Abstract
Background
Vascular injury following blunt pelvic fractures is a major source of morbidity and mortality. Angioembolization has become the standard of care for patients with contrast extravasation (CE) on CT scan; however, there are patients without CE who have a vascular injury. We aimed to determine the predictors of the need for angioembolization in patients with blunt pelvic fractures.
Methods
We performed a retrospective case–control study of blunt trauma patients with pelvic fractures who underwent angiography by interventional radiology (IR) at a single institution from 2018 to 2023. Patients with CE on CT scan were compared with patients without CE to determine the risk factors for a positive angiogram. A multivariable logistic regression analysis was conducted to assess the factors associated with having a positive angiogram.
Results
167 patients with blunt pelvic fractures underwent angiography: 120 with CE and 47 without CE on CT scan. Both groups were severely injured with a mean Injury Severity Score of 31; over 85% of patients requiring blood prior to angiography and 45% requiring massive transfusion protocol (MTP). There was no difference in rates of positive angiogram between patients with and without CE on CT scan (83% vs. 93%, p=0.08). Of the 47 patients without CE on their CT scan, 27 (57%) had active extravasation on angiography and an additional 12 (26%) had an injury requiring intervention. Initial systolic blood pressure, receiving blood prior to angiography, MTP activation, and CE on initial CT scan were not independently predictive of positive angiogram.
Conclusion
Although CE on CT scan is often the initial trigger for IR consultation for angiography in trauma patients with pelvic fractures, there are patients without CE who have an injury requiring intervention. In trauma patients with concerns for ongoing hemodynamic instability, IR consultation is reasonable even without CE on initial CT scan.
Level of evidence
Diagnostic test/criteria: level IV.
Keywords: angiography, hemorrhage
WHAT IS ALREADY KNOWN ON THIS TOPIC
Vascular injury following blunt pelvic fractures has high morbidity and mortality. Angioembolization is the standard of care for patients with contrast extravasation seen on CT scan.
WHAT THIS STUDY ADDS
There is a subset of patients without contrast extravasation seen on CT scan who have a vascular injury requiring intervention identified on angiography.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This study demonstrates that there is a subset of patients without contrast extravasation on CT scan who have a vascular injury requiring intervention. In practice, interventional radiology consult should be considered for patients with ongoing hemodynamic instability even if contrast extravasation was not seen on CT scan.
Background
Pelvic fractures and associated vascular injury can be a significant source of hemorrhagic shock and mortality in blunt force trauma patients.1 2 80–85% of pelvic hemorrhage comes from a venous or bony source and can therefore be controlled with external compression, pelvic packing or fixation.3 4 However, the 10–15% of fractures with associated arterial hemorrhage may require further intervention for hemorrhage control. Angioembolization is efficacious in 85–97% of cases5 and has become the gold standard for arterial hemorrhage control in the setting of a pelvic fracture.6
CT imaging has been used to identify patients who may need angioembolization. Patients with contrast extravasation (CE) on CT scan are thought to have ongoing arterial bleeding and therefore need angioembolization.6 However, the data supporting CE as a predictor of the need for angioembolization are mixed. Several groups have found CE to have a sensitivity of up to 95% for predicting the need for angioembolization.7 8 Other data suggest more modest values with multiple reports of ongoing bleeding on angiography after negative CT scan for CE.9 10
Given the disputed significance of CE, efforts have been made to identify additional predictive factors, including hypotension, pelvic fracture pattern, blood transfusion requirements, and injury severity.10,13 Notably, hemodynamically unstable patients without evidence of CE on imaging may still benefit from angioembolization.10 We hypothesized that there is a subset of patients without CE on initial CT scan who have a vascular injury requiring intervention. In this study, we aimed to identify predictors of the need for angioembolization in patients with blunt pelvic fractures.
Methods
We performed a retrospective case–control study of trauma patients with blunt pelvic fractures who underwent angiography by interventional radiology (IR) at a single level 1 trauma center from January 1, 2018 to September 30, 2023. All patients with pelvic fractures who underwent angiography during this time were identified via our institutional trauma registry. Patients were excluded if <18 years of age, an injury was due to a penetrating mechanism, a CT scan was not performed on initial evaluation, angiography of the pelvis was not performed by IR, and/or angiography occurred >24 hours after admission. Patients with CE noted on their initial CT scan were compared with those without CE. The primary outcome was patients without CE who had a positive angiogram. Secondary outcomes included angiogram findings and time to angiography.
