Article

Computed tomography angiography provides limited benefit in the evaluation of patients with pelvic fractures

a b s t r a c t

Introduction: Computed tomography angiography has been applied in imaging studies for the assessment of most abdominal and pelvic injuries in some trauma centers. However, in most institutions, CTA is not routinely performed as part of the computed tomography scan protocol. In this study, we aimed to assess the efficiency of CTA in the evaluation of patients with pelvic fractures.

Materials and methods: During the study period, patients with pelvic fracture were retrospectively analyzed. In addition to conventional Computed tomography scanning that includes only the single venous pHase, CTA with an additional arterial pHase was used to obtain more information regarding vascular injuries. Further angiographic examination was performed in the patients with positive results in either the arterial or venous phase. The sensitivity and specificity of the multiphasic CTA images in the evaluation of active arterial hemorrhage were investigated. Furthermore, the results obtained for the arterial and venous phases were also combined to evaluate associated active arterial hemorrhage.

Results: A total of 144 patients with pelvic fractures who underwent CTA were enrolled in this study. Of these patients, 49 (34.0%) had active arterial hemorrhage. The sensitivities of the venous and Arterial phase CTA images in the evaluation of active arterial hemorrhage were 100% (49/49) and 89.8% (44/49), respectively. Furthermore, all of the patients with positive results based on the arterial phase images were included in the group of patients with positive results based on the venous phase images. Although there were 4 patients without active arterial hemorrhage based on the angiographic examination, they still underwent embolization.

Conclusions: In the management of patients with pelvic fractures, CTA provides limited benefits in the evaluation of the active arterial hemorrhage. The additional arterial phase may be helpful for distinguishing between arterial and venous hemorrhage. However, this study showed that subsequent treatment was not changed.

(C) 2014

Introduction

Pelvic fracture is usually the result of blunt trauma with high kinetic energy and can cause extensive Retroperitoneal hemorrhage [1-3]. arterial injury has been reported in approximately 10% to 15% of hemorrhages related to pelvic fracture [4,5]. Therefore, rapid assessment and diagnosis of traumatic arterial injuries are critical in the evaluation of patients with pelvic fractures, enabling the performance of further angiography with embolization to achieve hemostasis [6,7].

* Corresponding author. Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, 5, Fu-Hsing St, Kwei Shan Township, Taoyuan, Taiwan. Tel.: +886 3 3281200 3651; fax: +886 3 3285818.

E-mail addresses: [email protected] (C.-Y. Fu), [email protected] (S.-Y. Wang), [email protected] (C.-H. Liao), [email protected] (S.-C. Kang), [email protected] (Y.-P. Hsu), [email protected] (B.-C. Lin), [email protected] (K.-C. Yuan), [email protected] (C.-H. Ouyang).

For the assessment of most abdominal and pelvic injuries, computed tomography (CT) scanning has become a universally used procedure. It can provide high-resolution images and may facilitate the detection of small fractures and soft tissue injuries [8-10]. With the advancement of multidetector CT technology, high-resolution images with shorter acquisition times have enabled the use of complex and multiphasic imaging studies of the entire body to determine active arterial hemorrhage. Furthermore, in contrast to conventional CT scans that include only a single venous phase, CT angiography (CTA) consisting of an additional arterial phase has been applied in imaging studies in some trauma centers. It has been reported that angiography could potentially be replaced by CTA due to its speed, noninvasive nature, accuracy, and widespread availability [11-13].

Although the benefit of CTA has been reported previously, there are discrepancies between the facilities and faculties among institu- tions. In particular, this procedure cannot be routinely performed as part of the CT scanning protocol in most institutions, especially Rural hospitals. Furthermore, the safety and potential biohazards of this Diagnostic modality should also be considered in addition to the diagnostic accuracy it affords.

http://dx.doi.org/10.1016/j.ajem.2014.07.021

0735-6757/(C) 2014

In the current study, we aimed to delineate the efficiency of CTA in the evaluation of patients with pelvic fractures. The diagnostic accuracy of CTA and its effect on subsequent treatment were also assessed.

