Vascular Trauma in War and Terror

Tal M Hörer^1,2, Offer Galili², Sami Nitecki³

 

Affiliation:

¹Dept of CardioThoracic and Vascular Surgery, Dept. of Surgery, Örebro University Hospital, Faculty of Life Science, Örebro University, Sweden

²Dept of Vascular Surgery, Carmel Lady Davis Hospital, affiliated to the Technion Institute Medical Faculty, Haifa, Israel

³Dept of Vascular Surgery, Rambam Medical Center and Technion Institute Medical Faculty, Haifa, Israel

 

Vascular trauma is always present in war and terror, and because of devastating consequences, vascular trauma needs immediate attention. While open surgery is the main field for vascular surgeons, especially in extremities traumatic-injury management, there is an increase in use of endovascular and hybrid methods for bleeding control and vascular repair. Good basic surgical knowledge and experience must be used to treat traumatic vascular injuries. The modern vascular surgeon must know how to manage all aspects of these injuries and treat them with both open and endovascular methods, at least to some extent. In this chapter, we discuss vascular injury and its diagnosis and management with a focus on clinical practice and evidence, with some input from emerging technologies, such as those involving the EndoVascular resuscitation and Trauma Management (EVTM) concept.

Vascular trauma has been present on the battlefield and in terror events at all times, while the main area of treatment and interest of vascular surgeons have been injuries to the vascular extremities¹De BM, Simeone FA. Battle injuries of the arteries in World War II; an analysis of 2,471 cases. Ann Surg. 1946;123:534-79.,²Asher Hirshberg, Kenneth L Mattox. Top Knife: tfm Publishing Limited, 2004.,³Beekley AC, Sebesta JA, Blackbourne LH, Herbert GS, Kauvar DS, Baer DG, et al. Prehospital tourniquet use in Operation Iraqi Freedom: effect on hemorrhage control and outcomes. J Trauma. 2008;64(2 Suppl):S28-37; discussion S.. When considering war-related injuries, the last decades have been characterised by better personal-protection gear and more effective medical evacuation from the field on the one hand, but by more deadly high-velocity weapons and explosives with high mortality on the other⁴Beekley AC, Sebesta JA, Blackbourne LH, Herbert GS, Kauvar DS, Baer DG, et al. Prehospital tourniquet use in Operation Iraqi Freedom: effect on hemorrhage control and outcomes. J Trauma. 2008;64(2 Suppl):S28-37; discussion S.,⁵Dua A, Patel B, Kragh JF, Jr., Holcomb JB, Fox CJ. Long-term follow-up and amputation-free survival in 497 casualties with combat-related vascular injuries and damage-control resuscitation. J Trauma Acute Care Surg. 2012;73(6):1517-24.,⁶Fox CJ, Gillespie DL, Cox ED, Mehta SG, Kragh JF, Jr., Salinas J, et al. The effectiveness of a damage control resuscitation strategy for vascular injury in a combat support hospital: results of a case control study. J Trauma. 2008;64(2 Suppl):S99-106; discussion S-7.. Evacuation time decreased from average of around 3 hours during the World-war II to around 45-60 minutes in reported data on the Iraq conflict, and leading to quicker vascular repair and lower amputations rates⁷De BM, Simeone FA. Battle injuries of the arteries in World War II; an analysis of 2,471 cases. Ann Surg. 1946;123:534-79.,⁸Asher Hirshberg, Kenneth L Mattox. Top Knife: tfm Publishing Limited, 2004.,⁹Beekley AC, Sebesta JA, Blackbourne LH, Herbert GS, Kauvar DS, Baer DG, et al. Prehospital tourniquet use in Operation Iraqi Freedom: effect on hemorrhage control and outcomes. J Trauma. 2008;64(2 Suppl):S28-37; discussion S.,¹⁰Fox CJ, Gillespie DL, Cox ED, Mehta SG, Kragh JF, Jr., Salinas J, et al. The effectiveness of a damage control resuscitation strategy for vascular injury in a combat support hospital: results of a case control study. J Trauma. 2008;64(2 Suppl):S99-106; discussion S-7.. These changes have impacted on the scale of injuries on modern battlefields in some places, while “classical” injuries, e.g., penetrating bullet injuries, have almost the same clinical appearance as a century ago. As injuries have become more complex, diagnosis and treatment have changed at a hospital level¹¹Khorram-Manesh A, Goniewicz K, Burkle FM, Robinson Y. Review of Military Casualties in Modern Conflicts-The Re-emergence of Casualties From Armored Warfare. Mil Med. 2022;187(3-4):e313-e21.,¹²Rasouli MR. Epidemiology of vascular injuries in modern wars. Ann Surg. 2014;259(6):e91,¹³Fox CJ, Patel B, Clouse WD. Update on wartime vascular injury. Perspect Vasc Surg Endovasc Ther. 2011;23(1):13-25.,¹⁴Callcut RA, Mell MW. Modern advances in vascular trauma. Surg Clin North Am. 2013;93(4):941-61, ix.,¹⁵Dente CJ, Feliciano DV, Rozycki GS, Cava RA, Ingram WL, Salomone JP, et al. A review of upper extremity fasciotomies in a level I trauma center. Am Surg. 2004;70(12):1088-93.. Diagnostic methods in the field have not changed dramatically, but there have been some changes in medical evacuation and diagnostic methods at some frontline military facilities. Ultrasound, Doppler, angiography and even Computed Tomography (CT) equipment has been introduced, with major effects on decision-making and treatment. While there has been knowledge and use of manual compression and tourniquets for bleeding over decades, new tools have been introduced successfully in the last 10-20 years for bleeding control and arterial reconstruction. One major development in the management of Non-compressible Torso Hemorrhage (NCTH) and junctional hemorrhage is the introduction of endovascular and hybrid methods (open and endovascular combined). Endovascular Resuscitation and Trauma Management (EVTM) is a concept that gathers these methods together and focuses on the use of endovascular and hybrid surgical tools for resuscitation, hemorrhage control, and the definitive management of both trauma and non-trauma patients. It can and, to some extent, is already being used in many places, ranging from austere environments or near-frontlines to highly sophisticated tertiary hospitals worldwide¹⁶Horer T. Resuscitative endovascular balloon occlusion of the aorta (REBOA) and endovascular resuscitation and trauma management (EVTM): a paradigm shift regarding hemodynamic instability. Eur J Trauma Emerg Surg. 2018;44(4):487-9.,¹⁷Horer T, McGreevy DT, Hoencamp R. The Concept of Endovascular Resuscitation and Trauma Management: Building the EVTM Team. Hot Topics Acute Car. 2020:1-12.,¹⁸Khan MA, Cotton B, Horer T, Duschesne J. DCR and EVTM: The Future of Trauma Research and Training. J Endovasc Resusc Tr. 2020;4(2):75-6.,¹⁹Endovascular Resuscitation and Trauma Management: Bleeding and Haemodynamic Control. Hot Topics Acute Car. 2020:1-262.. Use of aortic or other occlusion balloons, endografts, embolisation and other bleeding control tools, has increased dramatically in recent years for trauma patients²⁰Glaser JD, Kalapatapu VR. Endovascular Therapy of Vascular Trauma-Current Options and Review of the Literature. Vasc Endovascular Surg. 2019;53(6):477-87.,²¹Gamberini E, Coccolini F, Tamagnini B, Martino C, Albarello V, Benni M, et al. Resuscitative Endovascular Balloon Occlusion of the Aorta in trauma: a systematic review of the literature. World J Emerg Surg. 2017;12:42.,²²Akhmerov A, DuBose J, Azizzadeh A. Blunt Thoracic Aortic Injury: Current Therapies, Outcomes, and Challenges. Ann Vasc Dis. 2019;12(1):1-5.. Some methods, such as damage control surgery, rapid evacuation, permissive hypotension and whole-blood components resuscitation, are just some examples of the developments that are likely to have effected radical change to the way we treat bleeding trauma patients²³Benz D, Balogh ZJ. Damage control surgery: current state and future directions. Curr Opin Crit Care. 2017;23(6):491-7.,²⁴Muldowney M, Aichholz P, Nathwani R, Stansbury LG, Hess JR, Vavilala MS. Advances in hemorrhage control resuscitation. Curr Opin Anaesthesiol. 2022;35(2):176-81.,²⁵Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Critical Care. 2019;23.. Major trauma patients, with severe torso or junctional bleeding on the battlefield, may die before they reach a medical facility, but many trauma patients arriving with severe bleeding or in haemodynamic shock, usually due to combined venous and arterial bleeding, might be saved or suffer less morbidity with modern treatment protocols²⁶Horer T. Resuscitative endovascular balloon occlusion of the aorta (REBOA) and endovascular resuscitation and trauma management (EVTM): a paradigm shift regarding hemodynamic instability. Eur J Trauma Emerg Surg. 2018;44(4):487-9.,²⁷Fox CJ, Gillespie DL, O’Donnell SD, Rasmussen TE, Goff JM, Johnson CA, et al. Contemporary management of wartime vascular trauma. J Vasc Surg. 2005;41(4):638-44.,²⁸Fox CJ, Starnes BW. Vascular surgery on the modern battlefield. Surg Clin North Am. 2007;87(5):1193-211, xi.. One clinical example of the importance of these changes is avoiding opening new cavities in a multiple-trauma bleeding patient. These changes apply, to various extents, to the military, terror, prehospital and civilian environments and are included in several recent guidelines²⁹Cotton BA, Jerome R, Collier BR, Khetarpal S, Holevar M, Tucker B, et al. Guidelines for prehospital fluid resuscitation in the injured patient. J Trauma. 2009;67(2):389-402.,³⁰Coccolini F, Coimbra R, Ordonez C, Kluger Y, Vega F, Moore EE, et al. Liver trauma: WSES 2020 guidelines. World J Emerg Surg. 2020;15(1):24.,³¹Coccolini F, Montori G, Catena F, Kluger Y, Biffl W, Moore EE, et al. Splenic trauma: WSES classification and guidelines for adult and pediatric patients. World J Emerg Surg. 2017;12:40.,³²Coccolini F, Moore EE, Kluger Y, Biffl W, Leppaniemi A, Matsumura Y, et al. Kidney and uro-trauma: WSES-AAST guidelines. World Journal of Emergency Surgery. 2019;14(1).,³³Coccolini F, Roberts D, Ansaloni L, Ivatury R, Gamberini E, Kluger Y, et al. The open abdomen in trauma and non-trauma patients: WSES guidelines. World J Emerg Surg. 2018;13:7.,³⁴Coccolini F, Stahel PF, Montori G, Biffl W, Horer TM, Catena F, et al. Pelvic trauma: WSES classification and guidelines. World J Emerg Surg. 2017;12:5.,³⁵Cannon JW, Khan MA, Raja AS, Cohen MJ, Como JJ, Cotton BA, et al. Damage control resuscitation in patients with severe traumatic hemorrhage: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2017;82(3):605-17.. In general, the battlefield and civilian environments are very different regarding the number of injured patients, pattern of injury, time of evacuation to a medical facility, level of care, and medical diagnostic tools and treatment and how they can be used. In the battlefield or war situation, time to evacuation is crucial as there is always a delay, and treatment possibilities are limited as well as highly dependent on the capacity of the treatment facility. In the civilian scenario, treatment is largely dependent on the amount of injured people and their proximity to a hospital, and there are also different possible levels of treatment (e.g., in a level-1 trauma centre vs in a local hospital). In the military scenario, there are military hospitals and facilities while, in the civilian scenario, there are the hospitals, of any kind, in the area in question. Obviously, there is also a great variety of team experience and capability in different facilities and locations. One highly relevant example for wartime vascular trauma and its practice is the ongoing war in Ukraine, where local hospitals are at the centre of the battlefield and treat trauma patients, civilians and soldiers, on a daily basis. Treatment strategies also depend on the type of injury, whether or not there are multiple injuries, number of casualties, the resources available, and other factors. Although different in many ways, most treatment options and algorithms for trauma are used in a similar manner, albeit with modifications. Better use of “old” tools, like tourniquets, and the rise of modern tools like endovascular and hybrid (EVTM) techniques for bleeding control, give better treatment opportunities in any medical facility, at least to some extent.

