has yet to be shown to reduce morbidity and mortality.
In fact, the mortality rates among patients who undergo successful embolism
remain high—from 35.5% to 75%
[1,2,3,4].
We believe the treatment of traumatic unstable pelvic ring disruptions
associated with abnormal pulse or blood pressure should include aggressive
early fluid resuscitation, control of obvious external hemorrhage, and
immediate pelvic stabilization with either bed-sheet or pneumatic antishock
garment compression. If hemodynamic instability persists after exclusion of
other potential sites of hemorrhage (intrathoracic, peritoneal, or
extremities) and causes of coagulopathy have been corrected, then urgent
angiography with embolization may be indicated.
References
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O'Neil PA, Riina J, Sclafani S, Tornetta P. Angiographic finding in
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Agolini SF, Shah K, Jaffe J, et al. Arterial embolization is a
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Stock JR, Harris WH, Athanasoulis CA. The role of diagnostic and
therapeutic angiography in trauma to the pelvis. Clin
Orthop 1980;151:3
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Wolinsky PR. Assessment and management of pelvic fracture in the
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References
