Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Linkou branch, and Chang Gung University 33302, Tao-Yuan, Taiwan. 5, Fu-Hsin St. Kweishan, 33302, Tao-Yuan, Taiwan.
Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung Branch, and Chang Gung University, Keelung City, Taiwan.
BMC Musculoskelet Disord. 2020 May 30;21(1):335. doi: 10.1186/s12891-020-03372-5.
In most institutions, arterial embolization (AE) remains a standard procedure to achieve hemostasis during the resuscitation of patients with pelvic fractures. However, the actual benefits of AE are controversial. In this study, we aimed to explore AE-related outcomes following resuscitation at our center and to assess the predictive value of contrast extravasation (CE) during computed tomography (CT) for patients with hemodynamically unstable closed pelvic fractures.
We retrospectively reviewed data from patients who were treated for closed pelvic fractures at a single center between 2014 and 2017. Data regarding the AE and clinical parameters were analyzed to determine whether poor outcomes could be predicted.
During the study period, 545 patients were treated for closed pelvic fractures, including 131 patients who underwent angiography and 129 patients who underwent AE. Nonselective bilateral internal iliac artery embolization (nBIIAE) was the major AE strategy (74%). Relative to the non-AE group, the AE group had higher values for injury severity score, shock at hospital arrival, and unstable fracture patterns. The AE group was also more likely to require osteosynthesis and develop surgical site infections (SSIs). Fourteen patients (10.9%) experienced late complications following the AE intervention, including 3 men who had impotence at the 12-month follow-up visit and 11 patients who developed SSIs after undergoing AE and osteosynthesis (incidence of SSI: 11/75 patients, 14.7%). Nine of the 11 patients who developed SSI after AE had undergone nBIIAE. The positive predictive value of CE during CT was 29.6%, with a negative predictive value of 91.3%. Relative to patients with identifiable CE, patients without identifiable CE during CT had a higher mortality rate (30.0% vs. 11.0%, p = 0.03).
Performing AE for pelvic fracture-related hemorrhage may not be best practice for patients with no CE detected during CT or for unstable patients who do not respond to resuscitation after exclusion of other sources of hemorrhage. Given the high incidence of SSI following nBIIAE, this procedure should be selected with care. Given their high mortality rate, patients without CE during imaging might be considered for other hemostasis procedures, such as preperitoneal pelvic packing.
在大多数机构中，动脉栓塞术（AE）仍然是骨盆骨折患者复苏期间止血的标准程序。然而，AE 的实际益处存在争议。在本研究中，我们旨在探讨我们中心复苏后与 AE 相关的结果，并评估 CT 期间对比剂外渗（CE）对血流动力学不稳定闭合性骨盆骨折患者的预测价值。
我们回顾性分析了 2014 年至 2017 年在一家中心接受治疗的闭合性骨盆骨折患者的数据。分析了与 AE 相关的数据和临床参数，以确定是否可以预测不良结局。
在研究期间，545 例患者接受了闭合性骨盆骨折治疗，其中 131 例患者接受了血管造影术，129 例患者接受了 AE。非选择性双侧髂内动脉栓塞术（nBIIAE）是主要的 AE 策略（74%）。与非 AE 组相比，AE 组的损伤严重程度评分、入院时休克和不稳定骨折模式较高。AE 组也更有可能需要进行骨固定并发生手术部位感染（SSI）。14 例（10.9%）患者在 AE 干预后出现迟发性并发症，包括 3 例男性在 12 个月随访时出现阳痿，11 例患者在接受 AE 和骨固定后发生 SSI（SSI 发生率：11/75 例，14.7%）。11 例发生 AE 后 SSI 的患者中有 9 例接受了 nBIIAE。CT 期间 CE 的阳性预测值为 29.6%，阴性预测值为 91.3%。与 CT 期间无法识别 CE 的患者相比，CT 期间无法识别 CE 的患者死亡率更高（30.0% vs. 11.0%，p=0.03）。
对于 CT 期间无法识别 CE 或复苏后无法排除其他出血源的不稳定患者，进行骨盆骨折相关出血的 AE 可能不是最佳实践。鉴于 nBIIAE 后 SSI 的发生率较高，应谨慎选择该程序。鉴于其高死亡率，影像学检查中无 CE 的患者可能需要考虑其他止血程序，例如腹膜前骨盆填塞。
