A CASE OF SUCCESSFUL APPLICATION OF ENDOVASCULAR BLEEDING STOPPING TECHNOLOGY IN A PATIENT WITH COMBINED PELVIC RING INJURY

A CASE OF SUCCESSFUL APPLICATION OF ENDOVASCULAR BLEEDING STOPPING TECHNOLOGY IN A PATIENT WITH COMBINED PELVIC RING INJURY

Savelenok I.D., Tseymakh E.A., Bondarenko A.V., Talashkevich M.N., Gubarenko E.Yu.

Altai State Medical University, Barnaul, Russia

The problem of treatment ofsevere associated pelvic injuries is one of the most urgent in modern surgery and traumatology. Their frequency ranges from 1.1 to 9.1 % of the total number of injuries of the musculoskeletal system [1-4]. Mortality in hospitals for pelvic fractures is 2.8-27.0 %, but in case of hemodynamic disorders, it increases to 38.0-62.0 %, which is explained by ongoing massive intrapelvic bleeding [5-10].
In modern conditions, a large number of treatment and diagnostic algorithms and protocols have been proposed for the treatment of patients with severe pelvic fractures that describe different procedures for the use of certain methods of surgical hemostasis available at level I trauma centers. Each method has its own indications, contraindications and conditions for use, advantages and disadvantages, but none can confidently ensure the final stop of intrapelvic bleeding [11-12].
In most published studies, pelvic injuries are considered from the standpoint of an isolated injury, and attention is not focused on the possibility of using modern methods of surgical hemostasis in intrapelvic bleeding based on endovascular technologies in polytrauma [13-15].
Objective - to demonstrate a clinical case of successful control of obturator artery bleeding in concomitant pelvic injury against the background of polytrauma using advanced endovascular technologies.
The article complies with ethical principles and with the patient's consent to the processing of data and publication of the study.

CLINICAL OBSERVATION

On October 20, 2021, a patient Kh., 29 years old, being intoxicated, fell out of the window of the 5th floor. He was taken by the ambulance team to the severe concomitant injury department of Clinical Hospital of Emergency Care 30 minutes after the fall in an extremely serious condition.
In the conditions of the operating room, he was examined by traumatologist, surgeon, neurosurgeon, and resuscitator. Clinical and laboratory studies, X-ray and ultrasound diagnostics were performed.
The condition was severe, with lethargy and sopor. Breathing was independent - 28 respiratory movements per minute; auscultatory - vesicular on the left, weakened on the right. Saturation with pulse oximetry – 94 %, blood pressure -90/40 mm Hg, pulse - 140 beats per minute of weak filling and tension. Allgover index - 1.55. The abdomen was soft.
Clinical tests: hemoglobin - 90 g/l, erythrocytes - 3.74 × 1012/l, hematocrit - 30.9 %, leukocytes - 8.8 × 109/l, platelets - 56 × 109/l, INR - 0.94 min, fibrinogen - 2.1 g/l, activated partial thromboplastin time - 9.6 sec.
Ultrasound of the internal organs determines diffuse-heterogeneous changes in the structure of the liver (subcapsular hematoma of the right lobe cannot be excluded), diffuse changes in the structure of the pancreas, and kidney parenchyma. About 400 ml of free fluid is located in the right pleural cavity.
Chest radiography revealed fractures of the ribs 3-11 on the right along the paravertebral line with displacement of bone fragments, pneumothorax, and subcutaneous emphysema of the soft tissues of the anterior chest wall on the right.
X-ray imaging of the pelvic bones reveals a fracture of the ascending branch of the right pubic bone, both branches of the left pubic bone, and a rupture of the right sacroiliac joint (Fig. 1).

Figure 1. Radiography of the pelvic bones of patient Kh. on admission. Fracture of the ascending branch of the right pubic bone, both branches of the left pubic bone, rupture of the sacroiliac joint on the right

The diagnosis was made: “Severe concomitant injury. Rotationally unstable damage to the pelvic ring: fracture of the ascending branch of the right pubic bone, both branches of the left pubic bone, rupture of the right sacroiliac joint. Blunt chest trauma. Closed fractures of the ribs 3-11 on the right. Hemopneumothorax. Traumatic subcutaneous emphysema of the soft tissues of the anterior chest wall. Blunt abdominal trauma. Subcapsular hematoma of the liver. Traumatic shock of 3 degree. The severity of injuries on ISS was 41 points at the time of admission.
On an emergency basis, the patient underwent drainage of the right pleural cavity according to Bulau in the 7th intercostal space and in the 2nd intercostal space. About 400 ml of hemolyzed blood with air was evacuated from the pleural cavity. Primary stabilization of the pelvic ring in the neutral position was performed with the Ex-Fix system based on the AO apparatus along the lower path with the installation of the Shants rods in the anterior-inferior pelvic spines on both sides.
Taking into account acute blood loss, the patient underwent replacement blood transfusion therapy in the form of a transfusion of 520 ml of erythrocyte mass, 480 ml of fresh frozen plasma, and 10 doses of cryoprecipitate.
30 minutes after admission to the clinic, hemodynamics remains unstable: BP - 90/50 mm Hg, pulse - 132 beats per minute, despite intravenous administration of high doses of catecholamines (norepinephrine: starting dosage of 0.3 mcg/kg/min, with an increase to 1.3 mcg/kg/min).
The patient was urgently admitted to the angiocomplex for angiography of the iliac arteries in order to identify the source of bleeding and subsequent embolization of the bleeding vessel.
Through the brachial approach, a puncture of the right brachial artery was made, and the introducer was installed.  Catheterization was performed with catheter JR 125 cm of the internal iliac artery on the left. Arteriography in its basin visualizes extravasation of the contrast agent from the branches of the obturator artery (Fig. 2).

