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10 • Stent-Grafts, Coils, and Plugs 115
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Table 10.1 Commonly Used Embolization Agents for
Trauma
Embolization
Agent Size Vessel Tips
Temporary
–
Gelfoam Large or
–
Fibrillated
collagen
Permanent
–
Coils Large Microcoils are also available
–
Amplatz
Vascular Plug
–
Particles Small Limited role in trauma
–
Liquid adhesive Small Risk of gluing catheter to vessel
–
Thrombin Small May cause nontarget
small
Small Recanalization of vessels in 2–3
Large Multiple different shapes and
Gelfoam slurry can be used for
large vessels
Gelfoam powder can be used for
small vessels
Recanalization is highly variable
months
Concern for distal embolization if
not anchored or when used for
arteriovenous fistula
lengths available
Can be used to make a backstop
for coils
Tends to cause more ischemia
and necrosis than large vessel
occlusion
wall
Delivery can be challenging with
mixing of glue
embolization
Most commonly used for narrow
neck pseudoaneurysms
embolization of proximal vessels by administering puffs
of the slurry under uoroscopy. The contrast medium in
the slurry allows for visualization of the Gelfoam cast in the
target vessel. Once vessel occlusion is achieved, no additional agent is injected, as it may reux into a more central vessel and cause unintended embolization elsewhere.
Recanalization typically occurs within 3 weeks but may
take up to 3 months. The rate of recanalization is very
unpredictable with Gelfoam. A powdered form of Gelfoam
is also available but has a small diameter of only 10 to
100 µm. This and other small diameter temporary occlusive
such as starch microspheres and brillated collagen tend
to travel more distally, increasing the likelihood of tissue
ischemia, and have limited utility in controlling the injured
larger parenchymal vessels in solid organ trauma.
PERMANENT EMBOLIZATION AGENTS
Permanent embolization agents include coils, plugs, and
particles. The decision of which agent to use is based on
the size of the target vessel, the blood supply to the affected
organ, and if ischemia is desired. In the setting of severe
injury, tissue ischemia should be minimized, which makes
the use of a large number of permanent small-particle
embolic agents less desirable. Polyvinyl alcohol (PVA) particles, tris-acryl gelatin (TAGM), and other types of microspheres, and liquid adhesives or sclerosants are frequently
used for elective vessel ablation and embolization of targeted
tissue. Experience in trauma is currently limited for these
agents, given the delivery systems can be difcult to control,
resulting in unintended distal ischemia or reux into central
vessels delivering embolization agent to other unintended
locations. They are not without advantages, however, as
liquid adhesives function independent of the clotting cascade and can occlude a vessel of a coagulopathic patient. In
the setting of trauma, large-vessel embolic agents are most
commonly used. In this setting, large vessels are considered
any vessel that can be seen on angiography.
Thrombin
Although not commonly used for catheter-directed therapy,
thrombin is used routinely for treatment of pseudoaneurysms at arterial access sites. Thrombin directly acts on
brinogen, converting it to brin monomers thereby allowing
it to cross-link and polymerize. This reaction results in almost
immediate clot production with administration of thrombin.
It is approved as a topical agent, and intraarterial use is offlabel, though there has been extensive experience using this
4–6
agent.
When treating a postcatheterization pseudoaneurysm or posttraumatic peripheral pseudoaneurysm, the target is accessed by direct puncture and a small syringe is used
to administer small aliquots of thrombin until thrombosis of
pseudoaneurysm is achieved. This generally takes less than
1000 units (1 mL of 1000 unit per mL preparation). Extreme
care must be taken when injecting thrombin, as embolization of an unintended target can have severe consequences,
including irreversible ischemia. Although there are reports
of using thrombin to treat posttraumatic solid organ pseudoaneurysms, we do not advocate this practice.
7
Coils
Coils are the most common agent for permanently embolizing large vessels, given their ease of use and availability. They may be used alone or in combination with other
agents that provide scaffolding for coils and prevent distal
embolization. When selecting a coil for embolization, the
size of the target vessel, sheath size, and ow in the target
vessel must be considered. Coils were originally a curled segment of steel guidewire. These needed to be tightly packed
because they were minimally thrombogenic. Now coils have
a thrombogenic adjunct attached, such as nylon ber, polyester, or biologically active material that promotes clotting
and allows for fewer coils needed for the desired effect. Modern coils are made mostly of a platinum alloy, as it is more
malleable than steel and easier to see under uoroscopy. To
achieve their nal conguration, coils may have a built-in
“memory” to which they assume after being released. There
is also a class of surface-modied coils that have a coating,
that when hydrated, expands and congures the wire and
increases the diameter of the coil for more efcient packing. The deployment method is also variable among different coils and commercial brands. Some coils may be pushed
through the deployment catheter, chased with a saline
ush, or advanced on a deployment system from which the
coils must be detached. Detachable coils offer the greatest
control and offer the possibility of repositioning prior to
nal deployment to prevent migration in high-ow systems.
Multiple diameters from 0.010- to 0.052-inch are
available for different applications. The combination of coil
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composition and diameter will determine the stiffness of the
coil, often reported as “softness.” Manufacturers also report
the recommended catheter inner diameter, number of loops,
extended coil length, and coiled diameter. This allows for
appropriate/accurate selection based on vessel size. Correct
sizing is crucial. Stiffer coils should not be oversized more
than 1 mm, whereas softer coils can be oversized by 20% to
30%. Oversizing of coils prevents distal migration, especially
in young patients who are vasoconstricted at the time of the
procedure. The drawback to oversizing is that too large of
a coil can push the delivery catheter backward, leading to
unintended proximal embolization or dislodgement from
the target vessel or failure of the coil to assume its intended
shape. In lower-volume trauma centers or if a dedicated
team is not available 24 hours a day, we favor selecting one
size of macrocoils and microcoils that works with the diagnostic catheters that are pulled for the trauma setup. This
prevents having to nd additional delivery catheters during the procedure. For simplicity, 0.035-inch coils can be
deployed through 4- or 5-Fr diagnostic catheters without
difculty. If smaller vessels are being selected, microcoils
are available that can be deployed through a 0.014- or
0.021-inch lumen (i.e., through a microcatheter). Microcoils may jam or start to form their deployed conguration
in a larger catheter, leading to obstruction of the catheter.
