• Indications​

  • Active arterial haemorrhage in stable or unstable patients

  • Delayed or recurrent haemorrhage

  • Insufficient medical control of the bleeding, in hemodynamically stable patients

  • Post-traumatic/iatrogenic pseudoaneurysm

 

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• Contraindications​

  • Special considerations:

    • Severe allergy to contrast

    • Uncorrectable coagulopathy

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• Medical History

  • Check

    • Clinical history

      • Mechanism of injury

      • Time of injury

      • Other known pathology?

        • eg. pelvic neoplasm, aneurysm

      • Physical examination 

        • Is the patient conscious?

        • Hemodynamic status?

    • ​Procedure indications

    • Current medications

      • Any anticoagulant or antiplatelet agents?

    • Allergies

    • Ask For:

      • Written/electronic request for the procedure

      • Is the patient capable to consent?

      • Available venous access?

      • Ask for anesthetic team cover if needed

      • Nil by mouth for 6hr prior to the procedure

  • Imaging Studies

    • CTA

      • Is the scan triple phase and recent?

      • Assess degree of pelvic trauma

        • Intra or extraperitoneal injury

        • Fractures?

        • Bladder, bowel, muscular, uterine injury?

        • Pelvic collection/hematoma

      • Identify the source of bleeding

        • Active extravasation?

        • Pseudoaneurysm

        • Vascular dissection, rupture, thrombosis

        • Venous injury?

      • Assess vascular anatomy

        • Aorta

        • Common iliac artery

        • External iliac artery

          • Deep circumflex

          • Inferior epigastric

        •  Internal iliac artery

          • Anterior division arteries

            • Superior vesical

            • Inferior vesical

            • Obturator

            • Middle rectal

            • Uterine

            • Internal pudendal

            • Inferior rectal

            • Penile/Clitoral

            • Perineal

            • Vaginal

            • Inferior gluteal

          • Posterior division arteries

            • Iliolumbar 

            • Lateral sacral 

            • Superior gluteal 

        • Safe access?

      • Exclude other causes of bleeding

        • eg. hepatic, renal, splenic

      • Exclude bowel perforation and pneumoperitoneum

    • Ask For:

      • New imaging if needed

  • Laboratory Exams

    • INR (<1.5), PT, aPTT, PLT (>50.000/μL), Htc, HB, WBC, CRP

    • Infectious Status

    • Ask For:

      • Manage anticoagulation (if needed)

      • Optimize blood products (if needed)

  • Medications​

    • Management of co-morbidities  (allergy, blood glucose, blood pressure, nausea, etc)

 

 

• Outcomes

  • Expected control of the bleeding source and prevent recurrence

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• Alternative Treatments

  • Conservative management of low-grade trauma

    • Small pseudoaneurysms may resolve spontaneously

  • Resuscitative endovascular balloon occlusion of the aorta (REBOA)

  • Surgical:

    • Internal iliac artery ligation 

    • Packing