Vascular injuries to the limbs are common in both armed conflicts and civilian motor-vehicle accidents and falls. These injuries are the main cause of severe bleeding, ischaemia, amputations, and death. Vascular injuries may be caused by blunt trauma, but more often they are the result of penetrating fragments, bullets and, recently, ball-bearings, foreign bodies, and high explosives¹Dua A, Patel B, Kragh JF, Jr., Holcomb JB, Fox CJ. Long-term follow-up and amputation-free survival in 497 casualties with combat-related vascular injuries and damage-control resuscitation. J Trauma Acute Care Surg. 2012;73(6):1517-24.,²Khorram-Manesh A, Goniewicz K, Burkle FM, Robinson Y. Review of Military Casualties in Modern Conflicts-The Re-emergence of Casualties From Armored Warfare. Mil Med. 2022;187(3-4):e313-e21.,³Fox CJ, Patel B, Clouse WD. Update on wartime vascular injury. Perspect Vasc Surg Endovasc Ther. 2011;23(1):13-25.,⁴Benz D, Balogh ZJ. Damage control surgery: current state and future directions. Curr Opin Crit Care. 2017;23(6):491-7.,⁵Fox CJ, Gillespie DL, O’Donnell SD, Rasmussen TE, Goff JM, Johnson CA, et al. Contemporary management of wartime vascular trauma. J Vasc Surg. 2005;41(4):638-44.. Vascular injuries take priority in treatment paradigms since shortening the time of bleeding and the length of ischaemia are of paramount importance in saving the limbs and lives of the injured. On the battlefield and during evacuation, rubber and improvised tourniquets are used to stop life-threatening bleeding but, in the setting of the operating room (OR), these should be removed as soon as feasible to prevent continued ischaemia of nerves and other soft tissues. Identification of the specific injured arteries and veins allows accurate clamping and appropriate repair of the vessels involved. Fasciotomies should be used liberally in this setting to improve functional outcome. Primary repair of vessels and use of autologous veins are preferred to synthetic grafts because of a greater risk of infection and thrombosis with the latter. In modern specialised vascular facilities, the success rate of repairs of combat and civilian vascular injuries is high, and mortality and amputation rates are low and continue to decrease⁶Fox CJ, Gillespie DL, O’Donnell SD, Rasmussen TE, Goff JM, Johnson CA, et al. Contemporary management of wartime vascular trauma. J Vasc Surg. 2005;41(4):638-44.,⁷Fox CJ, Starnes BW. Vascular surgery on the modern battlefield. Surg Clin North Am. 2007;87(5):1193-211, xi.,⁸Fox CJ, Gillespie DL, Cox ED, Kragh JF, Jr., Mehta SG, Salinas J, et al. Damage control resuscitation for vascular surgery in a combat support hospital. J Trauma. 2008;65(1):1-9.,⁹Nitecki SS, Karram T, Ofer A, Engel A, Hoffman A. Vascular injuries in an urban combat setting: experience from the 2006 Lebanon war. Vascular. 2010;18(1):1-8.,¹⁰Nitecki SS, Karram T, Ofer A, Engel A, Hoffman A. Management of combat vascular injuries using modern imaging: are we getting better? Emerg Med Int. 2013;2013:689473.,¹¹Rasmussen TE, Clouse WD, Jenkins DH, Peck MA, Eliason JL, Smith DL. Echelons of care and the management of wartime vascular injury: a report from the 332nd EMDG/Air Force Theater Hospital, Balad Air Base, Iraq. Perspect Vasc Surg Endovasc Ther. 2006;18(2):91-9..

 

The modern use of a variety of old and new ways to detect and stop bleeding and to achieve vascular repair, with surgical, hybrid and endovascular tools, will be discussed in this chapter. For vascular surgeons, the most common involvement has been with peripheral vascular injuries, but this is changing as EVTM methods are being used more frequently, worldwide, in trauma-related injuries. We will discuss vascular-injury patterns, diagnostics and treatment on modern battlefields, and in civilian and terror settings, with an emphasis on best evidence-based clinical practice, modern techniques and possibilities. As the subject is broad, we will try to define which injuries are vascular-related and how to treat them in both modern and austere facilities. We will discuss peripheral vascular injuries, where open surgery is predominant, somewhat separately from torso injuries where EVTM tools are starting to play a major role.

 

Incidence of vascular trauma in armed conflicts

The reported incidence of combat vascular trauma has been low in the past, with an incidence in the range of just 0.2-4%. This is probably due to excessive mortality during prolonged evacuation times. In more recent reports from the wars in Afghanistan and Iraq, the incidence has increased to 6.8%, probably due to better immediate resuscitation and evacuation from the battleground¹²De BM, Simeone FA. Battle injuries of the arteries in World War II; an analysis of 2,471 cases. Ann Surg. 1946;123:534-79.,¹³Rasouli MR. Epidemiology of vascular injuries in modern wars. Ann Surg. 2014;259(6):e91.,¹⁴Fox CJ, Gillespie DL, O’Donnell SD, Rasmussen TE, Goff JM, Johnson CA, et al. Contemporary management of wartime vascular trauma. J Vasc Surg. 2005;41(4):638-44.,¹⁵Fox CJ, Starnes BW. Vascular surgery on the modern battlefield. Surg Clin North Am. 2007;87(5):1193-211, xi.,¹⁶Rasmussen TE, Clouse WD, Jenkins DH, Peck MA, Eliason JL, Smith DL. The use of temporary vascular shunts as a damage control adjunct in the management of wartime vascular injury. J Trauma. 2006;61(1):8-12; discussion -5.,¹⁷Clouse WD, Rasmussen TE, Peck MA, Eliason JL, Cox MW, Bowser AN, et al. In-theater management of vascular injury: 2 years of the Balad Vascular Registry. J Am Coll Surg. 2007;204(4):625-32.. In one of the authors’ recent experiences in the 2006 Lebanon-Israel conflict, the rate of vascular injuries increased to 7.6% of all casualties and to 10.8% in the subgroup of soldiers only ¹⁸Nitecki SS, Karram T, Ofer A, Engel A, Hoffman A. Vascular injuries in an urban combat setting: experience from the 2006 Lebanon war. Vascular. 2010;18(1):1-8.,¹⁹Nitecki SS, Karram T, Hoffman A, Bass A. Venous trauma in the Lebanon War–2006. Interact Cardiovasc Thorac Surg. 2007;6(5):647-50.,²⁰Sfeir RE, Khoury GS, Kenaan MK. Vascular trauma to the lower extremity: the Lebanese war experience. Cardiovasc Surg. 1995;3(6):653-7.. As stated above, vascular injuries are mostly caused by penetrating trauma due to small armaments used in direct combat, high velocity bullets, and pellets. Less frequently, blunt trauma is the cause of acute vascular occlusion. Better torso protection of soldiers by advanced ceramic-armoured vests has led to a new injury pattern, such that vascular injuries of the limbs are now the main cause of severe bleeding, ischaemia, amputation and death. Almost half (46%) of all combat vascular injuries affect the lower limbs, while almost a quarter affect the upper limbs²¹Fox CJ, Patel B, Clouse WD. Update on wartime vascular injury. Perspect Vasc Surg Endovasc Ther. 2011;23(1):13-25.,²²Fox CJ, Starnes BW. Vascular surgery on the modern battlefield. Surg Clin North Am. 2007;87(5):1193-211, xi.,²³Rasmussen TE, Clouse WD, Jenkins DH, Peck MA, Eliason JL, Smith DL. Echelons of care and the management of wartime vascular injury: a report from the 332nd EMDG/Air Force Theater Hospital, Balad Air Base, Iraq. Perspect Vasc Surg Endovasc Ther. 2006;18(2):91-9.,²⁴Rich NM, Hughes CW. Vietnam vascular registry: a preliminary report. Surgery. 1969;65(1):218-26.,²⁵Starnes BW, Beekley AC, Sebesta JA, Andersen CA, Rush RM, Jr. Extremity vascular injuries on the battlefield: tips for surgeons deploying to war. J Trauma. 2006;60(2):432-42.. The incidence of war-related non-compressible torso injuries was reported in an American army study to be around 8-10%, and among them, around 8% were associated haemorrhages, half of which were torso-vessel injuries with very high mortality rates²⁶Kisat M, Morrison JJ, Hashmi ZG, Efron DT, Rasmussen TE, Haider AH. Epidemiology and outcomes of non-compressible torso hemorrhage. J Surg Res. 2013;184(1):414-21.. Some excellent information and data on these injuries can be found in textbooks, such as Rich Vascular Trauma, textbook of trauma and others listed as further reading at the end of the chapter.

 

Methods of prehospital peripheral-haemorrhage control

In vascular trauma, the goal of treatment is twofold: first, to stop continued bleeding and, second, to vascularise ischaemic limbs. Recent technological improvements, such as damage control, fluid resuscitation (permissive hypotension) and a correct ratio of blood products transfused, prevent physiological deterioration (hypothermia and coagulopathy), resulting in better life and limb salvage rates²⁷Fox CJ, Gillespie DL, Cox ED, Mehta SG, Kragh JF, Jr., Salinas J, et al. The effectiveness of a damage control resuscitation strategy for vascular injury in a combat support hospital: results of a case control study. J Trauma. 2008;64(2 Suppl):S99-106; discussion S-7.,²⁸Fox CJ, Patel B, Clouse WD. Update on wartime vascular injury. Perspect Vasc Surg Endovasc Ther. 2011;23(1):13-25.,²⁹Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Critical Care. 2019;23.,³⁰Fox CJ, Gillespie DL, O’Donnell SD, Rasmussen TE, Goff JM, Johnson CA, et al. Contemporary management of wartime vascular trauma. J Vasc Surg. 2005;41(4):638-44.,³¹Fox CJ, Starnes BW. Vascular surgery on the modern battlefield. Surg Clin North Am. 2007;87(5):1193-211, xi.,³²Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma. 2007;63(4):805-13.. Injured patients with limb vascular trauma are frequently saved from exsanguination by the liberal use of rubber tourniquets that are available to almost every soldier on the battlefield nowadays. Improvised tourniquets are seldom used by the modern armed forces. Local prolonged hand pressure to stop bleeding is used only temporarily until a tourniquet is applied. On the other hand, mortality has been reported in cases where injured arterial bleeding cannot be stopped before evacuation, as may happen with junctional injuries (like iliac artery injuries). Effective bleeding control with local compression up to and during transportation might be very challenging for practical reasons³³Starnes BW, Beekley AC, Sebesta JA, Andersen CA, Rush RM, Jr. Extremity vascular injuries on the battlefield: tips for surgeons deploying to war. J Trauma. 2006;60(2):432-42.. There are several mechanical compression devices to cope with junctional bleeding in military settings, but there are very limited data on their practical use.

 

Tourniquets

Extremity vascular injuries are associated with an approximately 9-10% mortality rate due to exsanguination. Tourniquets are the basic equipment of every medical team used to control battlefield haemorrhage. Nevertheless, they may result in limb ischaemia and paralysis, leading to amputation, and improper use does not stop the bleeding. Tourniquets were utilised in 3-8% of extremity injuries in Iraq³⁴Beekley AC, Sebesta JA, Blackbourne LH, Herbert GS, Kauvar DS, Baer DG, et al. Prehospital tourniquet use in Operation Iraqi Freedom: effect on hemorrhage control and outcomes. J Trauma. 2008;64(2 Suppl):S28-37; discussion S.,³⁵Fox CJ, Gillespie DL, O’Donnell SD, Rasmussen TE, Goff JM, Johnson CA, et al. Contemporary management of wartime vascular trauma. J Vasc Surg. 2005;41(4):638-44.,³⁶Fox CJ, Gillespie DL, Cox ED, Kragh JF, Jr., Mehta SG, Salinas J, et al. Damage control resuscitation for vascular surgery in a combat support hospital. J Trauma. 2008;65(1):1-9.,³⁷Sharrock AE, Remick KN, Midwinter MJ, Rickard RF. Combat vascular injury: Influence of mechanism of injury on outcome. Injury. 2019;50(1):125-30.,³⁸Schreiber MA, Tieu B. Hemostasis in Operation Iraqi Freedom III. Surgery. 2007;142(4 Suppl):S61-6.. In the Israeli Defense Forces, every soldier has a tourniquet that can be used when deemed necessary, even without the presence of a medical team. In the 2006 Lebanon-Israel conflict, tourniquets were liberally used in 39% of all extremity vascular injuries and were removed only in the operating room. Tourniquets were beneficial in 11 patients and overused (misused) in two patients without adverse effects³⁹Nitecki SS, Karram T, Ofer A, Engel A, Hoffman A. Vascular injuries in an urban combat setting: experience from the 2006 Lebanon war. Vascular. 2010;18(1):1-8.,⁴⁰Nitecki SS, Karram T, Ofer A, Engel A, Hoffman A. Management of combat vascular injuries using modern imaging: are we getting better? Emerg Med Int. 2013;2013:689473.. In a recent publication, seven tourniquets were reported to have been used at Kandahar Airfield Base: five saved lives, one was misused, and one was overused⁴¹Beekley AC, Sebesta JA, Blackbourne LH, Herbert GS, Kauvar DS, Baer DG, et al. Prehospital tourniquet use in Operation Iraqi Freedom: effect on hemorrhage control and outcomes. J Trauma. 2008;64(2 Suppl):S28-37; discussion S.. Pre-hospital tourniquet utilisation in Operation Iraqi Freedom was associated with improved hemorrhage control without adverse outcomes related to use⁴²Tien HC, Jung V, Rizoli SB, Acharya SV, MacDonald JC. An evaluation of tactical combat casualty care interventions in a combat environment. J Am Coll Surg. 2008;207(2):174-8.. These findings support the liberal use of tourniquets and refute the policy of having their utilisation as an option of last resort. The data on tourniquet use in recent terror events are hard to evaluate but, in the opinion of the authors, proximity to medical facilitates should encourage its use in bleeding patients.