When deploying coils, it is important to ensure the delivery system is well-positioned and stable. This allows for precise deployment without proximal migration of the catheter
and coil. The authors recommend that the catheter being
used for delivery of the coil be placed through a sheath or an
additional catheter that will not be moved during deployment. This gives the operator the ability to remove the entire
deployment catheter without losing purchase. Testing the
stability can be performed by advancing a wire several cm
from the tip of the delivery catheter to ensure the system
remains in place. There are several techniques for embolization. The two most common are the “anchor” technique,
which involves anchoring the end of the coil in a small
branching vessel, with the body of the coil remaining in the
target vessel preventing migration of subsequently placed
coils. The second is the “scaffold” technique, which initially
uses a large coil to create a scaffold so that smaller coils can
subsequently be packed proximally to form a dense coil nest.
If no branching vessel, is present, or it is a high-ow system and there is concern for embolization of the initial coil,
a plug device can be deployed. Detachable coils afford the
operator greater control/accuracy for deployment. These
systems allow for advancement, retraction, and repositioning of the coil before it is nally released from the delivery
wire. This can be an advantage when in a high-ow system
or if an arterial venous stula (AVF) is present that would
allow for a misplaced coil to migrate to the venous system
and cause a pulmonary embolus. Detachable coils are
released by an electrical current, a mechanical switch, or a
wire to break the bond of the coil to the deployment device.
Plugs
When no branching vessel is present to place an “anchor”
coil, or in a high-ow system where there is concern
for embolization of the initial coil, a plug device can
be deployed. A commerically available vascular plug is
Amplatzer Vascular Plugs (AVPs) (St. Jude Medical, AGA
Medical Corporation). AVPs are a series of four different
generations of self-expanding occlusive devices made of
nitinol mesh available in several shapes so that embolization/occlusion may be achieved in a variety of target vessels. These devices are available in a variety of diameters.
There are four distinct plugs. The AVP, AVP II, AVP III, and
AVP 4 have different numbers of segments, sizes of delivery catheter, and deployed sizes ranging from 3 to 22 mm.
When choosing a device, it should be oversized by 30% to
50% to the target vessel diameter. The AVPs are deployed
by unsheathing and can be withdrawn into the sheath for
repositioning if necessary. Once in position, the device is
detached by unscrewing the plug device from the delivery
system. The large nature of AVPs makes it ideal for large
vessels such as the proximal splenic artery or for AVF, where
there is concern for embolizing into the systemic system. The
size and stiffness of the system does make it challenging to
deploy after an acute angle or in a tortuous vessel.
Stents-Grafts
When the injured or target vessel provides inline ow to a
vital structure without good collateral circulation, occlusion with an embolization device is often not a viable option.
In many of these scenarios, such as with an injured peripheral vessel, there is minimal morbidity associated with an
open surgical approach to primary repair, or placement of
an interposition or bypass graft. In contrast, open surgical
repair of injured vessels in the chest, abdomen, or pelvis is
associated with a greater degree of morbidity, which may
be particularly precarious in severely injured patients with
compromised physiology. As such, the use of catheter-based
reconstructive options such as covered stents (i.e., stentgrafts) to manage vascular disruption in these anatomic
locations is often benecial. Deployed inside of the injured
vessel, covered stents or stent-grafts exclude or “seal” the
vascular disruption, while maintaining antegrade ow in
the affected artery or vein. Historically, stents could be modied by the surgeon by using vein to make a covered stent
from a bare metal stent. Currently, there is a wide range
of commercially available balloon-expandable and selfexpanding covered stents that can be used for the management of vascular trauma.
BALLOON-EXPANDING STENTS
Balloon-expandable stents are stored in a crimped state in
the delivery catheter and are expanded by inating a balloon within the stent, expanding it to the vessel diameter or
slightly larger. These stents are often stainless steel and have
higher radial stiffness. Radial stiffness describes how much
the diameter of the stent is reduced by a certain amount of
external pressure. Balloon-expanding stents have greater
degrees of radial stiffness or “hoop strength” and therefore require a higher amount of force to buckle. However,
balloon-expandable stents often lack the flexibility or
elasticity to recover once buckling occurs.8 The deployment
of balloon-expandable stents tends be more precise than
self-expanding stents, though the technology for accurately
deploying all types of stents continues to improve. The
higher radial stiffness of balloon-expandable stents tends to
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be ideal for preventing migration, and this feature coupled
with the precise delivery capability make them preferred
for placement in the ostia of large branch vessels. Due to
their relative inexibility, balloon-expandable stents are less
commonly used in tortuous vessel or in vessels located in
highly mobile anatomic areas (e.g., behind the knee).
SELF-EXPANDING STENTS
Self-expanding stents are manufactured at the desired size
and are then collapsed or constrained using a covering
delivery device. When the constraining or covering device
is removed, the stent expands and reconforms to its original
manufactured shape. This physical property is accomplished
through a spring mechanism inherent to the structure of
the stent, or by using a temperature-driven method using
the “shape memory” of the metal.9 Self-expanding stents
are most commonly made from the metallic alloy called
Nitinol, and they tend to have less radial stiffness than balloon-expandable stents. However, self-expanding Nitinol
stents or stent-grafts have greater degrees of elasticity to
recover their original conguration when the external force
is removed. These qualities make self-expanding stents ideal
to use in tortuous or exible anatomic areas, such as those
crossing joints, or in areas of movement, such as the cervical
vessels. An additional consideration is accurate placement
or deployment of the self-expanding stents. As it resumes
the manufactured shape upon removal of the covering or
constraining deployment device, self-expanding stents may
migrate or “jump,” thus making their precise placement
more challenging. Newer deployment systems used with
the most modern self-expanding stents or stent-grafts have
improved the ability to accurately land the proximal extent
of these devices in the desired location.
