Compare and contrast the roles of angiography and surgical management in the management of the critically ill patient with ongoing haemorrhage  due to pelvic fractures.

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College Answer

Practice management guidelines exist for the management of haemorrhage in pelvic fracture. The general principles are included below.

Angiography is not always required but may be life saving. It requires specialist radiology expertise (not necessarily widely available), requires transport to and needs to be performed in an area that may not be adequately set up for the complex monitoring and resuscitation that may be required in an unstable patient. Definitive selective embolisation may be able to be achieved to control arterial bleeding where other strategies (e.g. pelvic stabilisation or laparotomy) have failed.

Some form of surgical management is probably required in all cases, as at least some form of immobilisation (usually external fixation) will be required for unstable pelvic fractures. Laparotomy is indicated for the associated traditional signs of intra-abdominal bleeding or intestinal perforation. Apart from definitive stabilisation, other definitive surgical management is not usually helpful apart from general packing (without exploration) for venous haemorrhage, and rarely ligation of internal iliac arteries for uncontrollable arterial haemorrhage. Some aspects of surgical management may be able to be performed outside the operating room; otherwise transport is required (but to an area set up for ongoing monitoring and stabilisation).

Discussion

Since 2004, technology has moved on, and so the opinion has shifted in favour of early angioembolisation. Even in 2003 this study supported the use of earlier angio for anybody with evidence of arterial bleeding. Furthermore, there is good evidence for a angiographic "mop-up" of bleeding which has not resolved after external surgical fixation.

This question would benefit from a 2 × 2 table of advantages and disadvantages.

Comparision of Surgical and Angiographic Control of Bleeding
from Unstable Pelvic Fractures
  Surgery Angio-embolisation
Advantages
  • Definitive control of bleeding under direct vision
  • Definitive (external or internal) fixation of fractures
  • Venous bleeding can be controlled, as well as arterial
  • Ligation of large vessels is possible
  • Temporary bypass of major vessel injuries can be performed as a part of damage control surgery
  • Less invasive
  • More immediately available
  • May be performed before or after definitive surgery
  • A sheath can be left in situ, and the procedure can be repeated
  • An effective means of controlling bleeding which was not corrected by stabilisation surgery
Disadvantages
  • Invasive
  • Availability depends on specialist expertise
  • Damage control surgery may require a return to theatre to retrieve shunts and packs
  • Usually II requires some radiation exposure
  • Depends on the presence of arterial bleeding
  • May require CT angiography to localise the "blush", to guide catheterisation
  • Arterial bleeding has to be sufficiently vigorous to appear on CT and DSA
  • Ischaemia of pelvic muscles and organs may result
  • Vascular damage may result due to arterial access
  • Requires specialist expertise
  • Exposes the patient to radiation and contrast
  • Exposes the patient to risk of transport


 

References