CT 扫描下血管内对比剂外渗范围界定骨盆钝性创伤行骨盆血管栓塞术的必要性：对假阳性风险的具体评估。

Limits of intravascular contrast extravasation on computed tomography scan to define the need for pelvic angioembolization in pelvic blunt trauma: a specific assessment on the risk of false positives.

机构信息

From the Trauma Intensive and Critical Care Unit (S.R., X.C., J.C.), Department of Radiology (M.H., I.M.), Department of Urology and Renal Transplantation (T.M.,), Department of Interventional Radiology (V.M.), and Department of Orthopedic and Traumatology (M. H.), Regional Trauma Center of Montpellier, Lapeyronie University Hospital, Montpellier, France; and Montpellier University (I.M., X.C.), Montpellier, France.

出版信息

J Trauma Acute Care Surg. 2018 Sep;85(3):527-535. doi: 10.1097/TA.0000000000002001.

DOI:10.1097/TA.0000000000002001

PMID:29901544

Abstract

BACKGROUND

The objective was to assess the predictive performance of different intravascular contrast extravasation (ICE) characteristics for need for pelvic transarterial embolization (TAE) to determine the risk factors of false positives.

METHODS

A retrospective study was performed in our trauma center between 2010 and 2015. All severe trauma patients with pelvic fracture were included. Pelvic ICE characteristics on computed tomography (CT) scan were studied: arterial (aSICE), portal surface (pSICE), and extension (exSICE) anatomic relationships. The overall predictive performance of ICE surfaces for pelvic TAE was analyzed using receiver operating characteristic curves. The analysis focused on risk factors for false positives.

RESULTS

Among 311 severe trauma patients with pelvic ring fracture (mean age, 42 ± 19 years; mean Injury Severity Score, 27 ± 19), 94 (30%) had at least one pelvic ICE on the initial CT scan. Patients requiring pelvic TAE had significantly larger aSICE and pSICE than others (p = 0.001 and p = 0.035, respectively). The overall ability of ICE surfaces to predict pelvic TAE was modest (aSICE area under the receiver operating characteristic curve, 0.76 [95% confidence interval, 0.64-0.90]; p = 0.011) or nonsignificant (pSICE and exSICE). The high-sensitivity threshold was defined as aSICE 20 mm or more. Using this threshold, 76% of patients were false positives. Risk factors for false positives were admission systolic blood pressure of 90 mm Hg or greater (63% vs 20%; p = 0.03) and low transfusion needs (63% vs 10%; p = 0.009), extravasation in contact with complex bone fracture (78% vs 30%; p = 0.008), or the absence of a direct relationship between extravasation and a large retroperitoneal hematoma (100% vs 38%; p < 0.001).

CONCLUSION

A significant pelvic ICE during the arterial phase does not guarantee the need for pelvic TAE. Three quarters of patients with aSICE of 20 mm or more did not need pelvic TAE. Several complementary CT scan criteria will help to identify this risk of false positives to determine adequate hemostatic pelvic procedures.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

摘要

背景

本研究旨在评估不同血管内对比外渗（ICE）特征对骨盆经动脉栓塞（TAE）需求的预测性能，以确定假阳性的危险因素。

方法

本研究为回顾性研究，于 2010 年至 2015 年在我们的创伤中心进行。所有骨盆骨折的严重创伤患者均纳入研究。对 CT 扫描上的骨盆 ICE 特征进行研究：动脉（aSICE）、门静脉表面（pSICE）和延伸（exSICE）解剖关系。使用受试者工作特征曲线分析 ICE 表面预测骨盆 TAE 的整体预测性能。分析重点是假阳性的危险因素。

结果

在 311 例骨盆环骨折的严重创伤患者中（平均年龄 42 ± 19 岁；平均损伤严重度评分 27 ± 19），94 例（30%）在初始 CT 扫描中至少有一个骨盆 ICE。需要进行骨盆 TAE 的患者的 aSICE 和 pSICE 明显大于其他患者（p = 0.001 和 p = 0.035）。ICE 表面整体预测骨盆 TAE 的能力中等（aSICE 受试者工作特征曲线下面积，0.76[95%置信区间，0.64-0.90]；p = 0.011）或不显著（pSICE 和 exSICE）。高灵敏度阈值定义为 aSICE 20mm 或更大。使用此阈值，76%的患者为假阳性。假阳性的危险因素为入院收缩压 90mmHg 或更高（63% vs 20%；p = 0.03）和低输血需求（63% vs 10%；p = 0.009）、外渗与复杂骨折接触（78% vs 30%；p = 0.008）或外渗与大腹膜后血肿之间无直接关系（100% vs 38%；p < 0.001）。