Interventional Radiology Management of Vascular Trauma in the Pelvis: Literature, Current Practice, and Strategies for the Future

Abstract

The management of pelvic trauma has undergone a transformation with the advent of interventional radiologic techniques, particularly embolization procedures. Embolization allows for control of pelvic hemorrhage, utilizing real-time imaging to identify and treat injured vessels, thereby stabilizing patients and reducing the need for invasive surgical procedures. Through advanced imaging and evolving technologies, interventional radiologists continue to refine the management of pelvic trauma and improve clinical outcomes. This review describes the background and current endovascular management of pelvic trauma by IR.

The management of pelvic trauma has undergone a transformation with the advent of interventional radiology (IR). Traditionally, pelvic fractures and associated hemorrhage were managed through surgical methods, often accompanied by morbidity. ¹ The integration of IR-based techniques, particularly transarterial embolization (TAE), has introduced a minimally invasive yet effective approach to addressing these injuries. ² TAE allows for control of pelvic hemorrhage, utilizing real-time imaging to identify and treat injured vessels, thereby stabilizing patients and reducing the need for invasive surgical procedures. ^{3 4} This shift not only improves immediate patient outcomes but also aligns with broader trends in trauma care toward minimally invasive interventions. ⁵ Through advanced imaging and evolving technologies, interventional radiologists continue to refine the management of pelvic trauma and improve clinical outcomes. This review describes the background and current endovascular management of pelvic trauma by IR.

Anatomy

While injuries to the cancellous bone and the pelvic venous plexus are the most common sources of hemorrhage in pelvic trauma, arterial injuries account for hemorrhage in 10 to 20% and may require endovascular intervention. ⁶ Pelvic arterial supply arises from the distal abdominal aorta, which bifurcates into the right and left common iliac arteries (CIA). Each CIA is divided into internal (IIA) and external iliac (EIA) arteries. The IIA provides supply to each hemipelvis, branching into anterior and posterior divisions ( Fig. 1A ). The anterior division is the dominant arterial supply to the pelvic viscera, giving rise to the superior and inferior vesical, middle rectal, uterine (in females), and prostatic and ductus deferens (in males) arteries, though anatomical variability exists ⁷ ( Fig. 1B, C ). It also gives rise to parietal branches, including the internal pudendal, obturator, and inferior gluteal arteries, which are frequently injured in blunt pelvic trauma ( Fig. 1B, C ). Familiarity with the normal appearance of soft tissues and viscera supplied by the anterior division vessels is critical. For example, normal cavernosal blush arising from the distal internal pudendal artery should not be mistaken for a vascular injury ( Fig. 2A D ).

Fig. 1.

( A ) Aortography in a trauma patient with pelvic sheeting, demonstrating common iliac, ¹ internal iliac, ² external iliac, ³ anterior division of internal iliac, ⁴ posterior division of internal iliac, ⁵ and common femoral ⁶ arteries. ( B ) Internal iliac artery anatomy in a female pelvic trauma patient, demonstrating left iliolumbar, ¹ lateral sacral, ² superior gluteal, ³ inferior gluteal, ⁴ obturator, ⁵ internal pudendal, ⁶ and uterine ⁷ arteries. ( C ) Internal iliac artery anatomy in a male pelvic trauma patient, demonstrating right iliolumbar, ¹ lateral sacral, ² superior gluteal, ³ inferior gluteal, ⁴ obturator, ⁵ internal pudendal, ⁶ and dorsal penile ⁷ arteries. (Adopted with permission from BioRender. Som A. [2024] BioRender.com/l29e568.)

Fig. 2.

( A, B ) Cavernosal blush arising from penile branches of the internal pudendal artery identified during pelvic arteriography (a, arrow) and subsequent CT (b, arrow). Symmetric cavernosal blush was seen during arteriography of the contralateral internal pudendal artery (not shown). ( C, D ) Spasm, stretch injury, and hemorrhage from an internal pudendal artery branch (c, arrow), mistakenly interpreted as cavernosal blush during pelvic arteriography. No blush was seen during arteriography of the contralateral internal pudendal artery (not shown). This was proven to be an arterial injury on subsequent CT (d, arrows).