Demographics and clinical variables were collected from the patient’s medical record. These included age, sex, race, mechanism of injury, lower extremity Abbreviated Injury Scale (LE AIS), Injury Severity Score (ISS), initial systolic blood pressure, initial heart rate, traumatic brain injury, blood thinner use, and mortality. Variables regarding angiography were also collected, including time to angiography, findings of angiography, change in systolic blood pressure prior to angiography, PRBC received prior to angiography, activation of massive transfusion protocol (MTP), and use of other hemorrhage control adjuncts such as pelvic binder, pelvic external fixation device or resuscitative endovascular balloon occlusion of the aorta (REBOA).
At our institution, based on clinical stability, all blunt injured patients who are evaluated by the trauma team undergo a CT scan of the chest, abdomen, and pelvis on arrival to evaluate for traumatic injuries. For patients with any pelvic fractures and pelvic hematoma, it is our standard practice to place an IR consult for any patient with active CE noted on CT scan within the pelvis. The decision and timing of consults for patients without active CE are at the discretion of the attending trauma surgeon. IR is available 24 hours/day for consultation regardless of the days of the week or time of day.
Univariable associations between patients with and without CE were determined using Wilcoxon rank-sum (continuous outcomes) and χ2 tests (categorical), respectively. Nominal and False discovery Rate (FDR)-adjusted p values were reported to handle multiple comparisons. Primary outcomes were compared between those with and without CE on initial CT scan. If patients’ systolic blood pressure was too low to be obtained, their initial systolic blood pressure was imputed as the minimum recorded systolic blood pressure plus random noise from a standard normal distribution.
A multivariable logistic regression analysis was performed for having a positive angiogram adjusting for packed red blood cells (PRBC) prior to angiography, initial systolic blood pressure, CE on CT scan, and activation of MTP. A p value <0.05 was considered statistically significant.
A subgroup analysis was performed comparing patients with and without CE based on LE AIS. Less severe was classified as LE AIS scores 1–3 and more severe as LE AIS scores 4–5. Within each subgroup, we compared patients with and without CE for the outcome of positive angiogram. Due to limited sample size, formal multivariate logistic regression models were not feasible, so Fisher’s exact tests were used to evaluate the association. An additional subgroup logistic regression was performed restricted to patients with less severe LE AIS, with positive angiogram as the outcome and including PRBC prior to angiography, initial systolic blood pressure, CE on CT scan, and activation of MTP as covariates. All statistical analyses were performed using R V.4.3.2.
Results
During the study period, 167 patients met the inclusion criteria and underwent pelvic angiography performed by IR. 120 (72%) patients had CE on initial CT scan and 47 had no CE. The majority of patients were male (69%), and the median age was 52 years old (quartile 1, quartile 3: 30, 69). The most common mechanism of injury was motor vehicle collision, followed by motorcycle collision and auto vs pedestrian. Both groups were severely injured with a mean ISS of 31 (SD 13.5) and initial systolic blood pressure of 98 (quartile 1, quartile 3: 70, 120); 19% of patients had no obtainable initial blood pressure (table 1).
Table 1. Demographics comparing patients with and without CE on initial CT scan.
