Angiographic Diagnosis and Treatment of Bleeding by Selective Embolization Following

Pelvic Fracture in Children

By Barbara Barlow, Robert W. Rottenberg, and Thomas V. Santulli

ASSIVE retroperitoneal bleeding following pelvic fracture continues to produce high morbidity and mortality in victims of blunt trauma. ~,2

Angiographic evaluation of bleeding associated with pelvic fracture and treat- ment by selective embolization of clotted blood to bleeding sites in the vicinity of the fractures, usually branches of the obtura tor artery along the pubic rami, has recently been described in adults. 3,4 This technique has been used success- fully by others 5 and can be considered a nonoperative approach to massive pel- vic hematomas when contrasted with the hazards and limited success of surgical exploration 6,7

We recently used the same method for the evaluation and treatment of a child with a massive extraperitoneal hematoma secondary to pelvic fracture.

TECHNIQUE

Arterial catheterization was performed by the Seldinger technique on the side opposite the trauma because of hematoma formation on the involved side. Flush aortogram was first performed using Renografin with the catheter at the level of the renal arteries. Selective celiac axis arteriogram then followed to evaluate the liver and spleen. Visualization of the urinary tract was also ob- tained. Pelvic arteriography was carried out with the catheter in the left internal iliac artery. For embolization the catheter was advanced just proximal to the left obturator artery and 2-4-mm pieces of gelfoam mixed with contrast ma- terial were hand-injected into the obtura tor artery under fluoroscopic control. For the aortic flush 25 cc was injected over 2 sec; for selective studies 8 cc was injected.

CASE REPORT

An 18-kg, 7-yr-old boy was struck by a station wagon while crossing the street. On arrival in t h e emergency ward he was conscious, his blood pressure was 130/90, and his pulse, 120. There w a s a hematoma over the left eye and an abrasion over the pubic symphysis. The left thigh was swollen and the left leg externally rotated. Neurologic examination was normal. The abdomen was soft and there were good bowel sounds. There was suprapubic tenderness without a palpable m a s s , no blood on rectal exam, and the urine was clear. Skull and chest x-ray films were normal. Pelvic x-ray films demonstrated fractures of the superior and inferior rami and the left acetab- ulum. There was no femoral fracture (Fig. IA). Two hours after the accident the hematocrit was 30 and the urine remained clear.

From the Departments of Surgery and Radiology, College o f Physicians and Surgeons, Columbia University, and the Surgical Service o f the Babies Hospital, The Children's Medical and Surgical Center, Columbia-Presbyterian Medical Center, New York, N. Y.

Address for reprint requests: Thomas V. Santulli, M.D., Babies Hospital, 3975 Broadway, New York, N. Y. 10032.

�9 1975 by Grune & Stratton, Inc.

Journal of Pediatric Surgery, Vol. 10, No. 6 (December), 1975 939

940 BARLOW ET AL.

=,~.. ~o ~E

o

~._o ig

w @

n

O

O

~ E n . . f l ~ .

0

~ D

0 , . 1 r @

~E2. ~" O o

SELECTIVE EMBOLIZATION 941

During the next 12 hr the hematocrit fell to 24 with a fall in blood pressure to 50/10 and the pulse rose to 140. A pelvic hematoma had extended out of the pelvis and was palpable along the anterior abdominal wall to the umbilicus. The hematoma extended into both flanks and into the scrotum and left thigh. Bowel sounds were hypoactive and the child resisted all attempts to have his abdomen examined. With a blood transfusion running the child was taken to the angiographic suite where, with constant blood pressure monitoring and small intravenous doses of Valium for sedation, angiography was performed through the right femoral artery.

Selective celiac study showed normal vessels in the spleen and liver. The renal and mesenteric vessels were unremarkable. The bladder filled and was elevated and compressed on the left by the pelvic hematoma. Selective injection of the left lilac artery demonstrated extravasation of the contrast material from a branch of the obturator artery just below the superior ramus (Fig. IB). Gelfoam embolization with the catheter tip at the origin of the left obturator artery occluded the bleeding vessel and the catheter was removed (Fig. 1C).

The child received 1000 cc of blood during the angiogram, elevating the hematocrit to 32. Over the next 3 days the hematocrit fell to 22, and he required one additional unit of blood without ap- parent enlargement of the hematoma. Pulses remained full and equal in both legs following the procedure, and the child was discharged home on crutches 9 days following injury.

DISCUSSION

Margolies noted that hemorrhage after pelvic fractures was traditionally at- tributed to disruption of multiple pelvic veins. 3 Recent evidence suggests that laceration of small arterial branches at the fracture sites are most likely the major source of bleeding in pelvic fracture. 3,4 In this patient, as in many of Margolies' patients, the bleeding originated from branches of the obturator artery, which supplies the pubic rami.

As has been recommended by Margolies, embolization of the bleeding site was performed early in the treatment course of our patient, although the child had lost over half of his blood volume into the hematoma. The possible conse- quences of allowing continued rapid retroperitoneal blood loss, such as intra- peritoneal rupture with exsanguination, prolonged jaundice, renal failure, coagulopathy, and prolonged ileus, were avoided. In addition, angiography permitted evaluation of the spleen, liver, kidneys, and mesenteric vessels for associated injury. Surgical exploration would have been undertaken if abdom- inal injuries requiring intervention had been delineated. If major vessel injury were found the angiogram would facilitate the operative approach.

This technique previously described for adults with major trauma to the pelvis and abdomen can be used safely for children in centers experienced with angiography in children and adds a valuable tool to the evaluation and manage- ment of children following blunt trauma.

SUMMARY

A n g i o g r a p h y h a s b e e n u s e d s u c c e s s f u l l y in a d u l t s fo r e v a l u a t i o n f o l l o w i n g

m a j o r t r a u m a a n d to s u b s e q u e n t l y c o n t r o l h e m o r r h a g e a s s o c i a t e d w i t h p e l v i c

f r a c t u r e b y s e l ec t i ve e m b o l i z a t i o n . T h i s r e p o r t i l l u s t r a t e s t h a t t h e t e c h n i q u e is

a p p l i c a b l e in t h e e v a l u a t i o n a n d t r e a t m e n t o f c h i l d r e n w i t h s i m i l a r i n j u r i e s .

REFERENCES

1. Hauser CW: Initial treatment of pelvic 3. Margolies MM, Ring EJ, Waltman AC, et fractures. Lancet 86:285, 1966 al: Arteriography in the management of hemor-

2. Reynolds BM, Balsano NA, Reynolds FX: rhage from pelvic fracture. N Engl J Med 287: Pelvic fractures. J Trauma 13:1011, 1973 317, 1972

942 BARLOW ET At.

4. Ring EJ, Waltman AC, Athansoulis C, et al: Angiography in pelvic trauma. Surg Gynecol Obstet 139:375, 1974

5. Kadish L, Stein JM, Kotler S, et al: Angiographic diagnosis and treatment of bleed- ing due to pelvic trauma. J Trauma 13:1083, 1973

6. Ravitch MM: Hypogastric artery ligation in acute pelvic trauma. Surgery 56:601, 1964

7. Seavers R, Lynch J, Ballard R, et al: Hy- pogastric artery ligation for uncontrolled hem- orrhage in acute pelvic trauma. Surgery 55:516, 1964