The posterior division predominantly supplies musculoskeletal structures, giving rise to the iliolumbar, lateral sacral, and superior gluteal arteries ( Fig. 1B, C ). ⁷ A persistent sciatic artery, a rare anatomic variant present in 0.025 to 0.040% of patients, may arise from the internal iliac artery to supply the lower extremity, coursing through the greater sciatic foramen and alongside the sciatic nerve ( Fig. 3A ). Recognition of this variant is important in avoiding inadvertent lower extremity TAE during nonselective IIA treatments. ⁸

Fig. 3.

( A ) Persistent sciatic artery (arrow) identified during trauma arteriography, arising from the left internal iliac artery and supplying the lower extremity. ( B ) Selective injection of the right inferior epigastric artery (asterisk) during trauma arteriography demonstrates a replaced right obturator artery (arrow). ( C ) Selective injection of the right L3 lumbar artery during trauma arteriography demonstrates opacification of the artery of Adamkiewicz (arrow).

The EIA supplies the lower extremity via the common femoral artery, as well as the inferior abdominal wall via the deep circumflex iliac and inferior epigastric arteries. An accessory or replaced obturator artery (known as the “corona mortis”) may arise from the proximal inferior epigastric artery or distal EIA in 24 to 38% of hemipelvis ( Fig. 3B ). ^{9 10 11} Anastomotic connections are present between the IIA and EIA territories, and careful inspection for collateral sources of hemorrhage should be made during pelvic arteriography. Lastly, while uncommon, the dominant anterior radiculomedullary artery (known as the artery of Adamkiewicz) may rarely originate from the lumbar (L4 in 0.5% of patients and L5 in 0.5% of patients) or iliolumbar arteries ¹² ( Fig. 3C ). Recognition of this variant must be made to prevent cord infarction and neurologic adverse events during TAE.

Mechanism of Injury

While the majority of traumatic pelvic hemorrhage is due to low-pressure venous or osseous injury, pelvic arteries, and particularly IIA branches, are at risk of traumatic injury due to their proximity to osseous or ligamentous structures. ^{6 13} Particular mechanisms of trauma and their associated fracture patterns, as categorized in the Young and Burgess classification scheme, may result in characteristic vascular injuries. Mechanisms include lateral compression (LC), associated with sacral and superior pubic rami fractures; anteroposterior compression (APC), associated with pubic symphyseal and anterior sacroiliac joint widening; vertical shear (VS), associated with symphyseal and sacroiliac joint disruption and sacral fractures; and combined mechanisms. ^{14 15} LC injuries often decrease pelvic volume and rarely result in ligamentous injury. Arterial injury is less frequent in these patients, though the presence of an associated acetabular fracture more than doubles the risk of arterial hemorrhage relative to patients without acetabular fracture. ^{6 16} APC, VS, and combined-type injuries increase pelvic volume and commonly result in ligamentous disruptions, with up to 20% of patients with such injuries requiring arteriography. ⁶ Increasing injury severity correlates with a higher risk of vascular injury, with unstable fractures leading to increased pelvic hemorrhage risk compared with stable fractures. ¹⁷

Specific vessel injuries may also be associated with specific osseous or ligamentous injuries. For instance, superior and inferior gluteal artery injuries are often seen in the setting of iliac or posterior pelvic ring injuries ( Fig. 4A C ). ⁶ Internal pudendal artery injuries are common in the setting of anterior pelvic ring disruptions ( Fig. 4D ). ⁶ Lateral sacral or iliolumbar artery injuries are commonly seen in the setting of sacral fractures, sacroiliac joint disruption, or iliac crest injury ( Fig. 4E ). ⁶ Obturator artery injuries are frequently seen in conjunction with obturator ring or acetabular fractures ( Fig. 4F ). ^{6 11} EIA branch vessel injuries are likely in the presence of ipsilateral iliac or intertrochanteric fractures. ¹⁸ Assessment of the pelvic fracture pattern and mechanism may facilitate TAE by allowing interventional radiologists to focus on the most likely area(s) of arterial injury.