Management of Solid Organ Injury
Starting in the 1980s, there was a push for the nonoperative management of intraabdominal solid organ injuries in
patients who were hemodynamically stable on presentation
or who responded appropriately to resuscitation.
protocols for nonoperative management included catheterbased contrast arteriography for hemodynamically stable
patients with an injury to the spleen, kidney, or liver on CT
imaging. If extravasation was observed at the time of arteriography, an embolic agent could be deployed to increase
the likelihood of splenic salvage or the nonoperative management of splenic injury (versus open splenectomy). The
management of solid organ injury has evolved as newer
CT imaging technology provides quick, contrast-enhanced
imaging during the immediate diagnostic phase of care.
Advances in diagnostic imaging allow for a more selective
use of catheter-based arteriography in certain patients with
extravasation, high-grade injuries, and/or hemoperitoneum on the initial CT scan (Table 10.2).
12
SPLENIC INJURY
The spleen is the second most commonly injured abdominal organ but the most common source of massive bleeding
in blunt trauma.
13–15
Nonoperative management of splenic
10,11
Initial
injuries in hemodynamically normal patients has been pursued as a standard of care since the 1990s, with a goal of
preserving splenic function and lowering the risk of postsplenectomy spesis.16 Although nonoperative management
is well-accepted, the optimal application of splenic angioembolization (SAE) remains unsettled.
12,16,17
The Eastern Association for the Surgery of Trauma
(EAST) guideline on splenic trauma recommends angiography for patients with Association for the Surgery of Trauma
(AAST) grade III or higher injury, contrast extravasation,
moderate hemoperitoneum, or ongoing splenic bleeding.12
This guideline is in agreement with a large metaanalysis
showing a decrease in the failure of nonoperative management when SAE was used as an adjunct in patients with
grade IV or V injuries. In this report, SAE had a failure rate
of 12% for grade IV or V injuries, whereas nonoperative
management alone failed 50% of the time. The benecial
effect of SAE was not observed in the lower, grade I to III
groups, although there was likely selection bias, as many of
these patients had a separate indication for arteriography
and/or embolization.16 The authors’ practice is to perform
catheter-directed arteriography for stable patients or transient responders with extravasation on initial CT imaging
(Fig. 10.1A), or those with a moderate hemoperitoneum
and a grade IV or higher splenic injury. Embolization is only
performed at the time of arteriography if there is evidence
of bleeding (see Fig. 10.1B), pseudoaneurysm, or a concern
for secondary rupture (Fig. 10.2).
Once the decision is made to proceed with SAE, the next
step is selecting where, along the course of the splenic
artery, embolization should occur. Anatomically, the
options include the proximal splenic artery, distal arteries
near or in the hilum of the spleen, or a combined proximal
and distal approach. There is no consensus as to the optimal technique, but there are recognized patterns of success
and failure.
18,19
For example, proximal SAE is likely a better approach in patients with multiple areas of extravasation, a high risk of secondary splenic rupture, or as a rapid
intervention if the patient has hemodynamic deterioration
during the procedure. Proximal embolization also allows
collateral ow from the short gastric, gastroepiploic, and
pancreatic arteries to maintain some degree of splenic perfusion and function. In the case of proximal, large-vessel
embolization, the driving pressure of the main artery is
attenuated, which promotes hemostasis and decreases the
rate of splenic rupture, while allowing for some degree of
splenic function via small-vessel collateral ow.
The splenic artery is 5.6 mm ± 1.3 mm for both adult men
and women, and embolization is best achieved with appropriately sized coils or plugs.20 Distal embolization is indicated
in patients with a single or several small parenchymal injuries. This allows for preservation of antegrade ow from
the splenic artery to the remainder of the spleen and preservation of functional parenchyma. Distal embolization has
higher rates of infarction, abscess, and cyst formation.18 The
authors do not recommend the technique of distal subselective embolization followed by proximal embolization, with or
without use of a particulate embolization agent between the
coils, except in patients who are rebleeding after distal embolization and in whom the proximal embolization is being
performed as a salvage maneuver. Combining proximal and
distal embolization has the highest complication rate, with
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Table 10.2 AAST Organ Injury Scale Imaging Criteria (CT Findings)
Injury
Grade Spleen Liver Kidney
I
II
III
IV
V
AAST, American Association for the Surgery of Trauma; CT, computed tomography.
–
Subcapsular hematoma <10%
surface area
–
Parenchymal laceration <1 cm
depth
–
Capsular tear
–
Subcapsular hematoma
10%–50% surface area; intraparenchymal hematoma <5 cm
–
Parenchymal laceration 1–3 cm
–
Subcapsular hematoma >50%
surface area; ruptured subcapsular or intraparenchymal hematoma ≥5 cm
–
Parenchymal laceration >3 cm
depth
–
Any injury in the presence of
a splenic vascular injury or
active bleeding confined within
splenic capsule
–
Parenchymal laceration
involving segmental or hilar
vessels producing >25%
devascularization
–
Any injury in the presence of
splenic vascular injury with
active bleeding extending
beyond the spleen into the
peritoneum
–
Shattered spleen
–
Subcapsular hematoma <10% surface area
–
Parenchymal laceration <1 cm in depth
–
Subcapsular hematoma 10%–50% surface
area; intraparenchymal hematoma <10 cm
in diameter
–
Laceration 1–3 cm in depth and ≤10 cm
length
–
Subcapsular hematoma >50% surface
area; ruptured subcapsular or parenchymal
hematoma
–
Intraparenchymal hematoma >10 cm
–
Laceration >3 cm depth
–
Any injury in the presence of a liver vascular injury or active bleeding contained
within liver parenchyma
–
Parenchymal disruption involving
25%–75% of a hepatic lobe
–
Active bleeding extending beyond the liver
parenchyma into the peritoneum
–
Parenchymal disruption >75% of hepatic
lobe
–
Juxtahepatic venous injury to include
retrohepatic vena cava and central major
hepatic veins
–
Subcapsular hematoma and/or parenchymal
contusion without laceration
–
Perirenal hematoma confined to Gerota fascia
–
Renal parenchymal laceration ≤1 cm depth without urinary extravasation
–
Renal parenchymal laceration >1 cm depth
without collecting system rupture or urinary
extravasation
–
Any injury in the presence of a kidney vascular
injury or active bleeding contained within Gerota
fascia
–
Parenchymal laceration extending into urinary collecting system with urinary extravasation
–
Renal pelvis laceration and/or complete ureteropelvic disruption
–
Segmental renal vein or artery injury
–
Active bleeding beyond Gerota fascia into the
retroperitoneum or peritoneum
–
Segmental or complete kidney infarction(s) due to
vessel thrombosis without active bleeding
–
Main renal artery or vein laceration or avulsion of
hilum
–
Devascularized kidney with active bleeding
–
Shattered kidney with loss of identifiable parenchymal renal anatomy
Fig. 10.1 (A) High-grade splenic injury with active arterial extravasation seen on CTA. (B) The same patient with contrast extravasation seen on
angiography.