| Variables | No CE on CT (47) | CE on CT (120) | All patients (167) |
|---|---|---|---|
| Age (mean, SD) | 48.5 (21.7) | 51.7 (21.7) | 50.8 (21.6) |
| Male sex | 33 (70.2%) | 82 (68.3%) | 115 (68.9%) |
| Race | |||
| White | 36 (76.6%) | 92 (76.7%) | 128 (76.6%) |
| Black | 7 (14.9%) | 20 (16.7%) | 27 (16.2%) |
| Other | 4 (8.5%) | 8 (6.6 %) | 12 (7.1%) |
| Mechanism of injury | |||
| MVC | 23 (48.9%) | 46 (38.3%) | 69 (41.3%) |
| GLF | 0 (0%) | 7 (5.8%) | 7 (4.2%) |
| Fall from height | 4 (8.5%) | 10 (8.3%) | 14 (8.4%) |
| Auto vs Pedestrian | 5 (10.6%) | 23 (19.2%) | 28 (16.8%) |
| MCC | 9 (19.1%) | 26 (21.7%) | 35 (21.0%) |
| Bicycle | 3 (6.4%) | 0 (0%) | 3 (1.8%) |
| Other | 3 (6.4%) | 8 (6.7%) | 11 (6.6%) |
| LE AIS score | |||
| 2 | 10 (21.3%) | 46 (38.3%) | 56 (33.5%) |
| 3 | 26 (55.3%) | 54 (45.0%) | 80 (47.9%) |
| 4 | 8 (17.0%) | 12 (10.0%) | 20 (12.0%) |
| 5 | 3 (6.4%) | 8 (6.7%) | 11 (6.6%) |
| Injury Severity Score (mean, SD) | 34.3 (11.8) | 29.4 (14.0) | 30.8 (13.5) |
| Initial systolic blood pressure unobtainable | 11 (23.4%) | 21 (17.5%) | 32 (19.2%) |
| Initial systolic blood pressure (Q1, Q3, median) | 100.0 (63.0, 110.0) | 98.0 (70.0, 121.0) | 98.0 (70.0, 120) |
| Initial heart rate (Q1, Q3, median) | 104.0 (94.0, 119.0) | 105.0 (81.8, 124.2) | 105.0 (82.0, 123.0) |
| Traumatic brain injury | 17 (36.2%) | 39 (32.5%) | 56 (33.5%) |
| Blood thinner use | 1 (2.1%) | 11 (9.2%) | 12 (7.2%) |
CE, contrast extravasation; GLF, ground-level fall; LE AIS, lower extremity Abbreviated Injury Scale; MCC, motorcycle crash; MVC, motor vehicle crash.
From univariate tests, there was no statistically significant difference in the change in systolic blood pressure, receiving PRBC prior to angiography, activation of MTP, application of binder, or use of REBOA (table 2). The median time to IR was 190 minutes with no difference between the two groups. There was no statistically significant difference in rates of positive angiogram between patients with and without CE on CT scan (83% vs. 93%, p=0.08). Of the 47 patients without CE on CT scan, 83% had a positive angiogram, 27 (57%) had active extravasation on angiography and an additional 12 (26%) had no active extravasation but had an injury requiring intervention identified on angiography. There was no difference in angiogram findings or other organs embolized between the two groups (table 3). Overall, 16 patients had no injury identified on angiography—eight in each group. Of those without CE, four underwent empiric angioembolization of pelvic vessels compared with five who underwent empiric angioembolization in the CE group. The overall mortality was 23%, with no significant difference detected between those with and without CE (23.4% vs. 23.3%, p=1). Table 4 demonstrates the results of a multivariable logistic regression for having a positive angiogram. Initial systolic blood pressure, receiving PRBC prior to angiography, and MTP activation were not significantly associated with positive angiogram. Patients with CE on initial CT scan were 2.8 (95% CI 0.97 to 8.04) times more likely to have a positive angiogram, though this association was not independently predictive of positive angiogram in the current study (p=0.06).
Table 2. Clinical status and interventions in patients with and without CE on CT scan.
| Variables | No CE on CT scan (47) | CE on CT scan (120) | All patients (167) | Normal P value | FDR-adjusted P value |
|---|---|---|---|---|---|
| Drop in systolic blood pressure prior to angiography (mean, SD) | 23.8 (26.2) | 20.6 (25.1) | 21.5 (25.4) | 0.666 | 0.695 |
| PRBC prior to angiography | 44 (93.6%) | 101 (84.2%) | 145 (86.8%) | 0.171 | 0.695 |
| MTP initiated | 25 (53.2%) | 50 (41.7%) | 75 (44.9%) | 0.241 | 0.695 |
| REBOA | 11 (23.4%) | 23 (19.2%) | 34 (20.4%) | 0.691 | 0.839 |
| Ex-fix | 0 (0%) | 3 (2.5%) | 3 (1.8%) | 0.656 | 0.839 |
| Pelvic binder | 22 (46.8%) | 53 (44.2%) | 75 (44.9%) | 0.892 | 1 |
CE, contrast extravasation; Ex-fix, external fixation device; FDR, false discovery rate; MTP, massive transfusion protocol; PRBC, packed red blood cells; REBOA, resuscitative endovascular balloon occlusion of the aorta.
