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8 • Imaging for the Evaluation and Treatment of Vascular Trauma 105
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of the imaging slice through the imaged volume can be
selected. Thin-slice reconstructions have better edge denition, better high-contrast resolution, and fewer partialvolume artifacts at the cost of greater noise and poorer
low-contrast resolution.
Two-dimensional CTA postprocessing techniques include
multiplanar reformatting (MPR) of images, as well as
curved reformatting. MPR displays volumetric data in
orthogonal planes (axial, sagittal, coronal), as well as in
oblique planes selected and manipulated by the user. Samples through the volume dataset can be thin slices or thick
slabs. Curved reformats (CR) are used to view vessels over
their entire course, which facilitates evaluation of segment
patency or stenosis.
Three-dimensional postprocessing includes maximum
intensity projections (MIP) and surface shaded volume
rendering (VR). With MIP displays, the highest attenuation along the line projected through the image is brought
forward. MIP effectively displays structures with high HU,
such as contrast-lled vessels (Fig. 8.12). VR images are
helpful for understanding complex structural relationships,
and many surgeons prefer this view for operative planning.
No additional information is provided by VR. In fact, some
information may be lost, as vessels without sufcient contrast may not be displayed. Smaller imaging increments
(with overlap of adjacent slice acquisition) provide for better 3-D rendering.
CTA signs of arterial trauma in the extremities include
extravasation of contrast (i.e., pseudoaneurysm), narrowing (i.e., stenosis), loss of opacication (i.e., occlusion), and
rapid venous contrast (i.e., arteriovenous stula).
Fig. 8.12 Axillary artery gunshot wound. Maximum intensity projec-
tions (MIP) can create images that resemble conventional arteriography.
The thickness of the tissue in the image can be varied. This thick MIP slab
(44-mm reconstruction) in steep right anterior oblique projection shows
the abrupt cut off of flow in the left axillary artery after a gunshot wound to
the left shoulder. Metallic fragments from the bullet are seen in the large
hematoma on the anterior chest wall.
Postexamination Care
There are few specic concerns after CTA, although hypovolemia should be avoided to reduce the risk of kidney harm.
Urine output and renal function should be monitored.
Complications
CTA is generally safe, noninvasive, and associated with few
direct risks of complications. Early complications of CTA
are primarily those associated with contrast administration
(extravasation, renal failure, allergic-type reactions). Other
risks associated with CTA are those associated with errors in
image interpretation. The late risks associated with radiation
exposure are modest for most patients, but children may be at
increased lifetime risk for radiation-associated cancers.
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E me rg ing Technologies and
New Approaches to Vascular
Trauma and Shock
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9
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Endovascular Suites and
the Emergency Vascular Service
JOSEPH A. HERROLD, THOMAS M. SCALEA, and JONATHAN J. MORRISON
Introduction
Hemorrhage control is a critical component of any facility
that manages trauma patients. This core capability exists in
many forms, from mechanical devices, such as tourniquets
for extremity hemorrhage to invasive surgical procedures.
Within the domain of hospital care, operative exploration is
the gold standard for hemodynamically unstable patients,
whereas catheter-based endovascular techniques are
reserved for stable patients who can tolerate transfer to a
remote interventional radiology (IR) suite.
This paradigm has largely been a product of geography
and specialty boundaries. IR suites tend to be remote to
resuscitation personnel and equipment, such as anesthesiology support and blood banking. The option of converting
from an endovascular to an open surgical approach is often
limited by the logistical difculty of transferring patients
back and forth to the operating room (OR) from the IR suite.
Furthermore, in a conventional model of separated IR
and OR suites, there is often little cross-discipline appreciation of the burden of disease. The personnel performing the endovascular procedure may not promptly discern
the physiology of a declining trauma patient and recognize when a truncated procedure or conversion to an open
approach is desirable. Equally, the requestors of the endovascular approach may not appreciate the limitations of
endovascular technology and interventions.
To address this gap, a new concept is starting to emerge,
where operative hemorrhage control can be augmented
with endovascular adjuncts by a single, multidisciplinary
team in one location.1 This is especially useful in certain
anatomically challenging locations, such as noncompressible torso hemorrhage, or to preserve tissue plains to prevent cross contamination between elds, such as protecting
retroperitoneal vascular structures from an intraperitoneal
hollow viscous injury.
optimally managed by endovascular means with an operative approach held in reserve, such as blunt thoracic aorta
injuries (BTAI).