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Fig. 10.3 High-grade liver injury involving the medium-sized ves-
Fig. 10.2 Delayed splenic rupture after a high-grade blunt splenic injury
that was not managed with endovascular adjuncts.
sels. Extravasation seen on CTA and was subsequently treated with
embolization.
embolization is performed, it is not uncommon to see
up to one in three patients having infarction, abscess, or
cyst.21 Other complications include splenic atrophy, postprocedure bleeding, pleural effusion, and splenic abscess.22 The
authors favor the use of coils over particulate in most cases
of splenic embolization, as there tends to be less reaction and
pain with coils alone. Additionally, if proximal coils are used
to attenuate antegrade ow, the operator should expect to
see a pseudoaneurysm on subsequent imaging with CT and
should have a plan with that in mind.
revascularization from distal branches. For this reason,
if super-selective embolization distal and proximal to the
injury with microcoils is not possible, Gelfoam may be
needed to control the distal bleeding and coil embolization
used to control the proximal or inow artery. Embolization
of the liver is generally well tolerated, given the dual arterial and portal venous blood supply. With this in mind, Gelfoam or particle embolization should be avoided proximal
or just distal to the cystic artery, as there is concern for
reuxing of the agent into the cystic artery causing infarc-
LIVER
The liver is the most commonly injured intraabdominal
organ, and severe liver injury carries mortality rates of up
to 40%.
has been a standard method of treatment since a 1996
review of 13 level I trauma centers in the United States
reported high rates of success with this approach.24 As with
splenic injury, patients who are hemodynamically unstable
with evidence of severe liver injury or those who have diffuse peritonitis should undergo surgical exploration. In
the early days of nonoperative management, high-grade
injuries (AAST IV or V), altered neurologic status, contrast
extravasation on CT, moderate- to large-volume hemoperitoneum, or age greater than 55 were seen as an indication for operative exploration.
still contribute to decision making, none are considered a
contraindication to nonoperative management, and over
85% of liver trauma is now managed without open operative intervention.
endovascular embolization after open surgical intervention,
as a number of patients who undergo damage control laparotomy for hepatic injury continue to have bleeding after
leaving the operating room.
having an AAST grade I or II injury, with the average
liver grade of patients undergoing angioembolization
being 3.7.29 These tend to be parenchymal injuries involving small or medium branches (Fig. 10.3). If proximal
14,15,23
Nonoperative management of liver injuries
24,25
Although these factors
26,27
At least one study describes the use of
28
The majority of livery injuries are minor, with 68%
tion of the gallbladder. Although the common or proper
hepatic arteries may be embolized, stent-graft placement
to exclude the injury is often a better option that maintains inline arterial ow to the liver parenchyma.
There should be a high index of suspicion for a concomitant venous injury in patients with high-grade liver injury
who require continued uid resuscitation after embolization.
These injuries are often difcult to visualize on angiography and may require operative exploration and packing. For
patients who have undergone successful embolization of liver
bleeding, there are several mid- and long-term complications
which need to be considered, if not anticipated. These include
hepatic necrosis, abscess formation (Fig. 10.4), gallblad der
infarction, bile leak, and hemobilia (i.e., bleeding into the
bile system) after a combined ductal and vascular injury.
Although abscess and necrosis are most common, the rate
attributable to the embolization procedure itself is not clear,
as the liver injury alone contributes to a signicant portion of
this complication. With no intervention, these complication
rates have ranged from 5% to 24% for simple nonoperative
management and from 0 to 40% in patient’s managed with
angiography.
23,29
RENAL
The kidneys are the most commonly injured genitourinary
organ in trauma.
selective nonoperative management of blunt renal injury
is well-tolerated, and the majority of all kidney injuries are
14,15,30
Similar to other solid organ injuries,
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traversed with a wire. If the area of injury is able to be
crossed, a balloon-expandable stent-graft can be deployed.
In these cases, balloon-expandable stents are preferred
because of their radial force and because they tend to be
deployed with greater degrees of control and precision. Following renal stent-grafting, thrombosis of the repair can
occur resulting in kidney loss.37 If concomitant injuries do
not preclude, it is the authors’ practice to give the patient an
antiplatelet medication at the time of the procedure, and for
a number of weeks afterwards as a way to assist stent-graft
patency. However, successful stent patency has also been
reported in patients who are unable to receive antiplatelet
agents or coagulation.38 Complications related to endovascular management of renal trauma include impaired renal
function, urinoma, persistent hematuria, abscess, renal
failure, AVF, pseudoaneurysm, and urinary tract infection.
Fig. 10.4 Liver abscess that occurred after angioembolization of
medium sized hepatic arteries for high-grade blunt liver injury.
The rates of complication between patients undergoing
nonoperative management with and without angioembolization have been reported to be similar.