Fig. 4.

( A ) Right superior gluteal hemorrhage (arrow) and left superior gluteal stretch injury (asterisks). ( B ) Right inferior gluteal transection with hemorrhage (arrow) and right superior gluteal stretch injury (asterisk). ( C ) Left inferior gluteal traumatic occlusion (arrow) and left superior gluteal stretch injury (asterisk). ( D ) Right internal pudendal traumatic arteriovenous fistula (arrow). ( E ) Multifocal traumatic right iliolumbar pseudoaneurysms (arrows). ( F ) Replaced right obturator artery (arrow) with multifocal petechial hemorrhage (asterisks).

Clinical and Imaging Evaluation

Management of the pelvic trauma patient begins with primary and secondary surveys. Frontal chest and pelvic radiographs are obtained in parallel. Early closed reduction of the pelvis is critical, as bony and ligamentous approximation tamponades hemorrhage and reduce potential pelvic volume in which hematoma may accumulate. ^{6 19} Therefore, if an unstable pelvic fracture is present on the initial trauma series radiographs, the pelvis is immediately sheeted or clamped. In hemodynamically unstable patients with pelvic fractures and no evidence of intraperitoneal hemorrhage on focused assessment with sonography in trauma (FAST) or diagnostic peritoneal aspiration (DPA), the patient is resuscitated while IR is consulted for emergent arteriography. ⁴ Up to 58% of patients undergoing preperitoneal pelvic packing (PPP) showed arterial hemorrhage on subsequent arteriography. Therefore, in institutions with on-call IR capacities, PPP is no longer routinely performed. ¹⁷ Resuscitative endovascular balloon occlusion of the aorta (REBOA) is uncommonly used given the reported risk of iatrogenic injury and higher mortality rates, though it is occasionally employed in patients with life-threatening pelvic hemorrhage. ^{20 21}

If hemodynamically stable, patients with known pelvic fractures or concern for pelvic injury undergo computed tomography angiography (CTA), with imaging extending to the level of the lesser trochanters ( Fig. 5A, B ). IR is consulted for pelvic arteriography in the presence of arterial extravasation, as this finding reliably predicts arterial injury on subsequent arteriography with a specificity of 87 to 98%. The sensitivity of CTA for detecting arterial hemorrhage may be lower, ranging from 60 to 90%. ^{6 7} Signs of arterial injury on CTA include contrast extravasation, vessel truncation, pseudoaneurysm, arteriovenous fistula (AVF), or dissection. ²² Enlarging hematoma over serial CTs may also be a sign of intermittent arterial hemorrhage, even in the absence of clear arterial injury. ²² CT may also demonstrate venous injury, and venography may be reasonable in patients with clinical findings or imaging of large venous injury and hemodynamic instability. ²³

Fig. 5.

( A ) Coronal reformats of arterial-phase pelvic CT demonstrate a superior pubic ramus fracture (asterisk) and arterial hemorrhage (arrow) arising from an inferior epigastric artery branch. ( B ) The volume of extravasated contrast enlarges on venous-phase imaging (arrow), indicating ongoing hemorrhage.

