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Home > Blogs > Trauma Research Blog > Repeat transcatheter arterial embolization for the management of pelvic arterial hemorrhage

PubMed ID: 19204518
J Trauma. 2009 Feb;66(2):429-35
Authors: Fang JF, Shih LY, Wong YC, Lin BC, Hsu YP


BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSION: 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.

Notes & Commentary:

This paper and several others have discussed the incidence of subsequent haemorrhage following embolisation for pelvic haemorrhage.  While there is certainly the potential for rebleeding, certainly our rates are much lower than this (in fact I don't remember one in the last few years).  One possible explanation for this discrepancy is that we have had to re-learn how to read an angiogram for arterial distruption in the presence of haemorrhagic shock.  A contrast blush is rarely seen in these patients - blood pressure is low with permissive hypotension regimens and they are maximally vasoconstricted.  If vessels are not embolized because no blush is seen, when blood pressure is restored active haemorrhage will again ensue.  CT seems a lot better at picking up this contrast extravasation that angio - probably because of the delayed phase of the CT scan.  However of course CT is often bypassed in the exsanguinating patient.

Here's a patient with a left vertical shear fracture of the pelvis.  This is the initial left common iliac angiogram.  There's no blush or otherwise abnormal appearance.


However it's only when you look closely at the image that you can see that there is disruption in the superior gluteal artery territory.  On this close-up you can see severe 'pruning' of the vessels rather than the usual branching tree pattern.


Similarly if a patient is very haemodynamically unstable and has a unstable pelvic fracture, with no other obvious source for haemorrhage (abdomen, chest etc), we will gelfoam embolise both divisions of the internal iliac artery on that side (or sometimes bilaterally), even if no blush is seen.  We call this Damage Control Angioembolization, maybe others do too.


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