32
managed nonoperatively. Patient selection for nonoperative
management is similar to other intraabdominal solid organ
injuries, and is based on the patient’s physiology, associated
injuries, and anatomy. One unique factor of the kidney is its
retroperitoneal location, which makes the nding of hemoperitoneum less common, as Gerota fascia may tamponade bleeding from the injury. The majority of blunt renal
injuries are the result of sudden deceleration which applies
sheer forces to the renal pelvis or pedicle, as it is the only
xed attachment point of the kidney.
Renal injuries that are amenable to angioembolization include parenchymal injury with arterial contrast
extravasation, pseudoaneurysms, arteriovenous stulas,
and nonself-limiting gross hematuria.31 Successful use of
embolization in the setting of blunt kidney injury ranges
from 63% to 100%.
not mandate operative intervention, and a second attempt
may prove successful.
31–34
Initial failure of embolization does
32,35
If embolization of the injury is to
be undertaken, a super-selective approach should be undertaken to limit scarring and to preserve renal function. The
use of microcoils is preferred in these cases, as embolic
agents are prone to reux into neighboring arteries and
adversely affect uninjured parts of the kidney. If an embolization or sclerosing agent is to be used, we recommend using
a balloon catheter to deliver the agent, as it can be inated
to occlude the injured branch and prevent reux of material. Blind angioembolization or more proximal embolization should be avoided, as this will result in necrosis of the
renal parenchyma and other complications.36 If during the
endovascular procedure the patient becomes unstable or the
injury is deemed to require operative intervention, balloon
occlusion of the main renal artery is a useful maneuver to
reduce bleeding until open surgical control can be achieved.
Injuries to the renal artery or vein in hemodynamically
stable patients may be managed with revascularization
maneuvers including placement of a covered stent across
the area of vascular disruption to preserve ow to the renal
parenchyma. Unlike other solid organs of the abdomen,
there is no collateral ow to the kidney and the organ does
not tolerate proximal, large-vessel embolization/occlusion.
In order to place a covered stent in the main renal artery,
the injured portion of the vessel must be able to be safely
POSTINTERVENTION MANAGEMENT
After successful embolization of an abdominal solid organ
injury, close monitoring is necessary to assess for rebleeding. Up to 13% of patients will require either additional
embolization or splenectomy after initial SAE for splenic
trauma.39 Similar rates exist for patients undergoing embolization for liver or renal injury. No consensus exists at this
time for a monitoring algorithm after the procedure. We recommend trending hemoglobin/hematocrit every 6 to 8 hours
and monitoring in an ICU for at least the rst 24 hours after
the procedure. Once discharged from the ICU, these patients
remain in the hospital for a minimum length of stay of at least
3 days while we continue to trend hemoglobin and hematocrit at less frequent intervals. There is no evidence to suggest
pharmacologic prophylaxis for venous thromboembolism
(VTE) increases failure of nonoperative management of
solid organ injuries. We initiate VTE prophylaxis after two
consecutive stable hemoglobin checks and if there is no
other evidence of bleeding.
12,40
Repeat imaging during the
patient’s hospital course should be guided by clinical status.
Some groups advocate for reimaging of the solid organ 48
to 72 hours after the injury to assess for latent pseudoaneurysms or AVF that may benet from intervention, but this
practice is clinician and institution-dependent.
Pelvic Bleeding
Pelvic injuries with associated bleeding present a challenge for surgeons and the resuscitation team. It takes a
signicant amount of energy to cause a pelvic fracture,
and as such, these injuries are often associated with other
life-threatening ndings requiring acute intervention. Of
these patients, 15% will have an associated injury in the
chest, 32% an intraabdominal injury, and 40% a long
bone fracture.41 A multiplicity of injuries can confound
the initial workup and management of these critically ill
patients, whose risk of death is as high as 40%.42 A relatively small proportion of bleeding associated with pelvic fractures is secondary to an arterial source (15%). In
contrast, venous or osseous sources are responsible for up
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to 85% of the bleeding that occurs in conjunction with
this injury pattern.42 When arterial bleeding is present,
it is most commonly from a named branch vessel of the
internal iliac artery, such as the superior gluteal, internal
pudendal, lateral sacral, iliolumbar, or inferior gluteal.
Arterial bleeding is present in more than 60% of patients
who die from pelvic fractures.43 It is important to remember that the volume of the pelvis can increase by 20% with
a 5-cm pubic diastasis, allowing for potentially fatal hemorrhage in what is normally a conned space.
44
As with the management of other injury patterns,
patient selection is important to optimize success. Hemodynamically unstable patients should be initially managed
by advanced trauma life support guidelines including pelvic x-ray, external reduction of the pelvic fracture using a
binder or sheet, and performance of a focused assessment
with sonography for trauma (FAST) examination to assess
for hemoperitoneum. If the patient is hypotensive, and
there is no hemoperitoneum, the patient should undergo
arteriography if the capability exists in that given medical
center. In settings where these capabilities are not present or there is a signicant hemoperitoneum, the patient
should undergo preperitoneal packing and laparotomy. If
hemorrhage continues with preperitoneal packing, angiography/angioembolization may be used as an adjunct for
hemostasis after open surgery (Fig. 10.5).
If on initial presentation the patient is hemodynamically normal, he or she may undergo the usual trauma
evaluation including contrast-enhanced CT imaging of
the abdomen and pelvis, with a delayed phase to assess for
bleeding and injuries to pelvic or genitourinary structures.
If contrast extravasation is identied on CT imaging, diagnostic and potentially therapeutic arteriography should
be performed. This should be undertaken as quickly as
possible, as each hour of delay has been shown to be associated with increased mortality.
45
If obtained prior to the pelvic arteriogram, CT imaging
can direct or help improve the efciency of the catheterbased intervention. It is important to understand the vascular anatomy of the pelvis, including collateral pathways
that may contribute to bleeding. These include the contralateral internal iliac, lumbar, inferior mesenteric, inferior
epigastric, medial and lateral circumex, median sacral,
and deep circumex iliac arteries. This anatomy is variable,
and beginning the procedure with a pelvic arteriogram is
often benecial if there has been no preceding CT imaging.