Materials and methods

From January 2011 to December 2013, patients with pelvic fracture were retrospectively analyzed. Their general demographics, Fracture patterns, pelvic Abbreviated Injury Scale scores, injury severity scores, method of management, and outcome were routinely recorded. These patients were evaluated and treated according to our established protocol, which is based on the Advanced Trauma Life Support guidelines [14]. They underwent a pelvic x-ray and sonographic examination for the primary survey. A contrast- enhanced CT scan was performed for the evaluation of their associated Intra-abdominal injuries and retroperitoneal hemorrhage. During the period of study, in addition to conventional CT scanning with a single venous phase only, CTA with an additional arterial phase was used in our emergency department (ED) to gain more information regarding vascular injuries. Computed tomography angiography was performed in patients with (1) a positive sonographic examination, (2) an unstable pelvic fracture on the pelvic x-ray, (3) a hypotensive episode (systolic blood pressure b 90 mm Hg), and (4) other clinical features according to the physicians’ clinical experience or judgment.

Before the CTA examination, an 18- or 20-gauge intravenous catheter was placed in a superficial vein in the antecubital fossa, forearm, or dorsum of the hand for resuscitation and infusion of the contrast medium. In our ED, a 64-row scanner, which allows for the rapid acquisition of multiphasic images using a single bolus of intravenous Contrast material, was used. The images were acquired with 0.625-mm detector collimation, with a pitch of 0.984 and a gantry rotation time of 0.5 seconds (Aquilion 64; Toshiba Medical System Cooperation, Tochigi, Japan). The dose of the contrast medium was 90 to 100 mL, which is standard for an abdomen/pelvis study, and was injected at a rate of 3 mL/s. After the injection of the contrast medium, the standard delay was 30 seconds for the arterial phase scan and 58 seconds for the venous phase scan. The 2D and 3D images were reconstructed from the original data set and were used in the analysis. The CTA images were interpreted by board-trained trauma surgeons, ED physicians, and interventional radiologists. Further angiographic examinations were performed in the patients with positive results from either the arterial or venous phase scans. After the treatment, the patients were sent to the intensive care unit for

close observation.

In this study, the sensitivity, specificity, positive predictive value, and negative predictive value of the multiphasic images of CTA in the evaluation of active arterial hemorrhage were investigated. Further- more, the results from the arterial and venous phase scans were combined to evaluate the associated active arterial hemorrhage. In addition, some patients with positive CTA results but negative results from further angiographic examinations were analyzed in greater detail.

Results

During the 24-month study period, 377 patients with pelvic fractures were sent to our ED. A total of 144 patients with pelvic fractures who underwent CTA were enrolled in this study. Of these patients, 49 (34.0%) had active arterial hemorrhage that was confirmed by further angiographic examination, whereas the other 95 patients (66.0%) had no active arterial hemorrhage.

The distribution of CTA results is shown in Fig. 1. There were 53 patients with positive results from the venous phase images (V+ images), 91 patients with negative results from the venous phase images (V- images), 44 patients with positive results from the arterial phase images (A+ images), and 100 patients with negative results from the arterial phase images (A- images). In the current

study, all of the patients with active arterial hemorrhage (n = 49) were included in the group of patients with V+ images (n = 53). These 49 patients with active arterial hemorrhage also included all of the patients with A+ images (n = 44), that is, all of the patients with A+ images were included in the group of patients with V+ images. Accordingly, the sensitivities of the venous and arterial phase CTA images in the evaluation of active arterial hemorrhage were 100% (49/49) and 89.8% (44/49), respectively (Table 1). In contrast, all of the patients without active arterial hemorrhage (n = 95) had A- images, and 91 of them had V- images. The specificities of the venous and arterial phase CTA images in the evaluation of active arterial hemorrhage were 95.8% (91/95) and 100% (95/95), respectively (Table 1).

All of the patients with both A+ and V+ images (n = 44) had active arterial hemorrhage. In contrast, there were no patients with active arterial hemorrhage among those with both A- and V- images (n = 91). Differences between the results of the arterial and venous phase scans existed in 9 patients (A+ V- or A- V+). There were no patients with A+ and V- images. Therefore, all of these 9 patients had A- and V+ CTA images. Of these 9 patients, 5 (55.6%, 5/9) had active arterial hemorrhage (Table 2). Among the other 4 (44.4%) patients who had no active arterial hemorrhage, 2 of them underwent left- sided Internal iliac artery embolization, and 2 of them underwent nonselective bilateral IIA embolization (Table 3).