Table 3. Angiogram findings in patients with and without CE on CT scan.
| Variables | No CE on CT scan (47) | CE on CT scan (120) | All patients (167) | P value | FDR-adjusted P value |
|---|---|---|---|---|---|
| Time to angiography (min) (Q1, Q3, median) |
205.0 (158.5, 278.0) | 182.0 (146.8, 251.8) | 190.0 (148.5, 259.5) | 0.245 | 0.695 |
| Injury identified on angiography | 39 (83%) | 112 (93.3%) | 151 (90.4%) | 0.08 | 0.695 |
| Angiogram findings | 0.21 | 0.695 | |||
| No injury | 8 (17.0%) | 8 (6.7%) | 16 (9.6%) | ||
| Active extravasation | 27 (57.4%) | 85 (70.8%) | 112 (67.1%) | ||
| Dissection/cut-off/blunting/occlusion/truncation | 2 (4.3%) 5 (10.6%) |
1 (0.8%) 9 (7.5%) |
3 (1.8%) 14 (8.4%) |
||
| Irregularity | 3 (6.4%) | 12 (10%) | 15 (9.0%) | ||
| Pseudoaneurysm | 1 (2.1%) | 4 (3.3%) | 5 (3.0%) | ||
| Injury not further specified | 1 (2.1%) | 1 (0.8%) | 2 (1.2%) | ||
| Additional organ embolized | 9 (19.1%) | 14 (11.7%) | 23 (13.8%) | 0.311 | 0.717 |
CE, contrast extravasation; FDR, False discovery rate.
Table 4. Multivariable logistic regression for independent predictors of positive angiogram.
| Variables | Estimates | OR | 95% CI | P value |
|---|---|---|---|---|
| PRBC prior to angiography | −0.87 | 0.42 | 0.05 to 3.68 | 0.43 |
| MTP initiated | −0.26 | 0.77 | 0.24 to 2.45 | 0.66 |
| CE on CT scan | 1.02 | 2.79 | 0.97 to 8.04 | 0.06 |
| Initial systolic blood pressure | −0.01 | 0.99 | 0.98 to 1.01 | 0.33 |
CE, contrast extravasation; MTP, massive transfusion protocol; PRBC, packed red blood cells.
In the subgroup analysis based on LE AIS, there were 136 patients in the less severe LE AIS group and 31 patients in the more severe LE AIS group. Descriptive statistics are presented in table 5. In the less severe group, 83% of patients without CE had a positive angiogram, while in the more severe group, 81% of patients without CE had a positive angiogram. In the less severe subgroup, the odds of a positive angiogram were 2.6 times higher in the CE group compared with no-CE group (95% CI 0.68 to 9.98, p=0.11). In the more severe subgroup, the odds were 4.0 times higher (95% CI 0.19 to 261.40, p=0.28). While these trends may suggest a potential association, they were not statistically significant.
Table 5. Summary of positive angiogram by CE and LE AIS groups.
| Less severe (LE AIS scores 1/2/3) | More severe (LE AIS scores 4/5) | All patients | ||||
|---|---|---|---|---|---|---|
| CE=no (n=36) | CE=yes (n=100) | CE=no (n=11) | CE=yes (n=20) | CE=no (n=47) | CE=yes (n=120) | |
| Positive angiogram | ||||||
| No | 6 (16.7%) | 7 (7.0%) | 2 (18.2%) | 1 (5.0%) | 8 (17.0%) | 8 (6.7%) |
| Yes | 30 (83.3%) | 93 (93.0%) | 9 (81.8%) | 19 (95.0%) | 39 (83.0%) | 112 (93.3%) |
CE, contrast extravasation; LE AIS, lower extremity Abbreviated Injury Scale.
In the subgroup logistic regression analysis of patients with less severe LE AIS for positive angiogram, with PRBC prior to angiography, initial systolic blood pressure, CE on CT scan, and activation of MTP included as covariates, none of the covariates were significantly associated with positive angiogram. The results are shown in table 6.
Table 6. Multivariable logistic regression for independent predictors of positive angiogram among less severe patients (lower extremity Abbreviated Injury Scale scores=1/2/3).
| Variables | Estimates | OR | 95% CI | P value |
|---|---|---|---|---|
| PRBC prior to angiography | −0.71 | 0.49 | 0.05 to 4.46 | 0.53 |
| MTP initiated | −0.13 | 0.88 | 0.24 to 3.25 | 0.84 |
| CE on CT scan | 0.93 | 2.55 | 0.79 to 8.25 | 0.12 |
| Initial systolic blood pressure | −0.003 | 1.00 | 0.98 to 1.02 | 0.72 |
CE, contrast extravasation; MTP, massive transfusion protocol; PRBC, packed red blood cells.