Next, selective catheterization of the internal iliac artery is
performed and digital subtraction angiography obtained to
delineate the vascular anatomy. Once the bleeding source is
localized, embolization may be performed.
In these cases, selective embolization of the bleeding
arteries is ideal and can be achieved using either coil embolization which causes permanent occlusion or a temporary
agent such as Gelfoam. Angioembolization in the pelvis is
a risk factor for orthopedic interventions to the pelvic ring
to have higher complications rates.46 However, in hemodynamically unstable patients, less selective embolization is
often employed, including Gelfoam, which can be used as
an embolic agent for larger portions of the internal iliac
artery circulation. Because of extensive collateral circulation, it is often necessary to complete embolization of vessels in the contralateral internal iliac system to achieve a
more complete hemostasis. If the patient continues to have
evidence of bleeding after initial selective embolization
maneuvers, occlusion of bilateral internal iliac arteries may
be performed in an attempt to decrease ow (i.e., pressure
head) through the system and allow for tamponade of small
arterial and venous bleeding.
Fig. 10.5 (A) Patient with active extravasation of contrast from the mid left internal iliac artery that was not controlled with per-peritoneal packing
(retractor and radio-opaque laparotomy pads seen in negative on digital subtraction angiography). Laparotomy was performed and proximal control
of distal aorta (zone III) was performed while awaiting endovascular support. (B) Image after embolization without additional extravasation.
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In certain hemodynamically unstable patients, when surgical xation of the pelvic fracture is necessary, temporary
balloon occlusion of the internal iliac arteries may be performed to slow bleeding. Denitive angioembolization may
then be performed after the anatomy of the bony pelvis is
restored. These interventions are not without complications. The most common complications are at the vascular
access site or involve contrast-induced nephropathy. Complications related to the embolization include pelvic infection, poor bone healing, skin sloughing, skin or muscle
necrosis, rectal ischemia, and neurologic effects on the
bladder and/or sexual function.
43,44,47
Cervical Vascular Injury
Trauma to vessels at the thoracic outlet and in the cervical
region may be preferentially managed with endovascular
techniques depending on the size of the vessel and its accessibility via an open surgical approach. In hemodynamically
stable patients with penetrating neck injuries or a concern
for blunt cerebral injury, the workup begins with contrastenhanced CT imaging to assess for extravasation, vessel disruption, dissection, intimal ap, pseudoaneurysm, AVF, or
thrombosis. Once the defect is identied in this scenario, the
choice of management is based on the anatomic location of
the injury. The location of neck injuries is described in one
of three zones reported by Monson et al. in 1969. Zone I is
below the cricoid cartilage, zone II is located between the cricoid cartilage and the angle of the mandible, and zone III is
above the angle of the mandible.48 Zone II injuries are readily
accessible via a cervical incision, which has the added benet of direct visual inspection of adjacent aerodigestive tract
structures. This accessibility and the low morbidity of a cervical incision make open repair the approach of choice for zone
II injuries. Patients with hard signs of vascular injury including expanding hematoma, pulsatile bleeding, neurologic
changes, or loss of distal pulse require operative exploration
irrespective of the zone of injury. Although not the primary
therapy, endovascular adjuncts such as proximal balloon
occlusion may be used to gain temporary bleeding control of
the great vessels or at the skull base.
In patients with proximal zone I injuries, the area of
injury may be accessible through a cervical incision. However, many patients with zone I injuries will need a median
sternotomy to obtain proximal control to perform a repair. If
the patient’s physiology permits and there are endovascular
capabilities, a transfemoral approach with balloon occlusion
using a compliant balloon may spare the patient the morbidity of a thoracic exposure. Once the balloon is in place, angiography may be performed to locate the injury for surgical
planning. If there is adequate proximal vessel length after
open exposure, the balloon may be replaced with a clamp.
If proximal length is not adequate, the balloon can be maintained for proximal control during the repair.
Zone III injuries located above the angle of the mandible
are often difcult to expose and control. The use of selfexpanding covered stents has been described to treat acute
injuries that are not amenable to open exposure.49 Zone III
is also the most common site for blunt carotid artery injury.
Blunt cerebrovascular injury (BCVI) occurs in 3% of traumas and is the result of hyperextension or hyperexion
of the neck in the setting of a high-speed deceleration
injury.50 The Denver group proposed screening criteria in
the 1990s and revised them in 2012. The new guidelines
contain indication for screening as well as a grading system (Table 10.3). The mainstay of treatment for low-grade
BCVI is anticoagulation. For patients who are not eligible
for anticoagulation due to other injuries, either bare or covered stents have been used as an alternate therapy for these
injures.51 Pseudoaneurysms may result from blunt or penetrating trauma. When present, they can be treated using
endovascular coiling or exclusion with a covered stent.
52–54
Studies reporting the use of stents for BCVI have reported
Table 10.3 Blunt Cerebral Vascular Injury (BCVI)
Denver Screening Criteria for BCVI Denver Grading Scale for BCVI
Signs/Symptoms of BCVI
Arterial hemorrhage
Cervical bruit
Expanding cervical hematoma
Focal neurologic deficit
Neurologic examination incongruous with CT scan findings
Stroke on secondary CT scan
Risk factors for BCVI
High-energy transfer mechanism with:
– LeForte II or III fracture
– Cervical-spine fracture patterns: subluxation, fractures
extending into the transverse foramen, and fractures of
C1–C3
– Basilar skull fracture with carotid canal involvement
– Petrous bone fracture
– Diffuse axonal injury with GCS score <6
– Near hanging with anoxic brain injury
Adapted from Burlew et al. Blunt cerebrovascular injuries: redefining screening criteria in the era of noninvasive diagnosis. J Trauma Acute Care Surg.
2012;72(2):330–337.
Grade I: Irregularity of the vessel wall or a dissection/intramural hematoma with
<25% luminal stenosis
Grade II: Intraluminal thrombus or raised intimal flap is visualized, or dissection/
intramural hematoma with 25% or more luminal narrowing
Grade III: Pseudoaneurysm
Grade IV: Vessel occlusion
Grade V: Vessel transection
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a stroke rate of 0% to 5%, but the rate of cerebrovascular
events may be higher given the paucity of quality long-term
follow-up data with this injury pattern.