The limitations of a conventional model of nonintegrated IR and OR management can be addressed by a combination of technological and system solutions. The issue of
geography can be addressed by the development of a hybrid
trauma operating room (HTOR) which colocates operative
and endovascular capability. Although a specialist room
such as an HTOR is necessary for integrated care, it is not
sufcient to provide said care without the addition of a
seamlessly integrated service. Personnel who are trained in
both disciplines and the physical workings of the rooms are
required to make the integrated concept work.
4
2,3
Similarly, some injuries may be
This chapter aims to discuss all of these issues and the evidence surrounding HTOR and the clinical teams required to
deliver an integrated trauma vascular service. Much of this
data is borne out of the experience of establishing such a
service at the R Adams Cowley Shock Trauma Center at the
University of Maryland, Baltimore.
Endovascular Suites
PRINCIPLE
The concept of the HTOR takes its origins from vascular
surgery. Once vascular surgeons introduced endovascular
procedures into their practice and training, the integration
of radiological imaging into their ORs became essential.
This has enabled the full spectrum of hybrid operations,
where open surgery (e.g., femoral endarterectomy) can be
combined with endovascular interventions (e.g., iliac stenting) in a single setting.
Trauma surgery is similar to vascular surgery in several
important ways, as it pertains to the HTOR and endovascular interventions: the need for timely intervention, the risk
of signicant blood loss, and pathologies that may traverse
multiple anatomic planes and compartments. For these
reasons and more, endovascular techniques have become
increasingly essential components of trauma patient management.5 For example, endovascular interventions are
being used more and more as adjuncts in the treatment
of pelvic and solid organ hemorrhage, and BTAIs are now
treated almost exclusively endovascularly.
The extension of the hybrid vascular OR concept to
trauma surgery solves the issue of geography by allowing interventions to be delivered in a single location, while
maintaining active resuscitation, and providing the full
spectrum of operative capability. Thus, the HTOR is the optimal destination for most trauma patients with hemorrhage.
ROOM DESIGN
The minimum recommended size for an HTOR is 55 m2,
although many would argue that 70 m2 is a more appropriate gure. An HTOR requires space for the four traditional
zones of an operating room, plus an additional imaging
zone: sterile eld, circulation pathway, moveable equipment, anesthetic, and imaging zone. The imaging zone is
where the imaging system is located when not in operation,
and must not interfere with the movement of patients, personnel, or equipment.
The biggest HTOR design decision relates to the type of
imaging system to be installed. When considering a xed
4,6–8
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imaging system, these can either be oor or ceiling mounted.
Although such a difference may seem small, there are big
implications to this decision. In general, a oor-mounted
system offers the greatest exibility to the HTOR conguration (Fig. 9.1). A oor-mounted system allows for imaging
to occur over a greater oor space, allowing for the bed to be
positioned anywhere within that area. Furthermore, such
a system does not encroach on the ceiling, leaving this free
for the positioning of surgical lights, monitors, and other
such devices.
The drawback of a oor-mounted system is complexity.
Whereas the ability to freely position the OR table and imaging system can accommodate the widest variety of procedures, the long list of procedure-specic congurations can
be overwhelming for the OR staff and lead to confusion
about the room set-up, especially in hospital settings that
lack dedicated endovascular OR staff. This becomes problematic for complex patients, which is discussed in more
detail later.
A ceiling-mounted system consists of a gantry which
allows for an imaging system to travel from a parked location, up and down the length of an OR bed, with limited
side-to-side translation (Fig. 9.2). This type of system permits full body imaging, but the bed position is relatively
xed, limiting the exibility of the room conguration.
Furthermore, as the ceiling is occupied with the gantry, the
location of surgical lighting and monitors can be limited.
The optimal system type is often dependent on local
issues. A oor-mounted system offers the greatest exibility for the room conguration, especially if the room is used
by multiple different specialty groups, such as vascular and
trauma. A ceiling-mounted system can make OR setup
more straightforward by limiting options. As with many
complex clinical issues, planning is key.