Arteriography and Intervention

Pelvic arteriography may be performed via standard transfemoral access, though transradial access is a safe and feasible alternative if femoral access is limited due to overlying hematoma, open wound, or pelvic compression devices. ²⁴ Nonionic iodinated contrast agent is conventionally used for trauma arteriography, though carbon dioxide arteriography is an alternative in patients in whom iodinated contrast is contraindicated. ²⁵ Once arterial sheath access is established, flush catheter aortography is performed with the catheter positioned above the level of the aortic bifurcation, at a rate of 8 to 15 mL/second for a total of 16 to 30 mL of iodinated contrast is used. Aortography demonstrates vascular anatomy, may reveal vascular injury, and informs targeted arteriography. Selective IIA and EIA arteriography are then performed, as aortography alone is insufficiently sensitive to detect pelvic vascular injury. ^{2 4} From a femoral approach, the flush catheter may be exchanged for a five French Roberts Uterine Catheter or angled catheter (with or without a Waltman loop), used to select the IIA at highest suspicion for hemorrhage; from a radial approach, an angled catheter may be used. Selective internal iliac arteriography is performed at a rate of 3 to 6 mL/second for 12 to 18 mL. If selective anterior or posterior division arteriography is required, this may be performed via the base catheter or a 2.4 to 2.8 French microcatheter. Image acquisition both in anteroposterior and oblique views may be helpful to identify vessel origins and subtle vascular injuries; a contralateral anterior oblique view helps to identify the IIA origin, and ipsilateral anterior oblique views may distinguish origins of the anterior and posterior IIA divisions. A review of both native and digitally subtracted images may be needed to differentiate bowel peristalsis, patient motion, and other artifacts from true extravasation. ⁶ In addition to aortography and selective bilateral IIA arteriography, selective bilateral EIA arteriography is recommended at a rate of 4 to 6 mL/second for 6 to 12 mL. EIA branch vessel injury may be identified in up to 17% of trauma patients undergoing pelvic arteriography, with fewer than half of these injuries identified on nonselective pelvic arteriography. ¹⁸

Signs of arterial injury on arteriography include contrast extravasation, pseudoaneurysm, AVF, spasm or irregularity, dissection, or vessel truncation or occlusion ( Fig. 4A F ). ² When identified, these findings are assumed to represent acute injuries and warrant TAE. Selective embolization is desired whenever practical, though, in the setting of multifocal injury or patient instability requiring immediate intervention, nonselective embolization may be reasonable. ⁴ Multiple embolic devices are available, and embolic agent choice depends on the nature of the vascular injury, desire for temporary versus permanent vessel occlusion, need for selective versus nonselective embolization, patient coagulopathy, and operator familiarity. ²⁶

The most commonly used temporary embolic material in pelvic hemorrhage management is Gelfoam (Pfizer, New York City, New York), a porcine-derived gelatin foam, due to its wide availability, low cost, ease of use, multiple configurations, and temporary nature, which allows for vessel healing and eventual recanalization within 2 to 3 weeks. ² Gelfoam sheets may be cut into pieces and mixed with 5 to 10 mL of dilute contrast via a three-way stopcock, forming a slurry that may be injected into a base catheter or microcatheter for rapid, flow-directed occlusion of the downstream vessels. Larger pledgets or strips of Gelfoam sized to a target vessel diameter may be loaded into individual syringes, soaked in contrast, and used to occlude individual vessels; a rolled strip of Gelfoam, known as a “torpedo,” may be injected via an individual syringe, and used to target large vessels. While pledget and torpedo-mediated vessel occlusion are rapid, their use increases the risk of catheter occlusion relative to Gelfoam slurry. Powdered Gelfoam, while available, should be avoided for pelvic embolization due to small particle caliber and risk of ischemia, though larger particle embolics such as tris-acryl polymer microspheres or polyvinyl alcohol may be used with less risk of end-tissue ischemia. ^{2 4} Regardless of its composition, Gelfoam embolization should be performed slowly under fluoroscopy, avoiding reflux and nontarget embolization. The use of frequent saline flushes may help prevent catheter occlusion. TAE should be continued until pruning of distal vasculature, slow flow, or near-stasis is achieved on postembolization arteriography, with no residual hemorrhage or vessel injury ( Fig. 6A, B ). ^{2 4}

Fig. 6.