Discussion

The early diagnosis of arterial hemorrhage is important in the management of patients with pelvic fractures [1-5]. The identifi- cation of an efficient tool that provides timely and adequate information for guiding physicians in making appropriate decisions for further management is crucial in trauma medicine. Through multiphasic image acquisition (arterial and venous phases), CTA provides a large amount of information in a short period and is thus superior to conventional single-phase (venous phase) CT in the diagnosis of trauma patients [11-13,15,16]. However, these high-quality images cannot always be obtained due to the limitations of facilities. Furthermore, the attainment of repeated images during the multiphase acquisitions may be associated with increased radiation exposure. Therefore, physicians face a dilemma in balancing the accuracy of diagnosis, availability of diagnostic tools, and patient safety.

In patients with pelvic fractures, the extravasation of contrast material in the pelvis in contrast-enhanced CT is an accurate indicator of active arterial hemorrhage [17,18]. On conventional CT examina- tion, active arterial hemorrhage should be highly suspected in patients with contrast extravasation (CE) in the venous phase. Using CTA, which enables multiphase image acquisition, the active arterial hemorrhage can be seen as an area of extraluminal contrast in the arterial phase, which enlarges with time, and the later venous phases [19-21]. Furthermore, CE may be present as relative hyperattenuation persists throughout the various phases of image acquisition (Fig. 2). Therefore, even with the additional arterial phase that CTA provides, the detection of active arterial hemorrhage still depends on venous phase images because of their continuous and highly attenuated signals. In the current study, 92.5% (49/53) of the patients with CE in the venous phase of CT scans had active arterial hemorrhage that was confirmed by further angiographic examination. However, all of the patients with active arterial hemorrhage confirmed by the angio- graphic examination had CE in the venous phase of CTA (Table 1). Therefore, the venous phase of CTA provided high sensitivity (100%) in the evaluation of active arterial hemorrhage (Table 2). However, among the patients with active arterial hemorrhage (n = 49), only 44 patients exhibited CE in the arterial phase of CTA. Although the positive predictive value of CE in the arterial phase was 100% in detecting active arterial hemorrhage, its sensitivity was only 89.8%.

Fig. 1. Patient distribution in the current study.

In addition to CE, other abnormal vascular lesions such as pseudoaneurysms may also indicate associated vascular injuries that may require angiographic embolization [22,23]. Pseudoaneurysms are identical in size and shape, and the attenuation is similar to that of the aorta in all phases, washing out in later phases of image acquisition. Thus, the pseudoaneurysm may be seen during the arterial phase but not during the later venous phase [24,25]. Previous reports have indicated the benefit of CTA with both arterial and venous phase images in the diagnosis of traumatic pseudoaneurysms in some solid Organ injuries. Therefore, the application of CTA with multiphase image acquisition can increase the detection rate of traumatic pseudoaneurysms, enabling subsequent embolization without de- layed hemorrhage [26,27]. However, traumatic pseudoaneurysms are very rare in patients with pelvic fracture, and only a few cases have been previously reported in the literature [28-30]. Similarly, there were also no patients with traumatic pseudoaneurysms in the current study. Thus, it is reasonable that there were no patients with positive results in the arterial phase but negative results in the venous phase (Table 1).

The above results indicate that Active hemorrhage that presents as CE can be evaluated by conventional CT with a single venous phase only (sensitivity, 100%). The decision to pursue further angiography can be made effectively according to the results of the venous phase. However, active arterial hemorrhage may be missed in the evaluation of the arterial phase of CTA because of its relatively low attenuation

Table 1

The sensitivity, specificity, positive predictive value, and negative predictive value of the CT scans in the evaluation of different phases of active arterial hemorrhage associated with pelvic fractures

compared with the venous phase (sensitivity, 89.8%). In addition, the advantage of CTA in the detection of pseudoaneurysms seems insignificant with respect to the management of patients with pelvic fracture. Furthermore, compared with conventional CT scanning with a single phase only, patients may be exposed to higher doses of radiation during the additional arterial phase of CTA.