ORGANIZATIONAL ISSUES
The organization of an HTOR can be complex due to the
involvement of multiple teams: the scrub team, circulating staff, radiography, as well as the surgical and anesthetic
teams. For straightforward cases, where a single intervention or serial procedures are being performed, leadership can
come from the senior clinician performing the procedure.
When procedures are being done in parallel with multiple
teams, delivery of patient care in the HTOR can become
hampered if clear leadership is not established. In such scenarios, it is the trauma surgeon’s role to step forward and
command the room, as they have the greatest appreciation
for the pathophysiology of the injured patient. However, this
requires the trauma surgeon to also have a working knowledge of the room’s operation, the endovascular techniques at
hand, and all of the clinical factors in play.
The most complex of trauma patients can require the
use of an imaging system, power injection, suction reservoirs, energy devices, cell salvage, and—on rare occasion—
extra-corporeal circuits for venous bypass, renal replacement therapy, or membrane oxygenation. The arrival of all
of this ancillary equipment can rapidly crowd and reduce
the functionality of the room and requires forward planning.
Such scenarios are both a strength and weakness of HTORs. If
managed well, combined open and endovascular techniques
can make a huge difference in the management of complex
injury, but if the room functionality is not optimized, HTORs
can become a liability and hinder effective care.
The planning for these extraordinary cases should ideally happen at the room planning stage, where the most
complex clinical scenarios are simulated and practiced.
This rarely happens in modern health care, so a deliberate
Fig. 9.1 An example of a floor-mounted hybrid trauma operating room
fixed imaging system.
Fig. 9.2 An example of a ceiling-mounted hybrid trauma operating
room fixed imaging system.
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effort must be made by the teams using these rooms to simulate extremes of operation. This reduces the risk of critical
errors during actual patient care.
Many solutions to efcient operations are local, but in
Baltimore, we have developed a number of HTOR procedurespecic congurations. We have identied the most common
room congurations, which consist of three different bed
and imaging system positions. This covers 95% of our operations, and a drawing of these arrangements is prominently
displayed at both the booking desk and in the HTOR, so that
staff are aware of how the room should be congured.
For any case where open and endovascular surgery
is anticipated, we use a larger, double-decker instrument
table. On the lower deck, we place open instruments, and on
the upper deck, long catheters, wires, and sheaths can be
laid out. This allows for the ease of identication of catheter
types and for preparing long devices for deployments, such
as thoracic aortic stent-grafts.
Finally, we have deliberately elected to make endovascular surgery part of our standard scrub teams’ remit, and not
that of a specialist endovascular scrub team. This is to minimize the need for specialty call schedules, but does require
a signicant investment in training. We have yet to master
this program of education but recognize that a single training event is inadequate, and recurrent top-down training
of scrub teams is crucial for sustainable skills in the HTOR.
IMAGING CAPABILITY
Initially, imaging for endovascular interventions consisted
of stand-alone c-arm systems, which use an x-ray tube and
image intensier to produce dynamic images. Although
still common in orthopedic practice, image intensiers have
largely been superseded by at panel detectors (FPD) in vascular surgery, which increase the available image size and
dynamic range, while possibly reducing overall radiation
9–11
dose.
The mounting of FPDs onto a robotic arm has led to the
current generation of xed systems, which are inherently
more complex and capable than mobile c-arms. The resolution is greater and higher energy imaging can be acquired
(Fig. 9.3). As the detector is on a robot arm, the position relative to the OR table is always known, allowing for images
to be stored with their spatial data.
This allows for automation of certain imaging sequences,
such as stepped digital subtraction angiography, where a single bolus of contrast can be tracked down an entire extremity.
Additionally, image-specic bed and detector positions can
be stored and recalled for later use, which has the combined
effect of reducing both radiation and contrast use.
A specic advantage of xed systems is the availability
of cone-beam computed tomography (CBCT), which is an
advanced axial imaging protocol. CBCT obtains volumetric imaging data from a single 200-degree planar rotation
by projecting x-ray beams from a central voltage tube in a
cone-shaped projection through the object and onto a high
resolution two-dimensional FPD.
This is in contrast to multidetector CT (MDCT), which
collects data across multiple one-dimensional detector elements, scanning body cavities across a full 360 degrees in
a helical manner as the patient passes through the detector. CBCT detector panels are smaller and do not move
with respect to the anatomical plane of the patient. The
volume of acquisition is limited to the size of FPD. Additionally, increased radiation scatter creates increased
image artifact and decreased image quality when compared to MDCT.