( A ) Multifocal right internal iliac artery petechial hemorrhage and stretch injury (asterisks). ( B ) Internal iliac branch vessel pruning and near-stasis after nonselective Gelfoam slurry embolization (arrow), with no residual vascular injury identified. ( C ) Left internal iliac artery transection and hemorrhage (asterisk). ( D ) Coil embolization of the left internal iliac artery (arrow), with no residual hemorrhage. ( E ) Multifocal left internal iliac artery hemorrhage (asterisks) after attempted coil embolization in a coagulopathic patient. ( F ) No residual hemorrhage was identified after the left internal iliac artery NBCA embolization (arrow). ( G ) Traumatic occlusion of the left internal iliac anterior division branch arteries (asterisks). ( H ) No residual anterior division injuries were identified after embolization with shear-thinning embolic (arrow).

Permanent embolic agents may be appropriate in the treatment of focal pelvic vascular injuries in select patients. Platinum-based microcoils or vascular plugs have long been the embolic agents of choice in this setting and are available in a range of diameters, lengths, configurations, and deployment mechanisms designed to promote vessel occlusion. Coil or plug deployment requires navigation of a base catheter or microcatheter to or across the region of vascular injury. In the setting of pseudoaneurysm or collateral supply from other pelvic vessels, the embolic should be deployed distal to, across, and proximal to the area of injury ( Fig. 6C, D ). ² While size recommendations vary by coil or plug type, oversizing by 20 to 30% relative to the target vessel is common to prevent embolic migration and detachable devices may be used over pushable devices when precision deployment is required. ²⁶ Use of fibered or hydrogel coils increases the efficiency of vessel occlusion relative to metallic coils alone, though using a combination of thrombogenic and metallic coils, or coils and Gelfoam, may increase thrombogenicity. ^{27 28} Given the need for selective navigation and frequent use of multiple coils to achieve vessel occlusion, coil embolization increases procedural length relative to nonselective Gelfoam embolization. Lastly, both coil and plug efficacy depends upon an intact coagulation cascade, and consideration of other embolic types should be made in coagulopathic patients.

In coagulopathic patients, or when rapid permanent TAE is desired, n-butyl-2 cyanoacrylate (NBCA) glue may be employed. NBCA is a free-flowing monomer that polymerizes in ionic environments, such as saline or blood, at a rate proportional to NBCA concentration. ²⁶ Because of this polymerization mechanism, all catheters and syringes must be flushed with 5% dextrose in water (D5W) to prevent premature anionic contact. For use, NBCA is mixed with ethiodized oil at a desired ratio (ranging from 1:2 to 1:8 NBCA to ethiodized oil), with smaller proportions of NBCA used when slow polymerization and increased glue penetration is required (such as in distal, difficult-to-reach hemorrhage), and larger proportions of NBCA when more immediate polymerization is required (as in treatment of pelvic AVF). ^{29 30} Injection is performed using arteriography or negative roadmap techniques to confirm glue deployment and avoid reflux or nontarget embolization. Once sufficient glue has been deployed, the catheter is briskly removed to prevent catheter adherence to the vessel or glue pack. NBCA polymerization does not depend on an intact coagulation cascade, and vessel occlusion is immediate ( Fig. 6E, F ). NBCA alternatives include ethylene vinyl alcohol copolymer-based products (Onyx, Medtronic, Minneapolis, Minnesota, or Lava, SIRTex, Woburn, Massachusetts). These permanent tantalum-containing liquid embolic are mixed with dimethylsulfoxide (DMSO) and polymerize into a cast as DMSO diffuses into the bloodstream. Their use in acute trauma, however, has been limited due to cost and the need for 5 to 20 minutes of continuous shaking prior to implementation. ²⁶