Another concern regarding the application of CTA is its benefit in the accurate differentiation between arterial and venous injury. This differentiation has important Therapeutic implications. Arterial hemorrhages require urgent endovascular or surgical management, whereas venous hemorrhages need to be treated conservatively. Theoretically, arterial hemorrhages may present as CE in both the arterial and venous phases. In contrast, a CE seen on a venous phase image but not on the earlier arterial phase image is more likely to be venous in nature [31,32]. The latter imaging findings were observed in 9 patients in our study. However, even when considered as having venous hemorrhage, 55.6% (5/9) of them still had active arterial hemorrhage that was confirmed by further angiographic examination. In these patients, the hemorrhage may have originated from a small branch of arteries that are too small to be seen in the arterial phase. Thus, their signals may be augmented over time in the delayed venous phase. In addition, under the same timing of contrast injection and image acquisition, patients with poor cardiac output or hemodynamic status may exhibit similar presentations. In contrast, although venous hemorrhage may be the reason for negative angiographic examina- tion results, the possibility of arterial hemorrhage cannot be excluded completely. The release of spasmogens from lysed Blood clots and the inflammatory response of injured vascular walls have been demon- strated to contribute to the development of vasospasms in patients

Hemorrhage (+) (n = 49)

Arterial phase

Hemorrhage (-) (n = 95)

Table 2

The number of patients with pelvic fractures and their active arterial hemorrhage rate classified according to the CT scan results

A+ 44

0

Sen = 89.8%

PPV = 100%

Patient number (n)

Active arterial hemorrhage (n, %)

A- 5

95

Spe = 100%

NPV = 95%

(confirmed by further angiography)

Venous phase

A+ V+

44

44 (44/44, 100%)

V+ 49

4

Sen = 100%

PPV = 92.5%

A+ V-

0

V- 0

91

Spe = 95.8%

NPV = 100%

A- V+

9

5 (5/9, 55.6%)

Abbreviations: A, arterial phase; V, venous phase; Sen, sensitivity; Spe, specificity;

PPV, positive predictive value; NPV, negative predictive value.

A- V- 91 0 (0/91, 0%)

Abbreviations: A, arterial phase; V, venous phase.

Table 3

Characteristics of the patients with CE on the CT scans but negative angiographic examinations

Patient

Age/sex

Arterial phase of CT scan

Venous phase of CT scan

AIS (pelvis)

ISS

Subsequent treatment

1

48/M

Negative

Positive

3

18

Left-sided IIA embolization

2

26/M

Negative

Positive

3

9

Left-sided IIA embolization

3

71/M

Negative

Positive

3

13

Nonselective bilateral IIA embolization

4

62/F

Negative

Positive

3

9

Nonselective bilateral IIA embolization

Abbreviations: AIS, Abbreviated Injury Scale; ISS, Injury Severity Score; M, male; F, female.

with active arterial hemorrhage [33,34]. Because of this temporary vasospasm effect, the arterial hemorrhage may be missed during angiography. Accordingly, embolization should still be considered even if the angiographic examination reveals no active hemorrhage.

The characteristics of the abovementioned patients are listed in Table 3. Of the patients, 2 underwent unilateral IIA Gelfoam (Gelfoam

(R) Baxter, Hayward, CA) embolization according to the CE in the CT scan, whereas the other 2 underwent nonselective bilateral IIA Gelfoam embolization. All of the patients survived after resuscitation and treatment. The patients had no complications related to the embolization, although there are risks of complications after IIA embolization such as skin ulcers, pelvic infection, claudication, and Erectile dysfunction [35-38]. However, it has also been reported that no significant increase in long-term or short-term complications was noted in trauma patients who underwent IIA embolization [39]. Gelfoam is a temporary embolic agent and is likely biodegraded in 7 to 21 days, allowing for recanalization [35]. This property may limit long-term complications compared with coil occlusion or surgical ligation of IIAs. Usually, in patients with a negative angiographic examination, Gelfoam is used as an embolization material to prevent both active retroperitoneal hemorrhage masked by a vasospasm effect and complications related to embolization. Therefore, although the additional arterial phase CTA images provide extra information for the evaluation of hemorrhage, this information does not impact subse- quent treatment and outcomes.

The limitations of this study are its retrospective nature and the small number of cases examined. Our conclusions may have also been limited by a possible selection bias. We agree that CTA can provide more information in the evaluation of trauma patients. However, the results of the current study revealed the limited role of CTA in patients with pelvic fractures. Further studies with larger sample sizes and prospective designs are needed to establish precise treatment plan algorithms in the ED.

Conclusions

In the management of patients with pelvic fractures, CTA provides limited benefits in the evaluation of active arterial hemorrhage. Although additional information from the arterial phase may be helpful for distinguishing between arterial and venous hemorrhage, this information does not alter the subsequent treatment of patients.

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