 

Evacuation methods for casualties with vascular injuries

Rapid evacuation from the arena of injury to the nearest vascular facility is of the utmost importance in vascular trauma under both the civilian and war or terror scenarios. The time factor is important both for reducing continued uncontrolled bleeding and for reducing the tissue-ischaemic time of the injured limb when tourniquets are applied. Emergency evacuation should be arranged, or mortality may ensue. Evacuation by helicopter is the most rapid method when the vascular facility is remote. However, ground vehicles may prove to be faster when the arena is close-by⁴³Fox CJ, Patel B, Clouse WD. Update on wartime vascular injury. Perspect Vasc Surg Endovasc Ther. 2011;23(1):13-25.,⁴⁴Fox CJ, Starnes BW. Vascular surgery on the modern battlefield. Surg Clin North Am. 2007;87(5):1193-211, xi.. What is best, of course, depends on the scenario of the war, terror incidence, or nature of military activity. A good evacuation priority decision on which patient goes to which facility (if available) has an impact on survival, and on limb salvage⁴⁵McCulloch I, Valerio I. Lower extremity reconstruction for limb salvage and functional restoration – The Combat experience. Clin Plast Surg. 2021;48(2):349-61.,⁴⁶Beranger F, Lesquen H, Aoun O, Roqueplo C, Meyrat L, Natale C, et al. Management of war-related vascular wounds in French role 3 hospital during the Afghan campaign. Injury. 2017;48(9):1906-10.,⁴⁷Schrager JJ, Branson RD, Johannigman JA. Lessons from the tip of the spear: medical advancements from Iraq and Afghanistan. Respir Care. 2012;57(8):1305-13.,⁴⁸Fox CJ, Perkins JG, Kragh JF, Jr., Singh NN, Patel B, Ficke JR. Popliteal artery repair in massively transfused military trauma casualties: a pursuit to save life and limb. J Trauma. 2010;69 Suppl 1:S123-34..

 

Triage in the emergency room for patients with vascular-extremity injuries

Vascular injuries have first priority in treatment algorithms, since shortening the times of bleeding and ischaemia is of paramount importance in saving the lives and limbs of the injured. When a vascular injury is clearly identified, the patient should be rushed to the operating room without further delay. Delays are common and usually underestimated. Classical hard physical signs of vascular injury include active haemorrhage, pulsatile or expanding haematoma, bruit or thrill, and indicators of ischaemia: pain, pallor, paralysis, paraesthesia, pulselessness and poikilothermy (cold to touch) (the 6 Ps). Some of these signs may be misleading in complex injuries and cause both false-negative and false-positive diagnoses. When such injuries are suspected by physical examination but are not certain, vascular imaging is required. A simple hand-held Doppler apparatus is very helpful in identifying arterial flow in the dorsalis pedis or the tibialis posterior arteries, especially in patients with severe vasospasm. Duplex ultrasound can be used and may give needed information on flow, velocity and continuity of the vessels, but the data are scarce. Ultrasound use under these scenarios has yet to prove its efficacy in the treatment algorithm for a suspected vascular injury.

 

Peripheral vascular-injury imaging

Precise identification of injured blood vessels is of the utmost importance for the success of treatment. However, in complex modern war-limb injuries, with multiple penetrating wounds, identifying the exact extent, severity and location of the vascular injury is not always straightforward. High-quality vascular imaging helps to identify such injuries. In some cases, imaging may exclude significant injuries, especially in patients with shock, large hematomas, and large bone fractures. In these cases, opening new cavities or unnecessary vascular exploration may be avoided⁴⁹Horer T, McGreevy DT, Hoencamp R. The Concept of Endovascular Resuscitation and Trauma Management: Building the EVTM Team. Hot Topics Acute Car. 2020:1-12.. The routine utilisation of angiography is no longer indicated because it is time consuming, invasive and has inherent inaccuracies, including a 15% false-negative rate⁵⁰Miller-Thomas MM, West OC, Cohen AM. Diagnosing traumatic arterial injury in the extremities with CT angiography: pearls and pitfalls. Radiographics. 2005;25 Suppl 1:S133-42.,⁵¹Fleiter TR, Mervis S. The role of 3D-CTA in the assessment of peripheral vascular lesions in trauma patients. Eur J Radiol. 2007;64(1):92-102.. Angiography as part of the EVTM concept can be performed perioperatively as there is no need for patient transfer, and it can be used, for example, as a completion control at the end of the procedure. This will be discussed in this chapter below. Multi-slice CT angiography (CTA) with rapid reconstruction is the gold standard and the preferred method of imaging in war trauma, as it is in general trauma. CTA is rapid and accurate, and provides additional information, such as on hematoma size, peri-arterial hematoma, dissections, bone-fragment compression, unexpected injuries, proximity of shrapnel, and some further details⁵²Dreizin D, Smith EB, Champ K, Morrison JJ. Roles of Trauma CT and CTA in Salvaging the Threatened or Mangled Extremity. Radiographics. 2022;42(2):E50-E67.,⁵³Kelly SP, Rambau G, Tennent DJ, Osborn PM. The Role of CT Angiography in Evaluating Lower Extremity Trauma: 157 Patient Case Series at a Military Treatment Facility. Mil Med. 2019;184(9-10):e490-e3.,⁵⁴Madsen AS, Laing GL, Bruce JL, Oosthuizen GV, Clarke DL. An audit of penetrating neck injuries in a South African trauma service. Injury. 2016;47(1):64-9.,⁵⁵Pickering C, Muzaffar J, Reid C, Zakaria B, Coulson C, Sharma N, et al. Management and outcomes of military penetrating neck injuries: An eleven-year retrospective case note review. Injury. 2023;54(1):119-23.. A trauma CTA is extremely useful for excluding other injuries as well (e.g., head or chest injuries).

 

Priority in the operating room

The first priority in the OR is rapid haemorrhage control. This is done as the anaesthetic team works on vascular access, fluid replacement, ventilation and heat loss as parts of the urgent multidisciplinary resuscitation effort. Modern transfusion strategies (Full blood, or 1:1:1 blood components transfusion) should be followed with dedicated protocols for massive transfusion. Haemostasis with Tranexamic acid or other haemostatic products should be considered (but is beyond the scope of this chapter and will not be discussed here in details).

 

Continuous assessment of the patient’s status should be performed throughout the time spent in the OR. If tourniquets are still applied, they should be removed as soon as possible under controlled conditions. If bleeding resumes, direct pressure is applied to the point of bleeding, and proximal control of the artery is gained. Distal control is also required to reduce or stop the bleeding. Then, the injured segment of the blood vessel is approached, and repair is started by standard vascular methods⁵⁶Nitecki SS, Karram T, Ofer A, Engel A, Hoffman A. Vascular injuries in an urban combat setting: experience from the 2006 Lebanon war. Vascular. 2010;18(1):1-8.,⁵⁷Nitecki SS, Karram T, Ofer A, Engel A, Hoffman A. Management of combat vascular injuries using modern imaging: are we getting better? Emerg Med Int. 2013;2013:689473.,⁵⁸Starnes BW, Beekley AC, Sebesta JA, Andersen CA, Rush RM, Jr. Extremity vascular injuries on the battlefield: tips for surgeons deploying to war. J Trauma. 2006;60(2):432-42.. If the patient is successfully stabilised with no more overt or occult bleeding, the authors recommend intravenous heparin to avoid secondary thrombosis of the injured blood vessels. Only after bleeding is stopped and revascularisation secured are other necessary orthopaedic fixations and repairs undertaken. Admission to the Intensive Care Unit (ICU) is recommended for 24 hours following surgery due to the possibilities of hypovolaemic shock, reperfusion injury, hypothermia, and bleeding diathesis. One of the main reasons for ICU admission is the ongoing reevaluation of the patient’s status and extremities that can be performed safely in the ICU. In addition, multiple wound debridement or skin grafts are frequently necessary to clean devitalised tissues to prevent infection or graft exposure.

 

Mechanisms of vascular injury relevant to the repair options

The large physical forces and thermal effects applied to the vascular wall during the traumatic event may cause a spectrum of injuries. These range from mild contusion of the adventitia or minor intimal damage to complete transaction of the vessel. Sometimes, a small intimal flap may develop in to an occluding dissection with distal ischaemia, especially in the popliteal artery. A lateral laceration of the vessel wall sometimes causes unstoppable continuous bleeding because the blood vessel is unable to use the inherent protective mechanisms of contraction and spasm. These pathologies apply to both peripheral and torso vascular injuries but, as stated above, are seen more often in the extremities. Spontaneous thrombosis is frequently seen in the injured-vessel segments, usually on both sides of the injury up to the nearest uninvolved branch. A pseudoaneurysm or pulsating hematoma may develop if the arterial bleeding is partially contained by adjacent tissues and fasciae. An arterio-venous fistula may develop when both an artery and an adjacent vein are lacerated simultaneously. These patterns can also be seen in carotid and junctional injuries.

 

Methods of open surgical vascular repair

Proximal open surgical bleeding control can be achieved in the injured area itself, or in a “virgin territory” proximal to the injury. After control of bleeding, the vessel is inspected, and the best method of repair is decided upon. Simple repairs of injured blood vessels are preferred. A segment of the injured vessel is resected if required. Lateral suture of lacerations and debridement of short segments with end-to-end anastomosis when possible are rapid and effective with few complications. Reversed venous bypasses are used when required, usually if the gap is more than 3cm. Multiple segments of injured vessels may be repaired by short venous segments. Synthetic grafts should be avoided if possible, because of higher risks of thrombosis and infection, but there are a series of popliteal injuries, as also shown by our own experiences, where synthetic grafts have been used with good results⁵⁹Ratnayake A, Samarasinghe B, Bala M. Outcomes of popliteal vascular injuries at Sri Lankan war-front military hospital: case series of 44 cases. Injury. 2014;45(5):879-84.,⁶⁰O’Banion LA, Dirks R, Saldana-Ruiz N, Farooqui E, Yoon WJ, Pozolo C, et al. Contemporary outcomes of traumatic popliteal artery injury repair from the popliteal scoring assessment for vascular extremity injury in trauma study. J Vasc Surg. 2021;74(5):1573-80 e2.,⁶¹Dua A, Patel B, Desai SS, Holcomb JB, Wade CE, Coogan S, et al. Comparison of military and civilian popliteal artery trauma outcomes. J Vasc Surg. 2014;59(6):1628-32.,⁶²Fox N, Rajani RR, Bokhari F, Chiu WC, Kerwin A, Seamon MJ, et al. Evaluation and management of penetrating lower extremity arterial trauma: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S315-20.. The authors recommend using vein material whenever possible, and covering synthetic grafts with muscle flaps when possible. Ligation of a major vessel should be avoided and used only in dying patients. All vascular repairs should be well covered by viable clean tissues to prevent late infection and bleeding. One example is the use of the Sartorius muscle flap that has and is being used in vascular surgery, but there are no published data on their use in traumatic injuries⁶³Katsogridakis E, Pokusevski G, Perricone V. The role of sartorius muscle flaps in the management of complex groin wounds. Interact Cardiovasc Thorac Surg. 2019;28(4):635-7.. In the authors’ recent reported experience, interposition-reversed venous grafts were used in 38.5% of cases, end-to-end anastomosis in 23%, and lateral repair or patch in 15.5%, while primary ligation was reserved for small arteries and for veins (7.5%). In 13% of the recent cases of one of the authors, endovascular methods of embolisation or vascular occlusions were used⁶⁴Nitecki SS, Karram T, Ofer A, Engel A, Hoffman A. Vascular injuries in an urban combat setting: experience from the 2006 Lebanon war. Vascular. 2010;18(1):1-8.. Extra-anatomic bypasses are rarely required. Some illustrations of vascular open reconstructions basic features are seen in Figure 1a. Some open surgical repairs are seen in Figure 1b.

 

 

 

Figure 1a. This illustration shows some basic techniques for anastomosis and bypass. The recommended conduit, for interposition or a bypass graft, is always vein material, if possible. Good basic techniques for vascular repair and securing in- and out-flow are essentials.

