The main cause of mortality in patients with severe pelvic fractures is major hemorrhage. Over the years, trauma professionals have developed and tested a number of maneuvers to reduce mortality in these patients. These include wrapping or fixing the pelvis, embolization, and more recently, pre-peritoneal packing and REBOA.
Pelvic wrap/fixation and embolization have been around for a long, long time. For both, it’s been long enough so that we should have a fairly decent appreciation of the complications. For pelvic binders, they principally involve the skin. But aside for the potential access site complications (bleeding, pseudoaneurysm), angiography has been thought to be relatively benign.
But as with any medical procedure, especially invasive ones, there are risks. A paper published five years ago retrospectively reviewed the 13 year experience with pelvic angiography at UC Davis. Study patients were matched with controls who underwent angiography for pelvic fracture but not embolization. Short-term (within 30 days) and long-term complications were assessed while in hospital and by telephone survey. Mean followup time was 18 months.
Here are the factoids:
- There were no differences in complications attributable to embolization within 30 days of the procedure
- There were 5 cases of short-term skin sloughing or necrosis in 55 patients, and 4 of 5 occurred in patients with nonselective embolization. However, this was not a statistically significant complication.
- Long-term complications such as buttock claudication or skin ulceration, pain, and impotence were not significantly different in embolized vs non-embolized patients
- There was a significantly increased incidence of buttock, perineal, or thigh paresthesias in the long-term
Bottom line: Angiography with embolization is a very valuable tool in the management of complication pelvic fractures. Remember that a number of complications have been described:
- Skin sloughing or necrosis
- Buttock claudication, pain, paresthesias
- Skin ulceration
Other than an increase in paresthesias in the long-term, there did not appear that there was any difference in patients undergoing angiography with and without embolization. Although the numbers were small (100 patients total), this is the best study we have to date. Just keep in mind that complications are possible, and question your patients about them when they present for their followup visits.
Reference: Evaluation of Short-term and Long-term Complications after Emergent Internal Iliac Artery Embolization in Patients with Pelvic Trauma. J Vascular Interventional Rad 19(6):840-847, 2008.
Source: The Trauma Professionals’s Blog