Recent advances in materials science have led to the development of novel embolic, some of which are in ongoing clinical trials or have been recently approved for use. For instance, shear-thinning conformable embolics exhibit liquid properties when exposed to shear stress but act as solids in the absence of shearing. ³¹ A nanocomposite hydrogel containing tantalum microparticles (Obsidio, Boston Scientific, Marlborough, Massachusetts) was approved by the Food and Drug Administration (FDA) on July 1, 2022, for use as a permanent embolic in the setting of hemorrhage in the peripheral vasculature. ³² Conformable embolic do not depend on the coagulation cascade, are premixed for immediate use, and do not require variable dilutions. Conformable embolics are injected through a selectively-positioned microcatheter. Embolic penetration depends on the force and speed of injection, acting similar to a pushable embolic. ^{32 33} Use of aliquot techniques for deployment should be avoided, due to differential viscosity that may lead to nontarget embolization. ³² Once the desired volume of embolic has been injected, the microcatheter is removed, and postembolization arteriography is performed to confirm immediate occlusion ( Fig. 6G, H ).

Lastly, injuries to large pelvic vessels that perfuse the lower extremities, such as common or external iliac arteries, are usually not amenable to TAE. In these instances, stent-graft reconstruction may be performed ^{34 35} ( Fig. 7A C ). Arterial access should be obtained using a sheath large enough to accommodate the desired stent graft. Stable wire access should be established across the injured artery. Stent-graft diameter should approximate the normal diameter of the uninjured target vessel, and stent-graft length should cover the proximal and distal uninjured artery to provide an adequate seal and prevent leakage ^{23 34} ( Fig. 7B, C ). If an endovascular intervention fails, balloon tamponade and subsequent operative repair may be considered. ³⁴

Fig. 7.

( A ) Delayed right external iliac artery rupture and hemorrhage (arrow) after retroperitoneal mass resection. ( B ) After 8 × 50 mm Viabahn (W.L Gore, Newark, Delaware) stent-graft deployment (arrow) and dilation to 6 mm, there was reduced but persistent hemorrhage around the stent-graft (asterisk). ( C ) After stent-graft dilation to 8 mm, there was no residual hemorrhage (arrow).

Venography and Intervention

Indications for venography and endovascular interventions are uncommon in blunt pelvic trauma, where pelvic stabilization and volume reduction are frequently sufficient to tamponade low-pressure venous hemorrhage. ⁶ However, venography and endovascular intervention may be reasonable in the setting of a large-vessel, penetrating, or iatrogenic venous injury. ^{23 34} Transfemoral or more peripheral venous access may be obtained in standard fashion, using a sheath large enough to accommodate occlusion balloons or stent-grafts (e.g., 10 French or larger), and diagnostic venography may be performed ( Fig. 8 ). An occlusion balloon may be inflated peripheral to or across the region of venous injury to allow for tamponade ( Fig. 8B, E ), and less severe venous injuries may respond to prolonged balloon tamponade alone. Larger injuries may require treatment with stent grafts ( Fig. 8C ). Bare metal stents may effectively treat venous injuries if stent grafts are unavailable. ²³ Venous stents or stent-grafts should be sized to the native vessel caliber and cover sufficient uninjured veins peripheral and central to the injury to prevent leakage around the stent graft. ³⁶ In venous injuries not amenable to endovascular intervention, surgical repair may be required ( Fig. 8F ).

Fig. 8.

( A ) Pelvic venography demonstrates right external iliac vein hemorrhage (arrow) after iatrogenic trauma during sheath placement. ( B ) Balloon occlusion (arrow) tamponades the injury and prevents intraprocedural hemorrhage. ( c ) No further hemorrhage was seen after 13 × 100 mm Viabahn (W.L Gore) stent-graft deployment (arrow) across the injured venous segment. ( D ) Pelvic venography demonstrates right external iliac vein hemorrhage (arrow) after iatrogenic trauma during attempted right heart catheterization. ( E ) Balloon occlusion (arrow) tamponades the injury and prevents intraprocedural hemorrhage. ( F ) After exchange for an occlusion balloon-catheter (arrow) and unsuccessful attempts to cross the injury from ipsilateral femoral, contralateral femoral, and right jugular approaches (asterisks) as well as right saphenous vein access (not shown), the patient underwent operative common femoral vein ligation with cessation of hemorrhage.