However, despite these limitations, CBCT has the advantage of providing axial imaging capability in the HTOR,
which we use in two ways. Firstly, to perform a noncontrast
head CBCT on the OR table as a screening test for intracranial space-occupying lesions (Fig. 9.4). Secondly, to further
assess suspected vascular lesions (e.g., pseudoaneurysms,
arterio-venous stulas) in order to plan the strategy for
Fig. 9.3 Images of (A) a pre- and (B) postthoracic endoluminal stent grafting for a blunt thoracic aortic injury.
9 • Endovascular Suites and the Emergency Vascular Service 111
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Unfortunately, hemorrhage is rarely isolated and is always
time-sensitive, rendering the hemostasis-by-consultation
model inadequate for efcacious treatment of trauma
patients. However, as previously mentioned, endovascular hemostasis has become increasingly useful, if not the
norm, for certain injuries, placing denitive injury management under the jurisdiction of other specialties.5 Examples
include the use of interventional radiology to embolize
solid organ vascular injury and vascular surgery to deploy
thoracic stent-grafts for BTAI. In hemorrhaging patients,
time to hemostasis is the metric of utmost importance with
a strong correlation to mortality, as empirically shown in
several studies.
12,13
However, most trauma systems are
designed to expedite delivery of injured patients to the care
of a trauma surgeon but not necessarily the subspecialists
providing denitive hemostasis. Although this horizontal
model is presented as responsible clinical practice, where
everyone has the opportunity to provide expertise, we
believe that this model often provides cumbersome, committee-based care without clear leadership in a setting that
mandates prompt decisiveness.
We have instead adopted a vertically integrated system,
where a subset of our trauma faculty are dual-trained in
vascular and trauma surgery. These individuals provide
a 24/7 hemostasis service as part of a dedicated vascular
trauma service. Under this model, expedited delivery of
injured patients to the trauma surgeon is delivery to denitive hemostasis. This hastens and simplies access to early
Fig. 9.4 Noncontrast cone-beam CT scan of the head demonstrating a
right subdural hematoma.
hemorrhage control, as there are no consultants providing
an ancillary layer of decision-making from a frequently
off-site location. Furthermore, as the patient remains
within the sphere of trauma surgeons who understand the
hemostasis. Both of these applications provide vital diagnostic information in patients otherwise deemed too unstable to undergo imaging prior to the OR. As it is an emerging
technology, the evidence base for the use of CBCT imaging
in trauma is currently sparse; however, this represents fertile ground for future clinical research.
pathophysiology at hand, decision-making becomes more
stream-lined and holistic in the context of the patient’s
injury pattern. For example, complex subselective embolizations are not attempted in hemodynamically unstable
patients—damage control hemostasis and comprehensive
resuscitation in the ICU are prioritized instead.
This service model was adopted at our institution in
Emergency Vascular Service
CLINICAL NEED
The HTOR holds much promise for the judicious application of technology to improve trauma patient outcomes by
integrating endovascular techniques and advanced imaging into active resuscitation and operative management.
This concept is not new, having been around since the early
2000s, but few institutions have capitalized on the potential it offers. The requisite technology is constantly improv-
2015. Prior to adoption, catheter-based therapies were
delivered by an IR service, and the average time to pelvic
embolization was over 5 hours. With the advent of the
new service model, time to pelvic embolization has been
reduced by over an hour to around 3.5 hours.14 Fig. 9.5 is
an illustrative case of the workow efciencies created by
an HTOR that can be achieved in critical trauma patients.
Although this model is neither feasible nor appropriate at
every institution, the virtues of this system of care are still
highly relevant to those providing hemostasis to injured
patients (Box 9.1).
ing and readily available, placing the responsibility for slow
adoption elsewhere.
In our view, the biggest barrier to successful HTOR use is
the system of care built around the trauma service. The most
common model of trauma patient care is that of the classic
in-patient “primary team and consultation service” architecture. A patient is admitted under the primary team and,
as patient pathology extends beyond the scope of their discipline, relevant specialists are consulted for further evaluation
and management. This model of care works well when the
problem at hand is isolated and not time dependent.