Discussion
Our study demonstrates that there is a subset of patients without CE on CT scan who have a vascular injury requiring angioembolization identified on angiography. Of the 47 patients without CE on their initial CT scan, 83% had a positive angiogram for injury requiring intervention. In this patient population, we found no independent predictors of positive angiogram, including CE on initial CT scan. Additionally, we found no difference in the time to angiography between the two groups.
Although CE on CT scan is the usual trigger for IR consultation and angioembolization, our study demonstrates that there is a subset of patients without CE who have an injury requiring intervention. Our findings are consistent with previous literature that has shown patients without CE who require angioembolization.10 14 Kuo et al found that among patients without CE on CT scan who underwent angiography, 93% had CE on angiography.10 Although the majority (81%) of patients without CE on CT scan in their study did not undergo angiography, among the subset who did, there was a high rate of requiring intervention. In their study, the decision to proceed with angiography was based on deterioration during the period of observation quantified by hypotension or persistent requirement of blood transfusion. The authors found that patients who underwent angiography had lower initial systolic blood pressure and lower lowest recorded blood pressure. In this study, the decision to proceed with angiography was based on the clinical decision-making of the attending, yet we aimed to identify predictors of a positive angiogram. However, we were unable to find any independent predictors of positive angiogram that could be used to help guide clinical decision-making.
Other studies have questioned the need for angioembolization even with the identification of CE on CT scan. In a retrospective review of patients with pelvic fractures, Verbeek et al found that over half of the patients with active extravasation did not require a hemorrhage control procedure (surgical or radiological intervention).15 Other studies have reported similar findings, with as low as 30–70% of patients with CE even undergoing angiography.89 13 16,18 These studies argue that patients with CE who are hemodynamically stable do not require angioembolization, and that the decision for angiography should be based on the patients’ clinical picture. Although our study only focuses on patients who underwent angiography, we found that CE alone was not independently predictive of vascular injury being identified.
Surprisingly, we found no difference in time to angiography between the two groups. These findings are not consistent with previous reports that have shown increased time to angiography for patients without CE.19 20
As CT imaging has improved specifically to 64 or higher Multidetector Computed Tomography (MDCT) scanners, there is an increase in sensitivity in detecting active bleeding. With increased sensitivity, however, there is increased detection of small or self-limiting bleeds that do not require intervention, which may account for the subset of patients who had CE and no injury identified on angiography.7 21 Ultimately, as demonstrated in this study, there is still a subset of patients who have an arterial injury not identified by CT imaging. This may be due to low blood pressure or vasospasm at the time of the initial imaging.22 23
This study demonstrates that there is a subset of patients with pelvic fracture without CE on CT imaging but with a vascular injury requiring intervention; however, this study is not without limitations. We only included patients who underwent angiography with IR and were unable to comment on the incidence of vascular injury in pelvic fractures, as this study does not include all of our patients with pelvic fractures. Additionally, this is a single-center descriptive study and introduces the bias of our providers, as it is at the discretion of the attending trauma surgeon when to consult IR and that of the IR attending when to perform the procedure. However, it is our general practice to place an IR consult without the presence of CE for patients with ongoing hypotension who are not responding to blood resuscitation. Because of this, all patients who received an IR consult were relatively hypotensive and had received blood products, making it difficult to draw a conclusion when to call. We examined drops in systolic blood pressure; however, due to the retrospective nature of the study, we were unable to evaluate if these were clinically significant drops in blood pressure. We did not include all IR consults and were unable to determine whether there were consults placed by the trauma team but the IR attending chose not to perform the procedure. Some studies have shown that variables such as hematoma volume or fracture type are predictive of vascular injury requiring interventions.11 22 24 We did not include these factors as we wanted to include only clinical factors that could be easily determined by the trauma clinician in real time.
In conclusion, there is a subset of patients with pelvic fractures who had no CE on CT scan but with a vascular injury requiring intervention. Although CE on CT scan is often the initial trigger for IR consultation, IR should be considered for patients with concerns for ongoing hemodynamic instability. We were unable to identify any independent risk factors for positive angiogram, and we think that IR consultation should be at the discretion of the trauma surgeon in patients with hemodynamic instability. Further prospective studies of patients with pelvic fractures are needed to identify predictors of the need for angioembolization.
Footnotes
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Patient consent for publication: Not applicable.
Provenance and peer review: Not commissioned; externally peer reviewed.
Ethics approval: This study involves human participants and was approved by the Vanderbilt University Medical Center IRB (IRB No 231822).
Data availability statement
Data are available upon reasonable request.
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Associated Data
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Data Availability Statement
Data are available upon reasonable request.