 

 

Figure 1b.  From left to right, (a) popliteal artery and vein injury, (b, c) aortic injury and polyester (Dacron) repair, followed by (d) femoral vein trauma, (e, f) popliteal trauma exploration in trauma. The last photo is of interposition grafts, on both the popliteal artery and vein. Source: Authors’ own experience. Arteries marked in Red arrow and veins in Blue. The photos shown for general illustration of surgical exposure of vascular trauma.

 

Endovascular methods in extremity and junctional injuries

Although potentially easier, the use of endovascular techniques in combat injuries is still relatively rare, although more cases are being treated in combat-, terror- and trauma-related events⁶⁵DuBose JJ, Savage SA, Fabian TC, Menaker J, Scalea T, Holcomb JB, et al. The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) registry: multicenter data on modern vascular injury diagnosis, management, and outcomes. J Trauma Acute Care Surg. 2015;78(2):215-22; discussion 22-3.,⁶⁶Faulconer ER, Branco BC, Loja MN, Grayson K, Sampson J, Fabian TC, et al. Use of open and endovascular surgical techniques to manage vascular injuries in the trauma setting: A review of the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Trial registry. J Trauma Acute Care Surg. 2018;84(3):411-7.. In general, open repair is more expeditious for the limbs than the use of endovascular techniques, except with trunk vascular injuries. The preferred open arterial reconstruction of young patients in general is considered more appropriate by experienced surgeons but there are no randomised trials or high quality data to inform clinical practice. Covered stents (endografts) are seldom used in the extremities but are in use in inaccessible segments like the subclavian or iliac arteries, and this usage is increasing⁶⁷Boggs HK, Tomihama RT, Abou-Zamzam AM, Jr., Mukherjee K, Turay D, Teruya TH, et al. Analysis of Traumatic Axillo-Subclavian Vessel Injuries: Endovascular Management is a Viable Option to Open Surgical Reconstruction. Ann Vasc Surg. 2022;79:25-30.. Endovascular methods for bleeding control are used in junctional injuries but the preferred method is open surgery. Endovascular balloon occlusion can be used as a temporary bleeding control method and will be described in what follows. The PROOVIT American registry of vascular injuries and other studies have shown an exponential increase in the use of endovascular repair methods in the last decade in trauma patients, and endovascular methods are being used for different vascular injuries, even in junctional areas⁶⁸Horer T, McGreevy DT, Hoencamp R. The Concept of Endovascular Resuscitation and Trauma Management: Building the EVTM Team. Hot Topics Acute Car. 2020:1-12.,⁶⁹DuBose JJ, Savage SA, Fabian TC, Menaker J, Scalea T, Holcomb JB, et al. The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) registry: multicenter data on modern vascular injury diagnosis, management, and outcomes. J Trauma Acute Care Surg. 2015;78(2):215-22; discussion 22-3.,⁷⁰Faulconer ER, Branco BC, Loja MN, Grayson K, Sampson J, Fabian TC, et al. Use of open and endovascular surgical techniques to manage vascular injuries in the trauma setting: A review of the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Trial registry. J Trauma Acute Care Surg. 2018;84(3):411-7.,⁷¹Boggs HK, Tomihama RT, Abou-Zamzam AM, Jr., Mukherjee K, Turay D, Teruya TH, et al. Analysis of Traumatic Axillo-Subclavian Vessel Injuries: Endovascular Management is a Viable Option to Open Surgical Reconstruction. Ann Vasc Surg. 2022;79:25-30.,⁷²Scalea TM, Sclafani SJ. Angiographically placed balloons for arterial control: a description of a technique. J Trauma. 1991;31(12):1671-7.,⁷³Horer TM, Pirouzram A, Khan M, Brenner M, Cotton B, Duchesne J, et al. Endovascular Resuscitation and Trauma Management (EVTM)-Practical Aspects and Implementation. Shock. 2021;56(1S):37-41.. In the 2006 Israel-Lebanon conflict, covered stents were used in the context of limb vascular injury only for subclavian artery injuries, while other endovascular methods were used for embolisation and occlusions in vessels like the iliac arteries and veins⁷⁴Nitecki SS, Karram T, Ofer A, Engel A, Hoffman A. Vascular injuries in an urban combat setting: experience from the 2006 Lebanon war. Vascular. 2010;18(1):1-8.,⁷⁵Nitecki SS, Karram T, Ofer A, Engel A, Hoffman A. Management of combat vascular injuries using modern imaging: are we getting better? Emerg Med Int. 2013;2013:689473.. Some illustrations and images of junctional endovascular bleeding control features are seen in Figure 2.

 

 

Figure 2. Balloons can be used as temporary bleeding control tool in junctional bleeding as seen in these figures. External iliac artery and Femoral artery injury with balloon in place via contra-lateral access (a, b, c). The innominate artery injury (d, e, f) seen here can be controlled for open surgery (or hybrid procedure) using a balloon to facilitate the procedure. Metal fragments in a steel bar seen after a missile explosion demonstrating the possible injuries created by the blasts (g). Source: Authors’ own experience and Top Stent manual with permission.

 

Use of temporary shunts

The use of temporary shunts remains controversial. Eger and colleagues were among the first authors to report on the use of temporary vascular shunts in the modern era, and there are many publications on their use in recent times⁷⁶Borut LT, Acosta CJ, Tadlock LC, Dye JL, Galarneau M, Elshire CD. The use of temporary vascular shunts in military extremity wounds: a preliminary outcome analysis with 2-year follow-up. J Trauma. 2010;69(1):174-8.,⁷⁷Gifford SM, Aidinian G, Clouse WD, Fox CJ, Porras CA, Jones WT, et al. Effect of temporary shunting on extremity vascular injury: an outcome analysis from the Global War on Terror vascular injury initiative. J Vasc Surg. 2009;50(3):549-55; discussion 55-6.,⁷⁸Inaba K, Aksoy H, Seamon MJ, Marks JA, Duchesne J, Schroll R, et al. Multicenter evaluation of temporary intravascular shunt use in vascular trauma. J Trauma Acute Care Surg. 2016;80(3):359-64; discussion 64-5.,⁷⁹Johansen K, Bandyk D, Thiele B, Hansen ST, Jr. Temporary intraluminal shunts: resolution of a management dilemma in complex vascular injuries. J Trauma. 1982;22(5):395-402.,⁸⁰Mathew S, Smith BP, Cannon JW, Reilly PM, Schwab CW, Seamon MJ. Temporary arterial shunts in damage control: Experience and outcomes. J Trauma Acute Care Surg. 2017;82(3):512-7.,⁸¹Eger M, Golcman L, Goldstein A, Hirsch M. The use of a temporary shunt in the management of arterial vascular injuries. Surg Gynecol Obstet. 1971;132(1):67-70.. Although ischaemia in an extremity has a lower treatment priority than a massive haemorrhage, a temporary shunt may be inserted very quickly. The shunt serves for temporary revascularisation by restoring blood flow to the leg, thereby reducing the ischaemic time until the definitive vascular procedure is performed. Animal models have confirmed the physiological beneficial effect of temporary vascular shunts⁸²Taller J, Kamdar JP, Greene JA, Morgan RA, Blankenship CL, Dabrowski P, et al. Temporary vascular shunts as initial treatment of proximal extremity vascular injuries during combat operations: The new standard of care at Echelon II facilities? Journal of Trauma-Injury Infection and Critical Care. 2008;65(3):595-601.,⁸³Gifford SM, Eliason JL, Clouse WD, Spencer JR, Burkhardt GE, Propper BW, et al. Early versus delayed restoration of flow with temporary vascular shunt reduces circulating markers of injury in a porcine model. J Trauma. 2009;67(2):259-65.. Early shunting protects the extremity from further ischaemic insult and reduces circulating markers of tissue injury. Temporary shunt utilisation for a major-extremity vascular injury is recommended when other injuries assume first treatment priority or when prolonged evacuation/transportation times to a trauma centre are expected. When dealing with a combined vascular, skeletal, and soft-tissue trauma, treatment priorities are dictated by limb ischaemia. Such injuries, especially when involving the popliteal artery, are associated with high limb-loss rates. With a stable fracture, the vascular surgeon can perform the definitive repair followed by external or rigid internal fixation of the fracture. If, however, the fracture is unstable or the orthopaedic surgeon needs to shorten the limb, a temporary vascular shunt is needed, and the definitive vascular repair will be performed after the orthopaedic treatment. Temporary vascular shunts in wartime casualties have been used with beneficial effects by the authors and others⁸⁴Fox CJ, Patel B, Clouse WD. Update on wartime vascular injury. Perspect Vasc Surg Endovasc Ther. 2011;23(1):13-25.,⁸⁵Callcut RA, Mell MW. Modern advances in vascular trauma. Surg Clin North Am. 2013;93(4):941-61, ix.,⁸⁶Rasmussen TE, Clouse WD, Jenkins DH, Peck MA, Eliason JL, Smith DL. Echelons of care and the management of wartime vascular injury: a report from the 332nd EMDG/Air Force Theater Hospital, Balad Air Base, Iraq. Perspect Vasc Surg Endovasc Ther. 2006;18(2):91-9.,⁸⁷Rasmussen TE, Clouse WD, Jenkins DH, Peck MA, Eliason JL, Smith DL. The use of temporary vascular shunts as a damage control adjunct in the management of wartime vascular injury. J Trauma. 2006;61(1):8-12; discussion -5.,⁸⁸Clouse WD, Rasmussen TE, Peck MA, Eliason JL, Cox MW, Bowser AN, et al. In-theater management of vascular injury: 2 years of the Balad Vascular Registry. J Am Coll Surg. 2007;204(4):625-32.,⁸⁹Borut LT, Acosta CJ, Tadlock LC, Dye JL, Galarneau M, Elshire CD. The use of temporary vascular shunts in military extremity wounds: a preliminary outcome analysis with 2-year follow-up. J Trauma. 2010;69(1):174-8.,⁹⁰Inaba K, Aksoy H, Seamon MJ, Marks JA, Duchesne J, Schroll R, et al. Multicenter evaluation of temporary intravascular shunt use in vascular trauma. J Trauma Acute Care Surg. 2016;80(3):359-64; discussion 64-5.,⁹¹Mathew S, Smith BP, Cannon JW, Reilly PM, Schwab CW, Seamon MJ. Temporary arterial shunts in damage control: Experience and outcomes. J Trauma Acute Care Surg. 2017;82(3):512-7.,⁹²Taller J, Kamdar JP, Greene JA, Morgan RA, Blankenship CL, Dabrowski P, et al. Temporary vascular shunts as initial treatment of proximal extremity vascular injuries during combat operations: The new standard of care at Echelon II facilities? Journal of Trauma-Injury Infection and Critical Care. 2008;65(3):595-601.,⁹³Subramanian A, Vercruysse G, Dente C, Wyrzykowski A, King E, Feliciano DV. A decade’s experience with temporary intravascular shunts at a civilian level I trauma center. J Trauma. 2008;65(2):316-24; discussion 24-6..

 

Technical aspects

The injuries are exposed, proximal and distal control are achieved, vessel edges are debrided, thrombectomy or embolectomy is performed, heparinised saline is administered, and then a temporary shunt is inserted and secured in place. It is important to perform proximal and distal embolectomy as needed and verify good proximal and distal flow before any reconstruction is done. Shunts may be made of improvised plastic lines of different diameters or be specialised, like the Javid Shunt or Pruitt Shunt for carotid repair (Figure 3). Possible problems include dislodgment, and especially thrombosis, in the range of 2-22% in both military and civilian patients, and in particular with the shunts used in distal or very small arteries⁹⁴Borut LT, Acosta CJ, Tadlock LC, Dye JL, Galarneau M, Elshire CD. The use of temporary vascular shunts in military extremity wounds: a preliminary outcome analysis with 2-year follow-up. J Trauma. 2010;69(1):174-8.,⁹⁵Inaba K, Aksoy H, Seamon MJ, Marks JA, Duchesne J, Schroll R, et al. Multicenter evaluation of temporary intravascular shunt use in vascular trauma. J Trauma Acute Care Surg. 2016;80(3):359-64; discussion 64-5.,⁹⁶Subramanian A, Vercruysse G, Dente C, Wyrzykowski A, King E, Feliciano DV. A decade’s experience with temporary intravascular shunts at a civilian level I trauma center. J Trauma. 2008;65(2):316-24; discussion 24-6.. Another way to shunt blood is by an endovascular extra-anatomic path, as used in advanced endovascular surgery, but there are currently no data on its use in trauma.

