Fang Jen-Feng, Shih Lih-Yuann, Wong Yon-Cheong, Lin Being-Chuan, Hsu Yu-Pao
Trauma and Critical Care Center, Department of Surgery, Chang-Gung Memorial Hospital, Chang-Gung University, Taoyuan, Taiwan.
J Trauma. 2009 Feb;66(2):429-35. doi: 10.1097/TA.0b013e31817c969b.
Most arterial hemorrhage associated with pelvic fracture can be adequately controlled by a single transcatheter arterial embolization (TAE). However, there is a small group of patients who remain hemodynamically unstable after TAE, have no other identifiable source of bleeding, and who benefit from repeat TAE of the pelvis.
We conducted a retrospective study of patients with hemorrhage from pelvic fractures between January 2001 and June 2006. Clinical parameters and results were compared between patients requiring more than one pelvic TAE and those undergoing a single TAE. Risk factors for repeat TAE were identified by univariate and stepwise logistic regression analyses.
During the study period, 174 of 964 patients with pelvic fracture received pelvic angiography for suspected arterial hemorrhage. One hundred forty TAEs were performed. Thirty-four (24.3%) patients underwent more than one angiography for suspected recurrent arterial hemorrhage, and 26 (18.6%) underwent repeat TAE. Repeat angiography was performed 3 to 58 hours (mean, 21 hours) after initial TAE. Patients with repeat TAE had significantly more blood transfusions, higher mortality rate, and longer intensive care unit stay. Independent predictors for repeat TAE included initial hemoglobin level lower than 7.5 g/dL (OR, 6.22), superselective arterial embolization in initial TAE (OR, 3.22), and more than 6 units of blood transfusion after initial TAE (OR, 3.22).
Careful monitoring and prompt recognition of patients requiring repeat TAE is paramount. The arterial access sheath should remain in place for up to 72 hours after angiography. Initial hemoglobin level lower than 7.5 g/dL and more than 6 units of blood transfusion after initial angiography are predictors for repeat TAE. Superselective TAE is associated with a significantly higher risk of recurrent hemorrhage, and its use should be limited.
大多数与骨盆骨折相关的动脉出血可通过单次经导管动脉栓塞术（TAE）得到充分控制。然而，有一小部分患者在TAE后仍血流动力学不稳定，没有其他可识别的出血来源，且从骨盆重复TAE中获益。
我们对2001年1月至2006年6月期间骨盆骨折出血患者进行了一项回顾性研究。比较了需要多次骨盆TAE的患者与接受单次TAE的患者的临床参数和结果。通过单因素和逐步逻辑回归分析确定重复TAE的危险因素。
在研究期间，964例骨盆骨折患者中有174例因疑似动脉出血接受了骨盆血管造影。共进行了140次TAE。34例（24.3%）患者因疑似复发性动脉出血接受了不止一次血管造影，26例（18.6%）接受了重复TAE。重复血管造影在初次TAE后3至58小时（平均21小时）进行。接受重复TAE的患者输血次数明显更多，死亡率更高，重症监护病房住院时间更长。重复TAE的独立预测因素包括初始血红蛋白水平低于7.5 g/dL（OR，6.22）、初次TAE时进行超选择性动脉栓塞（OR，3.22）以及初次TAE后输血超过6单位（OR，3.22）。
仔细监测并及时识别需要重复TAE的患者至关重要。血管造影后动脉通路鞘应保留长达72小时。初始血红蛋白水平低于7.5 g/dL以及初次血管造影后输血超过6单位是重复TAE的预测因素。超选择性TAE与复发性出血风险显著更高相关，应限制其使用。