PRACTICAL IMPLEMENTATION
The implementation of a vascular trauma service depends
upon numerous local factors that relate to access to personnel, trauma system resources, and patient volume. To justify
a dedicated service, the patient volume has to be adequate.
Although the volume-outcome relationship is well established in surgery, the appropriate threshold for such service
is unknown.15 At Shock Trauma, we see between 6000 and
8000 trauma activations a year and perform roughly 500
112 SECTION 3 • Emerging Technologies and New Approaches to Vascular Trauma and Shock
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MCC
Shocked
Low GCS
Unstable Pelvis
Femur & SFA Injury
MCC
Shocked
Low GCS
Unstable Pelvis
Femur & SFA Injury
Fig. 9.5 Example of a patient pathway using both a conventional and hybrid operating room approach. The patient in question was a motor cyclist
involved in a crash who presented in hemorrhagic shock with a pelvic fracture, femur fracture, and superficial femoral arterial (SFA) injury. In a conventional model of care, the pelvis would have been managed initially in a radiology suite, followed by transfer to the operating room for exploration of the
SFA. Once stabilized, a pan-CT would have been undertaken, followed by the insertion of an intraventricular drain (IVD) for a brain injury and damage
control orthopedics (DC-Ortho). With a hybrid room model of care, all of this imaging can be undertaken in a single location. CBCT, Cone-beam computed tomography; GCS, Glasgow coma score; MCC, major complication and comorbidity; SI, iliosacral.
Stabilize Pelvis
Angioembolization
SI Screw
Hybrid Trauma Operating Room Model of Care
Stabilize Pelvis
Angioembolization
SI Screw
Pan CT Scan
&
Plain Films
CBCT of Head
Plain Imaging
Insertion of IVD
Repeat Head CT
DC-Ortho
DC-Ortho
Insertion of IVD
Repeat Head Imaging
Box 9.1 Top 10 Lessons of Hybrid Trauma Operating
Room Use
1. Use the largest room possible.
2. Train the team who will use the room, in its operation.
3. Engage all of the disciplines that will use the facility (radiology,
vascular, trauma, etc.).
4. If possible, employ trauma surgeons who are also trained vascular
surgeons.
5. Track your case utilization – case number and when do they
happen?
6. Think big – this is a new frontier with enormous room for innovation and study.
7. Be practical – try and consolidate operating sets that include
endovascular tools as well as open.
8. Rehearse specific scenarios – e.g., the management of hemodynamically unstable pelvic fracture.
9. Have a champion for the facility within the nursing and surgical
groups, who can identify and solve problems.
10. Have a specific plan for when the room has technical problems
and an alternative facility is required.
vascular procedures a year. We believe that this is sufcient
volume to justify three dual-trained surgeons, who also
participate in the trauma service.
TRAINING ISSUES
In both the United States and the United Kingdom, vascular
surgery training had followed a pathway of general surgical
training followed by additional vascular training. However,
vascular surgery training is becoming increasingly isolated
from general surgery training, which is the foundation of
trauma surgery. In the United Kingdom, vascular surgery
training is a separate pathway from general surgery, with
minimal overlap. The United States has developed both
integrated programs as well as the classic general surgical followed by vascular fellowship pathway. It is unclear
whether the latter will be continued into the long term.
Other countries training programs are in similar states of
evolution.
The end result is that both vascular- and trauma-interested
trainees are struggling to gain adequate exposure to both
disciplines short of completing fellowship training in both.
This arduous and time-consuming training path has produced predictably few dual-trained practitioners. The lack
of surgeons with sufcient training in trauma and vascular
surgery is of signicant concern for many of the reasons
listed previously. Our favored solution is the creation of a
trauma vascular training module that would consist of a
cross-specialty curriculum that is available to both vascular
and trauma trainees. This is at an early stage of development, although cross-discipline training has been successfully delivered in the United Kingdom via trauma training
interface groups.
Whereas a core curriculum would serve both trauma
and vascular trainees, the emphasis of the training would
need to differ between groups. For example, vascular trainees would need an emphasis on trauma decision-making,
whereas trauma trainees would need to focus on the development of procedure-based skills. This area remains contentious, but a comprehensive strategy to ll this training
gap is badly needed to provide trauma vascular training
sufcient to meet the demand for such providers.