 

 

Figure 3. illustration of shunt use (a, b) for the carotid artery and a shunt used in traumatic injury (c). In general, the same principles apply for elective and emergent trauma surgery use of shunts with good proximal and distal flow, prevention of embolisation, and restoration of flow. Source: Authors’ own experience and illustrations. The shunt insertion place is marked with red arrow.

 

Compartment syndrome and fasciotomy

Prophylactic fasciotomy should be performed every time the question “Should it be done?” is raised with a trauma patient. Four-compartment fasciotomy of the lower leg has proved to be effective in limb salvage after ischaemia-reperfusion. Exact measurement of the compartment pressure is seldom helpful. Classical indications for prophylactic fasciotomy are prolonged limb ischaemic time (more than 6 hours), a combined arterial and venous injury, and a massive soft-tissue injury⁹⁷Asher Hirshberg, Kenneth L Mattox. Top Knife: tfm Publishing Limited, 2004.,⁹⁸Arato E, Kurthy M, Sinay L, Kasza G, Menyhei G, Masoud S, et al. Pathology and diagnostic options of lower limb compartment syndrome. Clin Hemorheol Microcirc. 2009;41(1):1-8.,⁹⁹Kluckner M, Gratl A, Gruber L, Frech A, Gummerer M, Enzmann FK, et al. Predictors for the need for fasciotomy after arterial vascular trauma of the lower extremity. Injury. 2021;52(8):2160-5.,¹⁰⁰Olson SA, Glasgow RR. Acute compartment syndrome in lower extremity musculoskeletal trauma. J Am Acad Orthop Surg. 2005;13(7):436-44.. However, compartment syndrome may develop even after short periods of ischaemia. Clinical judgment is preferred; there is no real need to use sophisticated instruments to measure compartment pressure. The aim is to prevent compartment syndrome from happening rather than to treat it once it is diagnosed, resulting in irreversible neuronal damage. If fasciotomy is not performed immediately, then treatment with an intravenous hypertonic 20% mannitol solution should be considered in an attempt to prevent the development of compartment syndrome¹⁰¹Oredsson S, Plate G, Qvarfordt P. The effect of mannitol on reperfusion injury and postischaemic compartment pressure in skeletal muscle. Eur J Vasc Surg. 1994;8(3):326-31.. Fasciotomy of the forearm and palm should be considered if prolonged hand ischaemia occurs, or if a large hematoma is threatening hand function. Fasciotomy as a treatment for compartment syndrome should be performed on clinical grounds: pain (active or passive stretch), paralysis, swelling, oedema, and paraesthesia. Once compartment syndrome is diagnosed, fasciotomy is an urgent procedure for limb salvage. Seven to eight percent of patients in our facilities with combat-sustained extremity vascular trauma underwent fasciotomy, a similar percentage to that in American data reported from Iraq¹⁰²Fox CJ, Patel B, Clouse WD. Update on wartime vascular injury. Perspect Vasc Surg Endovasc Ther. 2011;23(1):13-25.,¹⁰³Fox CJ, Gillespie DL, O’Donnell SD, Rasmussen TE, Goff JM, Johnson CA, et al. Contemporary management of wartime vascular trauma. J Vasc Surg. 2005;41(4):638-44.,¹⁰⁴Fox CJ, Starnes BW. Vascular surgery on the modern battlefield. Surg Clin North Am. 2007;87(5):1193-211, xi.,¹⁰⁵Nitecki SS, Karram T, Ofer A, Engel A, Hoffman A. Vascular injuries in an urban combat setting: experience from the 2006 Lebanon war. Vascular. 2010;18(1):1-8.,¹⁰⁶Starnes BW, Beekley AC, Sebesta JA, Andersen CA, Rush RM, Jr. Extremity vascular injuries on the battlefield: tips for surgeons deploying to war. J Trauma. 2006;60(2):432-42.,¹⁰⁷Lagerstrom CF, Reed RL, 2nd, Rowlands BJ, Fischer RP. Early fasciotomy for acute clinically evident posttraumatic compartment syndrome. Am J Surg. 1989;158(1):36-9..

 

Arterial vs. venous injury

Arterial injuries of the extremities are manifested by life-threatening haemorrhage or ischaemia resulting in limb loss. Hard signs of vascular injuries are active arterial bleeding, expanding or pulsating haematoma, ischaemia (pallor, pulselessness, paresis or paralysis), and a thrill/bruit (as mentioned above). The presence of a hard sign with a single entry and/or exit wound leads to surgery after primary assessment in the emergency room. Soft signs, which call for further investigation of a possible vascular injury, include a history of a moderate haemorrhage, hypovolaemic shock, decreased but existent peripheral pulses, a peripheral neurological deficit, and proximity to a named large artery. With multiple injuries or the presence of soft signs of a possible vascular injury, imaging is necessary for both correct diagnosis and preferred treatment. CTA at both the arterial and venous phases should be performed, which will help detect not only venous bleeding, but also enable localisation of arterial-venous fistula¹⁰⁸Fleiter TR, Mervis S. The role of 3D-CTA in the assessment of peripheral vascular lesions in trauma patients. Eur J Radiol. 2007;64(1):92-102.,¹⁰⁹Kelly SP, Rambau G, Tennent DJ, Osborn PM. The Role of CT Angiography in Evaluating Lower Extremity Trauma: 157 Patient Case Series at a Military Treatment Facility. Mil Med. 2019;184(9-10):e490-e3.. A high index of suspicion in high-energy trauma is mandatory, especially in cases of peri-articular knee and elbow injuries or a gross displacement fracture. In sharp contrast, severe venous trauma is manifested by haemorrhage, not ischaemia. Bleeding may be internal or external and is usually contained, and thus rarely leads to hypovolaemic shock. Unlike with arterial injuries, repair of major extremity veins has been a subject of controversy and is practiced rarely. The current teaching is to avoid venous repair in an unstable or multi-trauma patient. In stable patients, reconstruction of major veins is preferred to avoid post-injury or post-thrombotic syndrome¹¹⁰DuBose JJ, Savage SA, Fabian TC, Menaker J, Scalea T, Holcomb JB, et al. The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) registry: multicenter data on modern vascular injury diagnosis, management, and outcomes. J Trauma Acute Care Surg. 2015;78(2):215-22; discussion 22-3.,¹¹¹Williams TK, Clouse WD. Current concepts in repair of extremity venous injury. J Vasc Surg Venous Lymphat Disord. 2016;4(2):238-47.,¹¹²Quan RW, Adams ED, Cox MW, Eagleton MJ, Weber MA, Fox CJ, et al. The management of trauma venous injury: civilian and wartime experiences. Perspect Vasc Surg Endovasc Ther. 2006;18(2):149-56.,¹¹³Quan RW, Gillespie DL, Stuart RP, Chang AS, Whittaker DR, Fox CJ. The effect of vein repair on the risk of venous thromboembolic events: a review of more than 100 traumatic military venous injuries. J Vasc Surg. 2008;47(3):571-7.. One of this chapter’s authors’ experience in the 2006 Lebanon-Israel conflict has led to a personal preference for venous repair over ligation, even when an interposition graft, rather than simple repair, is needed¹¹⁴Nitecki SS, Karram T, Hoffman A, Bass A. Venous trauma in the Lebanon War–2006. Interact Cardiovasc Thorac Surg. 2007;6(5):647-50.. Repair of a vein is of special importance when this vein is the only venous drainage route, as is the case with the popliteal vein.

 

Amputation

Among the vascular risk factors for limb amputation are ischaemia of longer than 6 hours (a risk that may reach 50% with ischaemia of more than 12 hours), a combined injury of both the popliteal artery and vein, and a failed vascular reconstruction. Amputation rates due to vascular injuries are decreasing over time, from 60% in World War II to 12% in Vietnam, 9% in Iraq, 5% in Ireland, 2% in the 1982 Lebanon-Israel conflict, and 0% in the 2006 Lebanon-Israel conflict¹¹⁵De BM, Simeone FA. Battle injuries of the arteries in World War II; an analysis of 2,471 cases. Ann Surg. 1946;123:534-79.,¹¹⁶Nitecki SS, Karram T, Ofer A, Engel A, Hoffman A. Vascular injuries in an urban combat setting: experience from the 2006 Lebanon war. Vascular. 2010;18(1):1-8.,¹¹⁷Nitecki SS, Karram T, Ofer A, Engel A, Hoffman A. Management of combat vascular injuries using modern imaging: are we getting better? Emerg Med Int. 2013;2013:689473.,¹¹⁸Rich NM, Hughes CW. Vietnam vascular registry: a preliminary report. Surgery. 1969;65(1):218-26.,¹¹⁹DuBose JJ, Savage SA, Fabian TC, Menaker J, Scalea T, Holcomb JB, et al. The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) registry: multicenter data on modern vascular injury diagnosis, management, and outcomes. J Trauma Acute Care Surg. 2015;78(2):215-22; discussion 22-3.,¹²⁰Eger M, Golcman L, Goldstein A, Hirsch M. The use of a temporary shunt in the management of arterial vascular injuries. Surg Gynecol Obstet. 1971;132(1):67-70.. The continued improvement in results seems to be attributable to multiple factors, such as a high index of suspicion for vascular injury and better imaging techniques, coupled with quick and meticulous interventions performed by experienced vascular specialists in a multi-disciplinary team. Primary amputation of a severely mangled limb with irreversible ischaemia should be considered. However, some technical orthopaedic possibilities to shorten limbs initially and repair all neurovascular elements with later elongation may save some limbs from unnecessary amputation¹²¹Lerner A, Fodor L, Soudry M, Peled IJ, Herer D, Ullmann Y. Acute shortening: modular treatment modality for severe combined bone and soft tissue loss of the extremities. J Trauma. 2004;57(3):603-8.,¹²²Lerner A, Fodor L, Soudry M. Is staged external fixation a valuable strategy for war injuries to the limbs? Clin Orthop Relat Res. 2006;448:217-24..

