In the previous post in this series, I described an early review article summarizing several older studies comparing these two hemorrhage control techniques for pelvic fractures. Today, I’ll review another paper fresh off the press, published just this month.

This paper comes from the orthopedics and neurosurgical groups at the University of Texas-San Antonio. They scanned five years of data from the National Inpatient Sample, which included data from 35 million inpatient admissions in the US. They separated all patients with acetabular and pelvic ring fractures using ICD-10 codes.

They further narrowed their dataset to patients with angioembolization (AE) or peri-pelvic packing (PPP) as their primary procedure. This eliminated patients who might have received other additional management that could cloud the data. Various hospital outcomes were tabulated, including hospital charges, mortality, and discharge location.

Here are the factoids:

• Of the 3,780 patients identified, only 160 underwent PPP, and the remaining 3,620 had AE. This is probably a function of PPP’s newer and more novel nature.
• The AE patients were significantly older than the PPP patients (66 vs 53 years). This suggests that trauma professionals have a lower threshold to order AE in older patients.
• Time to procedure start was similar for both interventions
• Overall, there was no difference in mortality between the AE and PPP patients
• There was no difference in unfavorable discharge (other than home)
• Hospital charges were significantly lower in the AE group ($369K vs $250K)!

Bottom line: This is the largest comparison of AE and PPP to date. It mostly confirms earlier work and adds significant insights about cost and discharge status.

AE and PPP have equivalent outcomes. This is true even though the AE group is larger and significantly older. However, it is possible that the number of PPP cases was too low for the authors to demonstrate any significant differences. 

What should you do when faced with these patients? First, hemodynamic instability means that PPP is the only choice. You can feel comfortable that outcomes will be the same as AE. If there is concern that there could be ongoing bleeding, PPP can be followed by a trip to the interventional radiology suite. This is a common practice.

I shouldn’t have to say it, but AE should never even be considered in an unstable patient. 

What about stable patients? AE seems to be the way to go. It is tolerated even by older patients. And it ends up saving a lot of money when compared to PPP. 

There is still room for research in this space. As our PPP experience grows, we should hopefully be able to confirm the conclusions  in this paper. If any are refuted, I’ll revisit this post and make the needed updates. Which is what you should also do in your practice!

Reference: Angioembolization Has Similar Efficacy and Lower Total Charges than Preperitoneal Pelvic Packing in Patients With Pelvic Ring or Acetabulum Fractures. J Orthop Trauma 38(5):254-258, 2024.

In my last post, I reviewed an early paper on preperitoneal packing (PPP). Today, I’ll look at an earlier review article summarizing some smaller studies comparing it to angioembolization. In the next post, I’ll look at a brand new paper that includes a cost analysis as well.

Interestingly, the use of AE and PPP vary geographically. Angioembolization has been a mainstay in the US for some time, and PPP has been more commonly used in Europe. The use of both is becoming more widespread, and each has its pros and cons.

Angioembolization requires the presence of a special interventional radiology team and a reasonably stable patient. The procedure can take some time, and the IR suite is not really the place to house an unstable patient. Preperitoneal packing requires a reasonably stable pelvis to hold the packs in place for optimal tamponade, which may require application of an external fixator at the time of the procedure.

But is one better than the other? A number of relatively small studies have been performed, which means that it is time to synthesize them and see if some clearer answers can be found. The trauma group in Newcastle, Australia did just this. They performed a systematic search of the literature, analyzing the impact of each procedure on in-hospital mortality.

Here are the factoids:

• A total of 18 studies met the authors’ inclusion criteria: 6 studies on AE, 9 studies of PPP, and 3 that compared them to each other
• ISS was significantly higher in the PPP group vs AE (41 vs 36)
• Average time to OR in the PPP patients was 60 minutes vs 131 minutes to IR in the AE group (statistically significant)
• A quarter (27%) of the PPP patients did not get adequate hemorrhage control and required AE
• In-hospital mortality in the PPP papers was 23% vs 32% in the AE research
• Mortality in the papers that compared AE directly to PPP was no different

Bottom line: What does this all mean? Is packing “better” than embolization? The simple answer is that we don’t know yet. Due to the way this study was performed, it is not possible to tease out all of the possible confounders. 

We are taught that control of hemorrhage is paramount. The time to definitive management in the AE group was twice that of the PPP patients. This could have a major impact on mortality. Two hours of bleeding can certainly kill. And the lower mortality in the PPP group occurred even though their injury severity was higher.

Many trauma centers have both of these interventions available to choose from. How should we approach their use? Unfortunately the literature is still to scarce to come to strong conclusions. Until we have better research to learn from, I suggest the following:

• Time is of the essence. Which procedure can you get the fastest? In many cases, this will be preperitoneal packing since it’s just a trip to your trauma OR, which should be ready and waiting. If you have an IR team standing by or available very quickly, you could consider them first.
• Pay attention to hemodynamic stability. An IR suite is no place for an unstable patient. The resuscitation equipment is not on par with the OR, and one never knows exactly how long the procedure will last.
• If you have a hybrid room, use it! This is the ideal situation. The surgeon can start the PPP while the orthopedic surgeon applies a fixator. And the radiologist can be preparing to finish it off with a quick squirt as soon as they move away from the groin.
• The use of one does not rule out the other. If one fails and the patient has increasing fluid and blood requirements move immediately to the other procedure to try to get control.

Reference: Preperitoneal packing versus angioembolization for the initial management of hemodynamically unstable pelvic fracture: A systematic review and meta-analysis. The Journal of Trauma and Acute Care Surgery, 92(5), 931–939.