Safety and Outcomes

Pelvic endovascular interventions in the setting of trauma are effective, safe, and well-tolerated. Technical success rates of pelvic TAE reach 100%, while clinical success rates, defined variably as nonvisualization of vascular injury on postembolization arteriography to correction of hemodynamic instability postprocedure, range from 74 to 93%. ^{3 37 38 39} Need for repeat pelvic arteriography is uncommon, with rates ranging from 2.2 to 10%; hemorrhage found during repeat arteriography more commonly originates from untreated vessels rather than from a previously embolized site. ^{3 37 40} Contemporary mortality estimates following pelvic TAE vary widely, ranging from 9.8 to 32%, though multiple studies report mortality rates of 64 to 75% in patients undergoing delayed (defined as >3–4 hours following admission) rather than early pelvic arteriography. ^{3 37 41 42 43 44 45}

Accurate assessment of adverse event rates in this patient population is challenging, as it is often difficult to distinguish between sequelae of pelvic trauma versus adverse events from TAE. Reported TAE adverse event rates therefore vary widely, ranging from 1.1 to 63%. ^{3 37 41 43 44 45} The most frequently reported adverse events include gluteal ischemia. While its incidence is controversial, gluteal muscle necrosis has been reported in up to 6% of pelvic TAE patients, with lower rates reported in those undergoing selective embolization and higher rates reported in patients undergoing nonselective bilateral IIA embolization and in patients with concomitant degloving injuries. ^{37 46 47 48 49} Gluteal necrosis may be asymptomatic and encountered only on subsequent imaging, focused gait assessments, or intraoperatively, but post-TAE gluteal ischemia has variably been associated with persistent gluteal claudication, skin sloughing or ulceration, or pelvic or perineal infection, though propensity score-matched studies have found equally low rates of infection and cutaneous necrosis in patients undergoing arteriography with TAE versus those undergoing arteriography alone. ^{41 43 47 50} Other manifestations of end-tissue ischemia are less common but include case reports of bladder, rectal, or osseous avascular necrosis. ^{49 51 52}

Estimates of genitourinary adverse events following TAE also range widely, as separating genitourinary adverse events of pelvic trauma from the effects of TAE remains challenging. Some cohort and case-control studies report increased rates of urinary dysfunction (including dribbling, retention, and increased rates of urinary tract infection in up to 50% of patients) and erectile dysfunction in TAE patients. ^{50 53} Other matched studies show similar long-term urogenital function and quality of life in post- and non-TAE pelvic trauma patients alike, including both male and female patients. ^{54 55}

Neurologic adverse events such as sequelae of postembolization ischemia or nontarget embolization are rare, though case reports of lower extremity neurologic deficits exist. ⁵² While the etiology of neurologic adverse events in these instances is unclear, embolization of iliolumbar and lateral sacral arteries and their anastomoses, or inadvertent nontarget embolization of variant anatomy, may increase the risks of neurologic adverse events. Such adverse events are rare; however, the benefits of endovascular intervention outweigh these adverse event risks.

Conclusion

The management of pelvic trauma has been transformed by the integration of IR, particularly through techniques including arteriography, microcatheters, and embolic. This shift from surgical methods to less invasive, image-guided approaches has proven to be effective in controlling pelvic hemorrhage while significantly improving clinical outcomes and minimizing adverse events.

Funding Statement

Funding None.

Corrigendum: The article has been updated as Corrigendum published on December 10, 2025 (DOI https://doi.org/10.1055/s-0045-1814101).