As diagnostic tools have emerged, especially the availability of ultra-fast CTA, the modern treatment algorithm for vascular injuries should be directed towards restoration of flow in the vessels and avoidance of ischaemia and reperfusion injuries. Although not available on the frontline, CTA can be performed in most hospitals and should be performed at both arterial and venous phases to detect major (and minor) injuries. This helps decision-making on the priorities and tools of treatment in accordance with general trauma guidelines (See Advanced Trauma Life Support, ATLS, of the committee of the American College of Surgeons.) Where possible, CTA is crucial to endovascular treatment since it avoids unnecessary searching for the bleeding organ and how to get there¹Horer T. Resuscitative endovascular balloon occlusion of the aorta (REBOA) and endovascular resuscitation and trauma management (EVTM): a paradigm shift regarding hemodynamic instability. Eur J Trauma Emerg Surg. 2018;44(4):487-9.,²Horer T, McGreevy DT, Hoencamp R. The Concept of Endovascular Resuscitation and Trauma Management: Building the EVTM Team. Hot Topics Acute Car. 2020:1-12.,³Endovascular Resuscitation and Trauma Management: Bleeding and Haemodynamic Control. Hot Topics Acute Car. 2020:1-262.,⁴Nitecki SS, Karram T, Ofer A, Engel A, Hoffman A. Management of combat vascular injuries using modern imaging: are we getting better? Emerg Med Int. 2013;2013:689473.,⁵Horer TM, Pirouzram A, Khan M, Brenner M, Cotton B, Duchesne J, et al. Endovascular Resuscitation and Trauma Management (EVTM)-Practical Aspects and Implementation. Shock. 2021;56(1S):37-41.,⁶Evans LL, Aarabi S, Durand R, Upperman JS, Jensen AR. Torso vascular trauma. Semin Pediatr Surg. 2021;30(6):151126.. There are several tools that have changed some elements in the treatment algorithm and practice in vascular trauma in recent years. Some of these tools have developed within vascular surgery, some in military or trauma practice, and some have been transferred from one field to another. The use of endovascular tools for bleeding control and the reconstruction of at least arterial injuries has revolutionised the care of some patient groups, with one obvious example being the treatment of blunt aortic trauma⁷Horer T, McGreevy DT, Hoencamp R. The Concept of Endovascular Resuscitation and Trauma Management: Building the EVTM Team. Hot Topics Acute Car. 2020:1-12.,⁸Horer TM, Pirouzram A, Khan M, Brenner M, Cotton B, Duchesne J, et al. Endovascular Resuscitation and Trauma Management (EVTM)-Practical Aspects and Implementation. Shock. 2021;56(1S):37-41.,⁹Horer TM. JEVTM 10th Edition. J Endovasc Resusc Tr. 2021;5(1):1-2.,¹⁰Hatchimonji JS, Chipman AM, McGreevy DT, Horer TM, Burruss S, Han S, et al. Resuscitative Endovascular Balloon Occlusion of Aaorta Use in Nontrauma Emergency General Surgery: A Multi-institutional Experience. Journal of Surgical Research. 2020;256:149-55.. The main treatment module for blunt descending-aorta injuries is now Thoracic Endovascular Aortic Repair (TEVAR)¹¹D’Alessio I, Domanin M, Bissacco D, Rimoldi P, Palmieri B, Piffaretti G, et al. Thoracic endovascular aortic repair for traumatic aortic injuries: insight from literature and practical recommendations. J Cardiovasc Surg (Torino). 2020;61(6):681-96.,¹²Alarhayem AQ, Rasmussen TE, Farivar B, Lim S, Braverman M, Hardy D, et al. Timing of repair of blunt thoracic aortic injuries in the thoracic endovascular aortic repair era. J Vasc Surg. 2021;73(3):896-902.,¹³Brown SR, Still SA, Eudailey KW, Beck AW, Gunn AJ. Acute traumatic injury of the aorta: presentation, diagnosis, and treatment. Ann Transl Med. 2021;9(14):1193.,¹⁴Dahal R, Acharya Y, Tyroch AH, Mukherjee D. Blunt Thoracic Aortic Injury and Contemporary Management Strategy. Angiology. 2022;73(6):497-507.,¹⁵Brown CVR, de Moya M, Brasel KJ, Hartwell JL, Inaba K, Ley EJ, et al. Blunt thoracic aortic injury: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg. 2023;94(1):113-6. Another developing area concerns injuries to the axillar-subclavian arteries, where balloon and endograft usage is increasing¹⁶Endovascular Resuscitation and Trauma Management: Bleeding and Haemodynamic Control. Hot Topics Acute Car. 2020:1-262.,¹⁷Hörer TM MJ, DuBose JJ, Reva VA, Matsumoto J, Matsumura Y, Falkenberg M, Delle M, Skoog P, Pirouzram A, et al. Top stent manual, The art of EndoVascular hybrid Trauma and bleeding Management. 1st ed. Hörer T, editor. Örebro, Sweden: Örebro University Hosptial; 2017.,¹⁸DuBose JJ, Rajani R, Gilani R, Arthurs ZA, Morrison JJ, Clouse WD, et al. Endovascular management of axillo-subclavian arterial injury: a review of published experience. Injury. 2012;43(11):1785-92., as described in the EVTM concept¹⁹Horer T. Resuscitative endovascular balloon occlusion of the aorta (REBOA) and endovascular resuscitation and trauma management (EVTM): a paradigm shift regarding hemodynamic instability. Eur J Trauma Emerg Surg. 2018;44(4):487-9.,²⁰Horer T, McGreevy DT, Hoencamp R. The Concept of Endovascular Resuscitation and Trauma Management: Building the EVTM Team. Hot Topics Acute Car. 2020:1-12.,²¹Horer TM, Pirouzram A, Khan M, Brenner M, Cotton B, Duchesne J, et al. Endovascular Resuscitation and Trauma Management (EVTM)-Practical Aspects and Implementation. Shock. 2021;56(1S):37-41.,²²Horer TM. JEVTM 10th Edition. J Endovasc Resusc Tr. 2021;5(1):1-2. (see also at www.jevtm.com). Some clinical examples can be seen in Figure 4.

 

 

Figure 4.  Different elements of endovascular (EVTM) solutions. Thoracic stent graft (TEVAR) in aortic blunt injury (a-f) CTA and angiography images as well as postoperative CTA reconstruction. The illustrations are used to show general endografts placements principles as discussed elsewhere. Subclavian arterial injury managed by endograft (g-i) showing the extravasation (g), general illustration of the graft placement (h) and the completion angiography (i). Through wire with endograft or balloon for bleeding control in subclavian artery injury (j, k). Source: Authors’ own experience and illustrations and Top Stent manual with permission.

 

We can list the EVTM tools as follows: haemodynamic tools, such as balloon catheters for temporary bleeding control or haemodynamic stabilisation, endografts for arterial (endo) reconstructions, endo-shunts or extra-corporal shunts for temporary ischaemia prevention, and embolisation and vessel occlusion tools for bleeding control. It should be mentioned that there are also other supportive tools, such as Extracorporeal Membrane Oxygenation (ECMO) but their role in vascular trauma is not defined and they are used only for general supportive treatment. EVTM tools can be used for some patients, but open surgical repair remains the gold standard for most trauma patients, especially those with extremity injuries. One reason for this is that in many cases, especially under war/terror scenarios, exclusion and open treatment of organ injuries should be performed as well, and endovascular tools will not solve the problems involved (e.g., with intestinal injuries). Hematoma can compress the nearby organs or vessels or nerves and open exploration with hematoma evacuation is indicated.

 

Hybrid treatment with endovascular and open surgery is another option that can be used in some traumatic injuries. In recent years, vascular femoral access has been introduced in several centres and guidelines for EVTM purposes, as part of the primary trauma survey protocol, on patient arrival²³Horer T. Resuscitative endovascular balloon occlusion of the aorta (REBOA) and endovascular resuscitation and trauma management (EVTM): a paradigm shift regarding hemodynamic instability. Eur J Trauma Emerg Surg. 2018;44(4):487-9.,²⁴Horer T, McGreevy DT, Hoencamp R. The Concept of Endovascular Resuscitation and Trauma Management: Building the EVTM Team. Hot Topics Acute Car. 2020:1-12.,²⁵Horer TM, Pirouzram A, Khan M, Brenner M, Cotton B, Duchesne J, et al. Endovascular Resuscitation and Trauma Management (EVTM)-Practical Aspects and Implementation. Shock. 2021;56(1S):37-41.,²⁶Maiga AW, Kundi R, Morrison JJ, Spalding C, Duchesne J, Hunt J, et al. Systematic review to evaluate algorithms for REBOA use in trauma and identify a consensus for patient selection. Trauma Surg Acute Ca. 2022;7(1)..

 

Balloon catheters and Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA):

The use of REBOA for haemodynamic support in trauma and non-trauma has been described widely in recent years and its use is growing²⁷Borger van der Burg BLS, van Dongen T, Morrison JJ, Hedeman Joosten PPA, DuBose JJ, Horer TM, et al. A systematic review and meta-analysis of the use of resuscitative endovascular balloon occlusion of the aorta in the management of major exsanguination. Eur J Trauma Emerg Surg. 2018;44(4):535-50.,²⁸Brenner M, Inaba K, Aiolfi A, DuBose J, Fabian T, Bee T, et al. Resuscitative Endovascular Balloon Occlusion of the Aorta and Resuscitative Thoracotomy in Select Patients with Hemorrhagic Shock: Early Results from the American Association for the Surgery of Trauma’s Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery Registry. J Am Coll Surg. 2018;226(5):730-40.,²⁹Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma. 2011;71(6):1869-72.. Although not specific to vascular trauma, it has potential use for major haemorrhage as a bridge to definitive treatment³⁰Horer T. Resuscitative endovascular balloon occlusion of the aorta (REBOA) and endovascular resuscitation and trauma management (EVTM): a paradigm shift regarding hemodynamic instability. Eur J Trauma Emerg Surg. 2018;44(4):487-9.,³¹Faulconer ER, Branco BC, Loja MN, Grayson K, Sampson J, Fabian TC, et al. Use of open and endovascular surgical techniques to manage vascular injuries in the trauma setting: A review of the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Trial registry. J Trauma Acute Care Surg. 2018;84(3):411-7.,³²McCracken BM, Ward KR, Tiba MH. A review of two emerging technologies for pre-hospital treatment of non-compressible abdominal hemorrhage. Transfusion. 2022;62 Suppl 1(Suppl 1):S313-S22.,³³Qasim Z. Resuscitative Endovascular Balloon Occlusion of the Aorta: A Practical Review. Emerg Med Clin North Am. 2023;41(1):71-88.,³⁴Schellenberg M, Owattanapanich N, DuBose JJ, Brenner M, Magee GA, Moore LJ, et al. Resuscitative Endovascular Balloon Occlusion of the Aorta in Penetrating Trauma. J Am Coll Surg. 2022;234(5):872-80.. Its role in battlefield, terror and civilian injuries is controversial but increasing. Although, in general, relative few patients need this modality, we thought it important to include it in this chapter. The use of balloons is not limited to the aorta but can be extended to every major vessel as a temporary occlusion tool prior to endovascular, hybrid or open-surgical treatment³⁵Scalea TM, Sclafani SJ. Angiographically placed balloons for arterial control: a description of a technique. J Trauma. 1991;31(12):1671-7.. Aortic balloon occlusion gives temporary haemodynamic support as its use, in the thoracic zone (zone 1) or abdominal region (zones 2-3), will cause an increase in blood pressure when done correctly. The main idea is to obtain femoral artery vascular access and insert a balloon catheter via small sheaths (4-8Fr in size) into the thoracic or abdominal aorta to serve as a temporary “endo-clamp”, preventing total haemodynamic collapse³⁶Horer T, McGreevy DT, Hoencamp R. The Concept of Endovascular Resuscitation and Trauma Management: Building the EVTM Team. Hot Topics Acute Car. 2020:1-12.,³⁷Khan MA, Cotton B, Horer T, Duschesne J. DCR and EVTM: The Future of Trauma Research and Training. J Endovasc Resusc Tr. 2020;4(2):75-6.,³⁸Horer TM, Pirouzram A, Khan M, Brenner M, Cotton B, Duchesne J, et al. Endovascular Resuscitation and Trauma Management (EVTM)-Practical Aspects and Implementation. Shock. 2021;56(1S):37-41.,³⁹Hörer TM MJ, DuBose JJ, Reva VA, Matsumoto J, Matsumura Y, Falkenberg M, Delle M, Skoog P, Pirouzram A, et al. Top stent manual, The art of EndoVascular hybrid Trauma and bleeding Management. 1st ed. Hörer T, editor. Örebro, Sweden: Örebro University Hosptial; 2017.. REBOA does not stop the bleeding but decreases perfusion pressure in the area under or distal to the balloon, and, in that way, its time limits become clear. Also, the release of REBOA (from a state of occlusion to non-occlusion) might lead to the emission and recirculation of ischaemic products, and thereby prevent multiple organ failure and complications⁴⁰Qasim ZA, Sikorski RA. Physiologic Considerations in Trauma Patients Undergoing Resuscitative Endovascular Balloon Occlusion of the Aorta. Anesth Analg. 2017;125(3):891-4.,⁴¹van der Burg BLSB, Kessel B, DuBose JJ, Horer TM, Hoencamp R. Consensus on resuscitative endovascular balloon occlusion of the Aorta: A first consensus paper using a Delphi method. Injury-International Journal of the Care of the Injured. 2019;50(6):1186-91.,⁴²van der Burg BLS, van Dongen TTCF, Morrison JJ, Joosten PPAH, DuBose JJ, Horer TM, et al. A systematic review and meta-analysis of the use of resuscitative endovascular balloon occlusion of the aorta in the management of major exsanguination. Eur J Trauma Emerg S. 2018;44(4):535-50.,⁴³Sadeghi M, Dogan EM, Karlsson C, Jansson K, Seilitz J, Skoog P, et al. Total resuscitative endovascular balloon occlusion of the aorta causes inflammatory activation and organ damage within 30 minutes of occlusion in normovolemic pigs. BMC Surg. 2020;20(1):43.,⁴⁴Sadeghi M, Horer TM, Forsman D, Dogan EM, Jansson K, Kindler C, et al. Blood pressure targeting by partial REBOA is possible in severe hemorrhagic shock in pigs and produces less circulatory, metabolic and inflammatory sequelae than total REBOA. Injury-International Journal of the Care of the Injured. 2018;49(12):2132-41.,⁴⁵Sadeghi M, Nilsson KF, Larzon T, Pirouzram A, Toivola A, Skoog P, et al. The use of aortic balloon occlusion in traumatic shock: first report from the ABO trauma registry. Eur J Trauma Emerg S. 2018;44(4):491-501.. The use of REBOA has changed dramatically in recent years. It has become a temporary tool, used preferably for partial occlusion of the aorta (pREBOA), with clear time limits, in order to give fast support while proceeding to definitive solutions, such as surgery, embolisation, endografting, etc.⁴⁶Horer T. Resuscitative endovascular balloon occlusion of the aorta (REBOA) and endovascular resuscitation and trauma management (EVTM): a paradigm shift regarding hemodynamic instability. Eur J Trauma Emerg Surg. 2018;44(4):487-9.,⁴⁷Hörer TM MJ, DuBose JJ, Reva VA, Matsumoto J, Matsumura Y, Falkenberg M, Delle M, Skoog P, Pirouzram A, et al. Top stent manual, The art of EndoVascular hybrid Trauma and bleeding Management. 1st ed. Hörer T, editor. Örebro, Sweden: Örebro University Hosptial; 2017.,⁴⁸DuBose JJ. How I do it: Partial resuscitative endovascular balloon occlusion of the aorta (P-REBOA). J Trauma Acute Care Surg. 2017;83(1):197-9.,⁴⁹Horer T, Hebron D, Swaid F, Korin A, Galili O, Alfici R, et al. Aorta Balloon Occlusion in Trauma: Three Cases Demonstrating Multidisciplinary Approach Already on Patient’s Arrival to the Emergency Room. Cardiovasc Inter Rad. 2016;39(2):284-9.,⁵⁰Hörer T CP, Jans A, Nilsson K. A case of partial aortic balloon occlusion in an unstable multi-trauma patient. J Trauma. 2016;18(2):150-4.. The use of REBOA in trauma should not delay care or evacuation in any way. There is a need for some clear indications for usage among patients with non-compressible torso bleeding, especially pelvic bleeders and unstable haemodynamic patients with systolic pressure under 70mmHg who are non-responsive to fluids. Since the procedure is invasive, and might lead to severe complications, it should be used only in selected patients where there are no other good alternatives for haemodynamic support until definitive care and should be used by highly trained teams⁵¹Horer TM, Pirouzram A, Khan M, Brenner M, Cotton B, Duchesne J, et al. Endovascular Resuscitation and Trauma Management (EVTM)-Practical Aspects and Implementation. Shock. 2021;56(1S):37-41.,⁵²Coccolini F, Ceresoli M, McGreevy DT, Sadeghi M, Pirouzram A, Toivola A, et al. Aortic balloon occlusion (REBOA) in pelvic ring injuries: preliminary results of the ABO Trauma Registry. Updates Surg. 2020;72(2):527-36.. The use of REBOA is now a part of several guidelines, in trauma and non-trauma haemorrhage control and we will continue following the data to filter out the correct use of this tool in the correct patient⁵³Coccolini F, Coimbra R, Ordonez C, Kluger Y, Vega F, Moore EE, et al. Liver trauma: WSES 2020 guidelines. World J Emerg Surg. 2020;15(1):24.,⁵⁴Coccolini F, Montori G, Catena F, Kluger Y, Biffl W, Moore EE, et al. Splenic trauma: WSES classification and guidelines for adult and pediatric patients. World J Emerg Surg. 2017;12:40.,⁵⁵Coccolini F, Stahel PF, Montori G, Biffl W, Horer TM, Catena F, et al. Pelvic trauma: WSES classification and guidelines. World J Emerg Surg. 2017;12:5.,⁵⁶van der Burg BLS, van Dongen TTCF, Morrison JJ, Joosten PPAH, DuBose JJ, Horer TM, et al. A systematic review and meta-analysis of the use of resuscitative endovascular balloon occlusion of the aorta in the management of major exsanguination. Eur J Trauma Emerg S. 2018;44(4):535-50.,⁵⁷Coccolini F, Ceresoli M, McGreevy DT, Sadeghi M, Pirouzram A, Toivola A, et al. Aortic balloon occlusion (REBOA) in pelvic ring injuries: preliminary results of the ABO Trauma Registry. Updates Surg. 2020;72(2):527-36.,⁵⁸Wanhainen A, Mani K, de Borst GJ. The most important news in the new ESVS 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysm. J Cardiovasc Surg (Torino). 2019;60(4):485-9. In times of terror and war, the tool can be, and has already been, used for evacuation or as a temporary tool when there are no resources free for multiple injured patients. Examples are waiting for another medical team to arrive (e.g., an angiography team), and evacuating to a trauma centre or from the field⁵⁹Thrailkill MA, Gladin KH, Thorpe CR, Roberts TR, Choi JH, Chung KK, et al. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): update and insights into current practices and future directions for research and implementation. Scand J Trauma Resusc Emerg Med. 2021;29(1):8.,⁶⁰Reva VA, Petrov AN, Samokhvalov IM. First Russian experience with endovascular balloon occlusion of the aorta in a zone of combat operations. Angiol Sosud Khir. 2020;26(2):61-75.,⁶¹Reva VA, Horer TM, Makhnovskiy AI, Sokhranov MV, Samokhvalov IM, DuBose JJ. Field and en route resuscitative endovascular occlusion of the aorta: A feasible military reality? J Trauma Acute Care Surg. 2017;83(1 Suppl 1):S170-S6.,⁶²Singer KE, Morris MC, Blakeman C, Stevens-Topie SM, Veile R, Fortuna G, et al. Can Resuscitative Endovascular Balloon Occlusion of the Aorta Fly? Assessing Aortic Balloon Performance for Aeromedical Evacuation. J Surg Res. 2020;254:390-7.,⁶³Knight RM. A Perspective on the Potential for Battlefield Resuscitative Endovascular Balloon Occlusion of the Aorta. J Spec Oper Med. 2017;17(1):72-5.. The potential use of REBOA in these scenarios and in multiple-casualty events is interesting, but there are currently no robust data on its use. More detailed information on the use of REBOA is beyond the scope of this chapter but can be found in the Top Stent manual⁶⁴Hörer TM MJ, DuBose JJ, Reva VA, Matsumoto J, Matsumura Y, Falkenberg M, Delle M, Skoog P, Pirouzram A, et al. Top stent manual, The art of EndoVascular hybrid Trauma and bleeding Management. 1st ed. Hörer T, editor. Örebro, Sweden: Örebro University Hosptial; 2017., DSCT manual, and the journal of EndoVascular resuscitation and Trauma Management (www.jevtm.com) (see also further reading recommended at the end of this chapter). The authors highly recommend REBOA for use only as part of EVTM by a highly experienced and trained team, for the correct patients, and following current ethical codes of treatment and guidelines. Some examples of REBOA in clinical use can be seen in Figure 5.