54,55
Vertebral arteries may also be injured from penetrating
or blunt trauma resulting in free hemorrhage, pseudoaneurysm, AVF, dissection, or occlusion. Encompassing only 0.5%
of vascular trauma, the rarity of injury and the relationship
to the cervical spine can make treatment a challenge.56 The
rst portion of the vertebral artery may be readily accessible
via open exposure, whereas the second and third portions
are within the cervical spine foramina and skull base, respectively, making endovascular intervention preferred. In a retrospective review of 101 patients with extracranial vertebral
artery injuries (95 of which were penetrating injuries), 81
patients were treated with endovascular intervention, with
the majority being coil embolization. Of these, six patients
had failed intervention and required open surgery. Primary
open surgery was performed in 20 patients, with 10 of those
patients subsequently undergoing endovascular procedure
for bleeding or AVF.57 Embolization of the vertebral arteries
has a complication rate of 0% to 5%, with the most feared
complication being stoke, reported at less than 1%.
57
Junctional Vascular Trauma
Junctional trauma includes injury to vessels in the axillosubclavian and iliac/femoral regions. Injuries to these
vessels are not amenable to tourniquet control and are difcult, if not impossible, to control with direct pressure. As
such, patients with these injuries are at high risk of bleeding to death.58 The challenge of managing injuries in the
thoracic outlet is obtaining proximal control. Using the
open surgical approach requires a median sternotomy to
control the innominate and right subclavian arteries or
high, left anterolateral thoracotomy with or without clavicular resection for left subclavian artery. Even with the
associated morbidity of exposure, open surgery remains
a standard for hemodynamically unstable patients with
junctional hemorrhage.
outlet junctional trauma is less problematic for the general
or vascular surgeon, as it is accomplished via laparotomy.
Penetrating injury to the axillo-subclavian vasculature
often has the added morbidity associated with injury to the
brachial plexus that runs adjacent to the artery and vein.
Blunt injury to this region is similarly challenging due to the
shear and/or traction forces applied to the vessels and nerve
bundles. When evaluating vascular injury in the axillosubclavian (i.e., junctional) region, it is especially important
to consider concomitant nerve, aero-digestive tract, boney,
or lymphatic injury.61 In stable patients, CT angiography
can aid in identifying the location and extent of vascular
injury. Once the area of injury is identied, an operative
plan can be formulated based on accessibility of the vessel
and if balloon proximal control is needed to prevent exsanguination. One advantage of the hybrid operating room is
being able to place a proximal occlusion balloon to provide
hemostasis while open exposure of the vessel is obtained by
a second team for repair. This allows for an arteriogram to
be performed under a controlled setting, preventing exsanguination of the whole area of injury, to identify the injured
segment of the vessel. Once the injury is identied, it can
59,60
Proximal control for pelvic
safely be repaired endovascularly with a covered stent or
open if easily accessible. This hybrid approach reduces the
morbidity of an open repair for this pattern of injury.
62
While experience using stent-grafts for axillo-subclavian
pseudoaneurysm, iatrogenic injury, and trauma extends
back to the 1990s, its overall use in trauma remains
59,61,63
low.
In 2012, it was reported that 9% of subclavian
arterial trauma cases were managed using endovascular
techniques.64 In a 2017 multicenter trial, 17% of patients
with axillo-subclavian injuries were treated with endovascular intervention alone, and an additional 6% had hybrid
procedures.59 As hybrid operating rooms become more
common, we anticipate an increasing role for endovascular
therapy in the management of junctional vascular injuries.
This may assist in both proximal and denitive control of
the injury. At this time, endovascular intervention offers
hope of decreasing the morbidity of a thoracotomy or sternotomy in patients appropriate for endovascular hemorrhage control. Postprocedure, there are reports of using
anticoagulation or antiplatelet agents over variable time
periods to maintain stent patency.55 No consensus exists at
this time, and it is our practice to use antiplatelet therapy
with 81 mg aspirin daily for life in these patients.
Lower extremity junctional trauma often requires
intraabdominal proximal control which is easily obtained
by vascular or general surgeons at the infrarenal aorta or
through endovascular techniques such as REBOA. With
this injury pattern, the transabdominal approach is often
used, as there is concern for concomitant intraabdominal
injuries. If the injury is more distal, a single iliac artery may
be isolated with a retroperitoneal dissection via hockey stick
incision or bilateral iliac vessels may be exposed via midline extraperitoneal incision.65 An exception is in military
trauma, as these patients are wearing body armor that may
protect from intraabdominal injuries, while still leaving the
wearer susceptible to lower extremity junctional injury.
58
Extremity Vascular Trauma
Extremity vessel trauma is almost always amenable to control
with manual pressure or a tourniquet. A proximal tourniquet
is generally easily placed for the majority of these injuries and
may be replaced with a pneumatic tourniquet on arrival to
the hospital. This allows full workup of life-threatening torso,
junctional, thoracic, abdominal, or pelvic sources of bleeding
while the tourniquet is in place. Extremity vascular injuries
causing exsanguination or profound ischemia should be managed in an open fashion. There is a limited role for endovascular interventions for extremity vascular trauma. Delayed
sequalae from extremity vascular trauma such as pseudoaneurysms or AVF may be managed with open, endovascular,
or, in the case of pseudoaneurysms with a small neck, with
ultrasound-guided thrombin injection.
References
1. Callcut RA, Kornblith LZ, Conroy AS, et al. The why and how our
trauma patients die: a prospective multicenter Western Trauma Association study. J Trauma Acute Care Surg. 2019;86(5):864–870.
2. Romagnoli AN, Zeeshan M, Joseph B, Brenner ML. Utilization of
endovascular and open surgical repair in the United States: a 10-year
analysis of the National Trauma Databank (NTDB). Am J Surg.