Figure 2. Angiogram of the branches of the internal iliac artery on the left of patient X. The red square marks the area of extravasation of the contrast agent in the branch of the obturator artery on the left

Since it is impossible to selectively embolize the obturator artery due to its small diameter (< 2 mm), a decision was made to embolize the left internal iliac artery, which was performed with 5.6 mm coils (Fig. 3).

Figure 3. Angiogram of the branches of the internal iliac artery on the left of patient Kh. The red square marks the area of the installed spiral into the internal iliac artery. There is no extravasation of contrast in the basin of the left obturator artery. Embolization effect achieved

The control angiogram showed stagnation of the contrast. The effect of embolization was achieved. Since the patient, according to the ultrasound examination, was diagnosed with a subcapsular hematoma of the liver, angiography of the celiac trunk was performed with visualization of the common hepatic artery and its branches. In the basin of the celiac trunk and the common hepatic artery, extravasation of the contrast agent was not detected. With transcatheter retrograde cystography, there is no evidence of bladder injury.
After embolization in the early postoperative period, the patient’s condition stabilized: blood pressure - 136/86 mm Hg, pulse - 120 beats per minute. The filling and tension of the pulse was satisfactory. The dosage of catecholamines was reduced (the dose of norepinephrine in the first 5 minutes after embolization was reduced to 0.3 μg/kg/min).
Multislice computed tomography (MSCT) of the pelvis and abdominal organs was performed. In the pelvic area, the presence of prevesical and pararectal hematomas of a diffuse nature with a volume of about 400 ml was noted. The character of damage to the pelvic ring was clarified. There was a damage from the lateral impact - a transforaminal (Denis II) fracture of the sacrum on the left with displacement, the body and branches of the pubic and ischial bones on the left with displacement. Internal rotation of the hemipelvis exceeded 15°. A fracture of the right pubic bone and damage to the left sacroiliac joint were not detected on MSCT (Fig. 4).

Figure 4. Computed tomography of the small pelvis of patient X. The red square and rectangle indicate the area of hematoma, which has a diffuse character

The figure 5 shows a 3D volumetric modeling of the patient's pelvis after fixation of the pelvic ring with the Ex-Fix device and embolization of the internal iliac artery. As can be seen, the patient has a rotational displacement of the left half of the pelvis inward up to 15°, fixed by the apparatus, resulting from lateral compression.
Since the patient had signs of subcapsular hematoma of the liver, a diagnostic laparoscopy was performed. Data for the growth of hematoma and signs of ongoing bleeding were not found. The integrity of the internal organs was normal.

Figure 5. MSCT with 3D reconstruction of the pelvis of patient Kh. The figure shows the Ex-Fix system based on the AO apparatus. The internal rotation of the hemipelvis on the left is determined. The red square indicates the installed spiral into the internal iliac artery.


The patient was placed in the intensive care unit, where replacement blood transfusion therapy was carried out for 5 days in the total volume: fresh frozen plasma - 554 ml, erythrocyte suspension - 540 ml. During this time, pneumohydrothorax was stopped, the drainage from the pleural cavity was removed, and the patient was transferred for further treatment to the intensive care unit of the department of severe concomitant injury.
The next day after transfer to the specialized department, the patient under spinal anesthesia underwent dismantling of the device on the pelvic ring with a closed reposition using an orthopedic table. Internal rotation of the hemipelvis was eliminated, closed minimally invasive osteosynthesis of the sacrum and branches of the left pubic bone was performed using cannulated 7.3 mm screws. A week after osteosynthesis, the patient became active and began to walk with a walker. After 21 days from the moment of admission to the clinic, he was discharged for outpatient treatment.
When examining the patient 3 months after discharge, no complaints were noted. Moves were without extraneous means of support. The control X-ray of the pelvis showed the consolidation of fractures (Fig. 6).

Figure 6. Radiography of pelvic bones of patient Kh. 3.5 months after closed minimally invasive osteosynthesis of the pelvic ring with cannulated screws 7.3 mm


CONCLUSION

On the example of this clinical case, it can be concluded that in a patient with polytrauma and severe pelvic trauma with ongoing intrapelvic bleeding and unstable hemodynamics, despite the stabilization of the pelvic ring with the Ex-Fix system, an additional method of radiation contrast study was used to determine the source of bleeding and stop it, which led to the stabilization of the patient's condition.
Diagnostic angiography with endovascular embolization of damaged vessels quickly stabilizes the patient's condition, which makes it possible to perform closed surgical reconstruction of the pelvic ring in the shortest possible time using minimally invasive methods of osteosynthesis, given that it is problematic to perform a closed pelvic reconstruction 3 or more weeks after the injury.
The presented clinical observation also demonstrates the need for a mandatory MSCT study in pelvic injuries. The standard anterioposterior projection does not clearly identify all existing pelvic injuries, especially in the posterior pelvic ring.

Funding and conflict of interest information

The study was not sponsored.
The authors declare the absence of obvious and potential conflicts of interest related to the publication of this article.

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