9 • Endovascular Suites and the Emergency Vascular Service 113
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5. Branco BC, DuBose JJ, Zhan LX, etal. Trends and outcomes of endo-
Conclusions
HTORs have the potential to bring advanced imaging and
concomitant open and endovascular procedures to trauma
care. The environment of an HTOR is complex and requires
trained personnel who are familiar with trauma management and HTOR technology. A dedicated service consisting of dual-trained trauma and vascular surgeons is one
way to deliver HTOR operations. Although this model
may not work in all institutional environments, it seems
clear that the synergy of the HTOR combined with capable
staff with a unied decision-making structure optimizes
delivery of hemostasis to injured patients. This system can
provide more expeditious and comprehensive care, leading to improved patient outcomes. It is likely that a specic
trauma-vascular training pathway will be needed in the
future to deliver the care required in HTOR environments in
the quantity in which it is needed.
References
1. Kirkpatrick AW, Vis C, Dubé M, et al. The evolution of a purpose
designed hybrid trauma operating room from the trauma service perspective: The RAPTOR (resuscitation with angiography percutaneous
treatments and operative resuscitations). Injury. 2014;45:1413–
1421.
2. Dubose JJ, Rajani R, Gilani R, et al. Endovascular management of
axillo-subclavian arterial injury: a review of published experience.
Injury. 2012;43:1785–1792.
3. Morrison JJ. Noncompressible torso hemorrhage. Crit Care Clin.
2017;33:37–54.
4. Scalea 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;228:605–610.
vascular therapy in the management of civilian vascular injuries.
J Vasc Surg. 2014;60:1297–1307.
6. Tesoriero RB, Bruns BR, Narayan M, etal. Angiographic embolization
for hemorrhage following pelvic fracture: is it “time” for a paradigm
shift? J Trauma Acute Care Surg. 2017;82:18–24.
7. Adnan SM, Wasicek PJ, Crawford A, et al. Endovascular control of
pelvic hemorrhage: concomitant use of resuscitative endovascular balloon occlusion of the aorta and endovascular intervention.
J Trauma Acute Care Surg. 2019;86:155–159.
8. Bhullar IS, Tepas JJ, Siragusa D, Loper T, Kerwin A, Frykberg ER. To
nearly come full circle: nonoperative management of high-grade IV-V
blunt splenic trauma is safe using a protocol with routine angioembolization. J Trauma Acute Care Surg. 2017;82:657–664.
9. Weis M, Hagelstein C, Diehm T, Schoenberg SO, Neff KW. Comparison
of image quality and radiation dose between an image-intensier system and a newer-generation at-panel detector system — technical
phantom measurements and evaluation of clinical imaging in children. Pediatr Radiol. 2016;46:286–292.
10. Spira D, Kirchner S, Blumenstock G, etal. Therapeutic angiographic
procedures: differences in dose area product between analog image
intensier and digital at panel detector. Acta Radiol. 2016;57:
587–594.
11. Livingstone RS, Chase D, Varghese A, George PV, George OK. Tran-
sition from image intensier to at panel detector in interventional
cardiology: impact of radiation dose. J Med Phys. 2015;40:24–28.
12. Schwartz DA, Medina M, Cotton BA, etal. Are we delivering two stan-
dards of care for pelvic trauma? Availability of angioembolization
after hours and on weekends increases time to therapeutic intervention. J Trauma Acute Care Surg. 2014;76:134–139.
13. Teixeira PGR, Inaba K, Hadjizacharia P, etal. Preventable or poten-
tially preventable mortality at a mature trauma center. J Trauma.
2007;63:1338–1347.
14. Morrison JJ, Madurska MJ, Romagnoli A, etal. A surgical endovas-
cular trauma service increases case volume and decreases time to
hemostasis. Ann Surg. 2019;270:612–619.
15. Nathens AB, Jurkovich GJ, Maier RV, et al. Relationship between
trauma center volume and outcomes. J Am Med Assoc. 2001;285:
1164–1171.