 

 

Figure 5. Clinical use of aortic balloon in trauma (REBOA) in team work (a) on patient under resuscitation and with mechanical heart compression in different aortic zones I, II, III REBOA (b). REBOA seen on fluoroscopy during use in trauma patients. Illustration C shows parallel catheter access to the splenic artery for embolization. Illustration d shows infra-renal (zone III) REBOA in traumatic pelvic bleeder.

 

Use of balloons for iliac or subclavian artery injuries is not uncommon, not only in trauma, but also in vascular surgery and for iatrogenic injuries or cancer surgery⁶⁵Boggs HK, Tomihama RT, Abou-Zamzam AM, Jr., Mukherjee K, Turay D, Teruya TH, et al. Analysis of Traumatic Axillo-Subclavian Vessel Injuries: Endovascular Management is a Viable Option to Open Surgical Reconstruction. Ann Vasc Surg. 2022;79:25-30.. Once access is gained from the femoral artery or from the brachial/axillary artery, a balloon can be used over the wire for temporary bleeding control. Then, a decision can be made whether to open the injured site or to proceed with endovascular solutions or both. All this can be achieved with very basic angiography and ultrasound equipment⁶⁶Scalea TM, Sclafani SJ. Angiographically placed balloons for arterial control: a description of a technique. J Trauma. 1991;31(12):1671-7.,⁶⁷Hörer TM MJ, DuBose JJ, Reva VA, Matsumoto J, Matsumura Y, Falkenberg M, Delle M, Skoog P, Pirouzram A, et al. Top stent manual, The art of EndoVascular hybrid Trauma and bleeding Management. 1st ed. Hörer T, editor. Örebro, Sweden: Örebro University Hosptial; 2017.. Temporary balloon occlusion is extremely helpful for getting out of trouble when major bleeding occurs. One common example is bleeding from the access site in the femoral artery, especially in patients who have been operated there before. Other examples, as mentioned above, concern the subclavian artery or a junctional haemorrhage in the femoral region.

 

Endograft use for vascular injuries:

In general, endografts can be used in all major vessels, mostly in the arterial tree but also in some veins, but they are seldom needed in the latter and there are no dedicated venous endografts for bleeding control. For the arterial tree, tremendous technical developments have led to the presence of many types of endografts for all possible artery sizes⁶⁸Horer T, McGreevy DT, Hoencamp R. The Concept of Endovascular Resuscitation and Trauma Management: Building the EVTM Team. Hot Topics Acute Car. 2020:1-12.,⁶⁹Horer TM, Pirouzram A, Khan M, Brenner M, Cotton B, Duchesne J, et al. Endovascular Resuscitation and Trauma Management (EVTM)-Practical Aspects and Implementation. Shock. 2021;56(1S):37-41.,⁷⁰Hörer TM MJ, DuBose JJ, Reva VA, Matsumoto J, Matsumura Y, Falkenberg M, Delle M, Skoog P, Pirouzram A, et al. Top stent manual, The art of EndoVascular hybrid Trauma and bleeding Management. 1st ed. Hörer T, editor. Örebro, Sweden: Örebro University Hosptial; 2017. Even if not dedicated to trauma usage, most endografts can be used for different indications, the main factors to think about being the vessel length, injury type, landing zones and access size of the delivery system. One of the best examples of the benefits of the endovascular approach, in parallel with EVTM, is the use of endografts in blunt aortic trauma⁷¹DuBose JJ, Savage SA, Fabian TC, Menaker J, Scalea T, Holcomb JB, et al. The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) registry: multicenter data on modern vascular injury diagnosis, management, and outcomes. J Trauma Acute Care Surg. 2015;78(2):215-22; discussion 22-3.,⁷²Horer TM, Pirouzram A, Khan M, Brenner M, Cotton B, Duchesne J, et al. Endovascular Resuscitation and Trauma Management (EVTM)-Practical Aspects and Implementation. Shock. 2021;56(1S):37-41.,⁷³Azizzadeh A, Ray HM, Dubose JJ, Charlton-Ouw KM, Miller CC, Coogan SM, et al. Outcomes of endovascular repair for patients with blunt traumatic aortic injury. J Trauma Acute Care Surg. 2014;76(2):510-6.,⁷⁴Dubose JJ, Azizzadeh A, Estrera AL, Safi HJ. Contemporary management of blunt aortic trauma. J Cardiovasc Surg (Torino). 2015;56(5):751-62.,⁷⁵DuBose JJ, Leake SS, Brenner M, Pasley J, O’Callaghan T, Luo-Owen X, et al. Contemporary management and outcomes of blunt thoracic aortic injury: a multicenter retrospective study. J Trauma Acute Care Surg. 2015;78(2):360-9.. Graded as I-IV or low grade, medium or sever are used for description of aortic injuries. Low grade or low grade injuries involve the aortic wall without bleeding or wall rupture. High level/severe injuries will show blood around the aorta and damage to the aortic wall with or without bleeding/haematoma. While low grade injuries can be treated conservatively, middle and high level injuries usually require treatment due to ongoing bleeding or potential rupture⁷⁶DuBose JJ, Savage SA, Fabian TC, Menaker J, Scalea T, Holcomb JB, et al. The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) registry: multicenter data on modern vascular injury diagnosis, management, and outcomes. J Trauma Acute Care Surg. 2015;78(2):215-22; discussion 22-3.. Endograft use for aortic injuries has been practised for many years and the data are clear: there is a huge advantage to placing a thoracic-covered stent in injuries to the descending aorta and probably the distal arch⁷⁷Dahal R, Acharya Y, Tyroch AH, Mukherjee D. Blunt Thoracic Aortic Injury and Contemporary Management Strategy. Angiology. 2022;73(6):497-507.,⁷⁸Madigan MC, Lewis AJ, Liang NL, Handzel R, Hager E, Makaroun MS, et al. Outcomes of operative and nonoperative management of blunt thoracic aortic injury. J Vasc Surg. 2022;76(1):239-47 e1.,⁷⁹Jacob-Brassard J, Al-Omran M, Nathens AB, Forbes TL, de Mestral C. Management and In-hospital Mortality of 2203 Patients With a Traumatic Intimal Tear of the Thoracic Aorta. Ann Surg. 2022;276(1):186-92.. The approach can be used for penetrating injuries as well, but this largely depends on the area and degree of injury⁸⁰Dahal R, Acharya Y, Tyroch AH, Mukherjee D. Blunt Thoracic Aortic Injury and Contemporary Management Strategy. Angiology. 2022;73(6):497-507.,⁸¹Brown CVR, de Moya M, Brasel KJ, Hartwell JL, Inaba K, Ley EJ, et al. Blunt thoracic aortic injury: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg. 2023;94(1):113-6.,⁸²Sun J, Ren K, Zhang L, Xue C, Duan W, Liu J, et al. Traumatic blunt thoracic aortic injury: a 10-year single-center retrospective analysis. J Cardiothorac Surg. 2022;17(1):335.,⁸³Mouawad NJ, Paulisin J, Hofmeister S, Thomas MB. Blunt thoracic aortic injury – concepts and management. J Cardiothorac Surg. 2020;15(1):62.,⁸⁴Scalea TM, Feliciano DV, DuBose JJ, Ottochian M, O’Connor JV, Morrison JJ. Blunt Thoracic Aortic Injury: Endovascular Repair Is Now the Standard. J Am Coll Surg. 2019;228(4):605-10.. All bleeding and pseudoaneurysms in the aorta should be treated as an emergency or in a sub-acute manner (within approx. 48 h.), depending on the status of the patient, haemodynamic stability, and the panorama of other injuries⁸⁵Brown CVR, de Moya M, Brasel KJ, Hartwell JL, Inaba K, Ley EJ, et al. Blunt thoracic aortic injury: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg. 2023;94(1):113-6.. Placing an endograft in the descending aorta is a short procedure, can be done even under local anaesthesia, and is relatively safe. If needed, the subclavian artery can be covered (in most cases), but also re-vascularised by carotid-subclavian bypass grafting or other advanced methods. Most data on more complexed repairs come from aneurysm and dissection treatment and not from trauma trials⁸⁶Pini R, Faggioli G, Paraskevas KI, Alaidroos M, Palermo S, Gallitto E, et al. A systematic review and meta-analysis of the occurrence of spinal cord ischemia after endovascular repair of thoracoabdominal aortic aneurysms. J Vasc Surg. 2022;75(4):1466-77 e8.. The treatment should be individualised to the patient and anatomical considerations by trying to minimise the risk of stroke and spinal paraplegia⁸⁷Dahal R, Acharya Y, Tyroch AH, Mukherjee D. Blunt Thoracic Aortic Injury and Contemporary Management Strategy. Angiology. 2022;73(6):497-507.,⁸⁸Lounes Y, Belarbi A, Hireche K, Chassin-Trubert L, Ozdemir BA, Akodad M, et al. Physician-Modified Stent Graft for Blunt Thoracic Aortic Injuries: Do the Benefits Worth the Trouble? Ann Vasc Surg. 2022.,⁸⁹Kruger JL, Balceniuk MD, Zhao P, Ayers BC, Ellis JL, Doyle AJ, et al. Left Subclavian Artery Coverage is Not Associated with Neurological Deficits in Trauma Patients Undergoing Thoracic Endovascular Repair. Ann Vasc Surg. 2022;86:408-16.,⁹⁰Ghoddusi Johari H, Moein SA, Hosseinzadeh A, Kojuri J, Roshanshad A, Shahriarirad R. The Role of Surgical and Endovascular Repair of Blunt Traumatic Aortic Injury in the Modern Era: A Single-Center Experience. Bull Emerg Trauma. 2022;10(3):103-9.,⁹¹Prendes CF, Stana J, Schneidwind KD, Rantner B, Konstantinou N, Bruder J, et al. Blunt traumatic thoracic aortic injuries: a retrospective cohort analysis of 2 decades of experience. Interact Cardiovasc Thorac Surg. 2021;33(2):293-300.,⁹²Riambau V, Bockler D, Brunkwall J, Cao P, Chiesa R, Coppi G, et al. Editor’s Choice – Management of Descending Thoracic Aorta Diseases: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2017;53(1):4-52.. The risk of endograft infection in trauma is not well investigated but it should be taken into consideration. A highly experienced team should perform the procedure, preferably in regular hospital hours and with optimal anaesthesia resources as well as modern imaging equipment. The abdominal aorta can be covered by endografts in localised lesions or pseudoaneurysms, depending on the location, but this is rarely done. What should be considered first is what is of benefit to the patient and whether open surgery and aortic repair as the standard treatment, especially in young people, are probably the best option. There are no clear data or randomised studies on this issue. The main limitation concerns the visceral arteries, especially the superior mesenteric artery and the renal arteries, which should not be covered by endografts. Even here, there are advanced solutions that might be considered in highly experienced centers (parallel grafts or others), especially for blunt dissections and injuries to the mid-aorta in more stable patients. The iliac arteries can be managed by endovascular methods, at times even with transections, with through and through-wire methods (Rendezvous procedures) and endografts. The main benefit is that bleeding control can be achieved relatively quickly, avoiding surgical dissections with huge hematoma and ongoing bleeding. This has been achieved in both trauma and non-trauma patients, and the methods are well practiced and known to most experienced endovascular surgeons⁹³Wanhainen A, Mani K, de Borst GJ. The most important news in the new ESVS 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysm. J Cardiovasc Surg (Torino). 2019;60(4):485-9.. Hybrid methods can be used as well as open dissections, with puncture and endograft on the proximal vessel and end-to-side anastomosis or interposition graft using the endograft on the distal part of the iliac artery (the authors’ own experiences and data presented at international meetings and the EVTM symposium. Also can be seen on EVTM YouTube channels at 3:rd Pan-American EVTM Symposium 2022 (Day 2 ) – YouTube). Visceral bleeding of the vessel from 3mm and above can be also treated with endografts as can the hepatic, renal, spleen, celiac and other arteries. The subclavian artery is a great example of where an injury can be managed very quickly by endograft or balloon, for bleeding control first and then for endograft or open-surgery (hybrid) treatment. There are several techniques for getting fast endovascular bleeding control with endovascular reconstruction. In general, subclavian reconstruction (or just bleeding control by balloon) can be achieved from the femoral or brachial artery⁹⁴Scalea TM, Sclafani SJ. Angiographically placed balloons for arterial control: a description of a technique. J Trauma. 1991;31(12):1671-7.,⁹⁵Hörer T et al. Endovascular Resuscitation and Trauma Management: Bleeding and Haemodynamic Control. Springer 2019.,⁹⁶Hörer TM MJ, DuBose JJ, Reva VA, Matsumoto J, Matsumura Y, Falkenberg M, Delle M, Skoog P, Pirouzram A, et al. Top stent manual, The art of EndoVascular hybrid Trauma and bleeding Management. 1st ed. Hörer T, editor. Örebro, Sweden: Örebro University Hosptial; 2017.,⁹⁷Evans LL, Aarabi S, Durand R, Upperman JS, Jensen AR. Torso vascular trauma. Semin Pediatr Surg. 2021;30(6):151126.,⁹⁸D’Alessio I, Domanin M, Bissacco D, Rimoldi P, Palmieri B, Piffaretti G, et al. Thoracic endovascular aortic repair for traumatic aortic injuries: insight from literature and practical recommendations. J Cardiovasc Surg (Torino). 2020;61(6):681-96.,⁹⁹Piffaretti G, Carrafiello G, Ierardi AM, Mariscalco G, Macchi E, Castelli P, et al. Thoracic endovascular aortic repair for blunt thoracic aortic injuries in complex aortic arch vessels anatomies. Ann Vasc Surg. 2015;29(6):1320 e11-5.,¹⁰⁰Zhang L, Wu H, Li X, Lv K, Song H, Zeng C, et al. Thoracic endovascular aortic repair with left subclavian artery reconstruction for blunt traumatic aortic injury in elderly patients. J Interv Med. 2019;2(4):150-3.,¹⁰¹Keville MP, Ko A, Dubose JJ, Kundi R, Scalea TM, Morrison JJ. LASER Fenestration of Thoracic Endoluminal Stent Grafts for Preservation of the Left Subclavian Artery. J Trauma Acute Care Surg. 2021;91(1):e13-e7.. The endovascular approach is fast and effective for the treatment of major vessels and has been used for a ruptured aorta or iliac vessel, an injured subclavian artery, and other vessels¹⁰²Mayer D, Aeschbacher S, Pfammatter T, Veith FJ, Norgren L, Magnuson A, et al. Complete replacement of open repair for ruptured abdominal aortic aneurysms by endovascular aneurysm repair: a two-center 14-year experience. Ann Surg. 2012;256(5):688-95; discussion 95-6.. The choice is highly dependent on patient status, the composition of the team, and the trauma panorama. Some clinical examples can be seen in Figure 6.

 

 

Figure 6. Profunda femoris (deep femoral) artery traumatic bleeding with balloon and endograft seen on angiography images as marked with red arrow (a-c) . The illustration (d) shows an endograft in an injured iliac vessel. Photo e illustrates hybrid bleeding control and repair of the femoral artery, with vessel puncture and introducer distal to the wound and balloon control (red arrow) followed by open repair. This can be very useful for preventing massive bleeding and unnecessary dissection. It is also very useful in patients with scars due to previous surgery in the region. Source: Authors’ own experience and illustrations and Top Stent manual with permission.

 

Embolisation and vessel occluders

The use of occlusion material for bleeding vessels is very common. In general, vascular access and a path to the bleeding vessel are needed. There are many tools for embolisation, such as coils of different sorts, plugging material, foams, and liquid agents. It might be claimed that coils need more time for embolisation, but this depends on the vessel size and location. Back-door bleeding from the distal side of the vessel must be considered, and of course so too must the ischaemic effect on the target organ. Liquid embolisation agents can be used downstream, getting to distal bleeding and closing ‘back-doors’. Plugs are a sort of closed endograft and will close the vessel permanently. The use of different tools depends on the experience of the team, the tools available, and access to the vessels in focus¹⁰³Hörer TM MJ, DuBose JJ, Reva VA, Matsumoto J, Matsumura Y, Falkenberg M, Delle M, Skoog P, Pirouzram A, et al. Top stent manual, The art of EndoVascular hybrid Trauma and bleeding Management. 1st ed. Hörer T, editor. Örebro, Sweden: Örebro University Hosptial; 2017.. Embolisation itself should be performed by an experienced team, as fast as possible, targeting the bleeding vessel as specifically as possible. It can be done in a semi-hybrid room (OR with C arm and suitable table) or a hybrid suite. Embolisation in bleeding patients should be prioritised by the patient’s status and the medical facility’s capabilities. Generally and briefly, when the bleeding site is detected by CTA, embolisation, if possible, can be done in a semi-hybrid OR or hybrid suite without patient transfer¹⁰⁴Hörer T et al. Endovascular Resuscitation and Trauma Management: Bleeding and Haemodynamic Control. Springer 2019.,¹⁰⁵Hörer TM MJ, DuBose JJ, Reva VA, Matsumoto J, Matsumura Y, Falkenberg M, Delle M, Skoog P, Pirouzram A, et al. Top stent manual, The art of EndoVascular hybrid Trauma and bleeding Management. 1st ed. Hörer T, editor. Örebro, Sweden: Örebro University Hosptial; 2017.. It can be performed after damage control or a surgical procedure, or as a sole treatment as needed. A comprehensive discussion of embolisation is beyond the scope of this chapter, but some of the common indications of embolisation in trauma are spleen, liver, kidney, or pelvic extravasation seen on CTA. Some examples are seen in Figure 7.

 

 

Figure 7. Vascular coil in the internal iliac artery and angiography. Illustration shows graphic presentation (a). two cases with ongoing bleeding (traumatic) managed by coling via contralateral access (b-c). Source: Authors’ own experience and illustrations and Top Stent manual with permission.

As technology develops and new technologies, such as endovascular tools, are often being used, there is a need to know and appreciate their limitations. One might consider hybrid approach when open exposure is needed (i.e haematoma evacuation, debridement) For endovascular repair, a vessel access is needed to gain a treatment vector (line) for delivery of the endovascular tool to the appropriate location. At times, vascular access is difficult (an injured or occluded vessel) and might be time-consuming. Detection of the bleeding site and mapping how to get there may also be a limiting factor. Thus, endovascular treatment should not replace open surgery when effective and fast bleeding control can be achieved (by packing or another open method). When possible, it should be used to assist the appropriate patient and decision, and treatment should be performed by a highly experienced team.

 

Articles:

-Fox CJ, Starnes BW. Vascular surgery on the modern battlefield. Surg Clin North Am. 2007;87(5):1193-211, xi

-Rich NM, Rhee P. An historical tour of vascular injury management: from its inception to the new millennium. Surg Clin North Am. 2001;81(6):1199-215

 

Books and manuals:

-Rasmussen, Tai. Rich Vascular Trauma 2022 (4th edition). Elsevier  ISBN 978-0-323-69766-8

-Hörer T. et al EndoVascular resuscitation and Trauma Management (EVTM) 2020. Springer. ISBN 978-3-030-25340-0

-Boffard K. Manual of Definitive Surgical Trauma Care (DSTC) 2019. ISBN 978-0-367-24468-2

-DuBose J. et al Vascular Injury. 2023. McGraw Hill. ISBN 978-1-264-26982-2

-Hörer T. et al. EVTM landmarks articles 2021. Örebro University Hospital, Sweden. ISBN 978-91-519-8850-4

-Hörer T. et al Top Stent manual 2017. Örebro University Hospital. ISBN 978-97-639-2522-1