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Stent-Grafts, Coils, and Plugs
DAVID SCHECHTMAN and BRANDON W. PROPPER
Introduction
Hemorrhage is the leading cause of preventable death in
trauma patients, with 96% of those patients dying from noncompressible torso or junctional hemorrhage.1 As endovascular techniques have become more ubiquitous for elective
and emergent vascular cases, there has been a shift toward
endovascular interventions for trauma patients. Angioembolization devices, such as particulate, plug, or coil embolization have been the standard of care for nonoperative
management of hemodynamically normal trauma patients
with solid organ injury and contrast extravasation on imaging. More recently, endovascular stent-grafts have become an
adjunct for control of hemorrhage from axial vessels while
maintaining antegrade ow to distal structures. The acceptance and use of endovascular adjuncts in trauma patients
with arterial injury have been rapidly increasing. Only 3%
of vascular injuries captured in the National Trauma Data
Bank (NTDB) in 2004 were managed with endovascular
therapy. Ten years later, 9% of vascular injuries were being
managed with an endovascular approach.2 It is especially
appealing to use endovascular interventions for injured junctional vessels including subclavian, innominate, axillary, and
iliac arteries, where the morbidity from a high thoracotomy,
median sternotomy, or laparotomy may be avoided. Endovascular interventions may decrease the physiologic penalty
on these patients with polytrauma, avoid the need to enter a
second body cavity, limit vessel exposure with possible damage to adjacent structures or nerves, and possibly spare the
need for general anesthesia. This chapter reviews the current
literature for management of solid organ, pelvic, junctional,
and peripheral vascular injuries. Resuscitative endovascular
balloon occlusion of the aorta (REBOA) and endovascular
management of aortic injuries will be discussed elsewhere in
this textbook.
Principles of Endovascular
Hemorrhage Control
Appropriate patient selection is fundamental to optimizing outcomes in trauma patients undergoing endovascular
interventions for hemorrhage. Patients who are hemodynamically unstable, have diffuse peritonitis, or evidence
of hollow viscus injury should be taken for emergent open
intervention. Patients who are hemodynamically normal
or responders to uid resuscitation may undergo multidetector computed tomography (MDCT) with IV contrast.
Based on the results of imaging, these patients may require
urgent operative intervention, endovascular hemorrhage
control, or observation. The most common indication for
114
endovascular hemorrhage control is evidence of bleeding,
such as active extravasation from a liver, splenic, renal, or
pelvic injury. Other indications include high-grade solid
organ injuries or moderate hemoperitoneum. Additionally,
patients who have an injury to a junctional vessel as evidenced by contrast extravasation, dissection ap, or pseudoaneurysm on imaging may be appropriate for stent-graft
placement, which maintains distal perfusion while excluding the injured segment. For trauma patients managed in
a hybrid operating room, there is the option for concurrent or sequential open and endovascular interventions.
Several considerations that must be addressed when planning endovascular hemorrhage control include vascular
site of access, size of the target vessels, urgency of treatment, blood supply, collaterals, distal perfusion, embolization agent, and potential for migration of occlusive agent.
Age remains another factor of continued debate. There is
minimal data looking at endovascular technology when
deployed in growing vessels. Each of these considerations
will be addressed in the following anatomic sections.
Embolization Agents
The ability to perform catheter-directed mechanical occlusion to a vascular territory or affected parenchyma within
a specic organ has been an adjunct to open surgery for
trauma since the 1970s.3 These catheter-directed techniques have evolved with the expansion of nonoperative management for solid organ injury. Over the past ve
decades, embolization has moved from improvised embolic
agents, such as guidewires, suture material, or autologous
clots to commercially available permanent and temporary
embolic agents (Table 10.1).
TEMPORARY EMBOLIZATION AGENTS
Historically, biologic material such as autologous clots or
soft tissue were used as temporary embolization agents. In
current practice, Gelfoam (Pharmacia & Upjohn, Kalamazoo, MI) is the commercially available option most commonly used in trauma. Gelfoam is an insoluble porous
product made from puried porcine skin, gelatin granules,
and water. Although its use as an embolization agent is
off-label, clinical experience using Gelfoam embolization
extends back to the 1970s.3 During the embolization procedure, a slurry of 1 to 2 mm cubes of Gelfoam sponge
and contrast medium is combined using two syringes with
a three-way stopcock. The contents are alternated between
the two syringes until a homogenous slurry is formed with
the consistency of pudding. This may then be used for
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