2019;218(6):1128–1133.
124 SECTION 3 • Emerging Technologies and New Approaches to Vascular Trauma and Shock
https://t.me/medicina_free
3. Bass EM, Crosier JH. Percutaneous control of post-traumatic hepatic
hemorrhage by Gelfoam embolization. J Trauma. 1977;17(1):61–63.
4. Taylor BS, Rhee RY, Muluk S, et al. Thrombin injection versus
compression of femoral artery pseudoaneurysms. J Vasc Surg.
1999;30(6):1052–1059.
5. Edgerton JR, Moore DO, Nichols D, et al. Obliteration of femoral
artery pseudoaneurysm by thrombin injection. Ann Thorac Surg.
2002;74(4):1413–1415.
6. Kurzawski J, Janion-Sadowska A, Zandecki L, Sadowski M. Compari-
son of the efcacy and safety of two dosing protocols for ultrasound
guided thrombin injection in patients with iatrogenic femoral pseudoaneurysms. Eur J Vasc Endovasc Surg. 2020;59(6):1019–1025.
7. Francisco LE, Asunción LC, Antonio CA, Ricardo RC, Manuel RP,
Caridad MH. Post-traumatic hepatic artery pseudoaneurysm treated
with endovascular embolization and thrombin injection. World
J Hepatol. 2010;2(2):87–90.
8. Duerig TW, Wholey M. A comparison of balloon- and self-expanding
stents. Minim Invasive Ther Allied Technol. 2002;11(4):173–178.
9. Grenacher L, Rohde S, Gänger E, Deutsch J, Kauffmann GW, Richter
GM. In vitro comparison of self-expanding versus balloon-expandable
stents in a human ex vivo model. Cardiovasc Intervent Radiol.
2006;29(2):249–254.
10. Sclafani SJ. The role of angiographic hemostasis in salvage of the
injured spleen. Radiology. 1981;141(3):645–650.
11. Sclafani SJ, Shaftan GW, Scalea TM, etal. Nonoperative salvage of
computed tomography-diagnosed splenic injuries: utilization of
angiography for triage and embolization for hemostasis. J Trauma.
1995;39(5):818–825; discussion 826–827.
12. Stassen NA, Bhullar I, Cheng JD, etal. Selective nonoperative manage-
ment of blunt splenic injury: an Eastern Association for the Surgery
of Trauma practice management guideline. J Trauma Acute Care Surg.
2012;73(5 Suppl 4):S294–300.
13. Clancy TV, Gary Maxwell J, Covington DL, Brinker CC, Blackman D.
A statewide analysis of level I and II trauma centers for patients with
major injuries. J Trauma. 2001;51(2):346–351.
14. Arumugam S, Al-Hassani A, El-Menyar A, et al. Frequency, causes
and pattern of abdominal trauma: a 4-year descriptive analysis.
J Emerg Trauma Shock. 8(4):193–198.
15. Smith J, Caldwell E, D’Amours S, Jalaludin B, Sugrue M. Abdominal
trauma: a disease in evolution. ANZ J Surg. 2005;75(9):790–794.
16. Crichton JCI, Naidoo K, Yet B, Brundage SI, Perkins Z. The role of
splenic angioembolization as an adjunct to nonoperative management of blunt splenic injuries: a systematic review and meta-analysis.
J Trauma Acute Care Surg. 2017;83(5):934–943.
17. Cirocchi R, Boselli C, Corsi A, etal. Is non-operative management safe
and effective for all splenic blunt trauma? A systematic review. Crit
Care. 2013;17(5):R185.
18. Foley PT, Kavnoudias H, Cameron PU, Czarnecki C, Paul E, Lyon SM.
Proximal versus distal splenic artery embolisation for blunt splenic
trauma: what is the impact on splenic immune function? Cardiovasc
Intervent Radiol. 2015;38(5):1143–1151.
19. Schnüriger B, Inaba K, Konstantinidis A, Lustenberger T, Chan LS,
Demetriades D. Outcomes of proximal versus distal splenic artery
embolization after trauma: a systematic review and meta-analysis.
J Trauma - Inj Infect Crit Care. 2011;70(1):252–260.
20. Machálek L, Holibková A, Tůma J, Houserková D. The size of the
splenic hilus, diameter of the splenic artery and its branches in
the human spleen. Acta Univ Palacki Olomuc Fac Med. 1998;141:
45–48.
21. Ekeh AP, Khalaf S, Ilyas S, Kauffman S, Walusimbi M, McCarthy MC.
Complications arising from splenic artery embolization: a review of
an 11-year experience. Am J Surg. 2013;205(3):250–254.
22. Wu SC, Chen RJ, Yang AD, Tung CC, Lee KH. Complications associ-
ated with embolization in the treatment of blunt splenic injury. World
J Surg. 2008;32(3):476–482.
23. Duane TM, Como JJ, Bochicchio GV, Scalea TM. Reevaluating the
management and outcomes of severe blunt liver injury. J Trauma - Inj
Infect Crit Care. 2004;57(3):494–500.
24. Pachter HL, Knudson MM, Esrig B, etal. Status of nonoperative man-
agement of blunt hepatic injuries in 1995: a multicenter experience
with 404 patients. J Trauma. 1996;40(1):31–38.
25. Fang JF, Chen RJ, Wong YC, etal. Pooling of contrast material on
computed tomography mandates aggressive management of blunt
hepatic injury. Am J Surg. 1998;176(4):315–319.
26. Stassen NA, Bhullar I, Cheng JD, etal. Nonoperative management
of blunt hepatic injury: an Eastern Association for the Surgery of
Trauma practice management guideline. J Trauma Acute Care Surg.
2012;73(5 SUPPL.4):S288–293.
27. Tinkoff G, Esposito TJ, Reed J, et al. American Association for the
Surgery of Trauma organ injury scale i: spleen, liver, and kidney,
validation based on the National Trauma Data Bank. J Am Coll Surg.
2008;207(5):646–655.
28. Matsushima K, Hogen R, Piccinini A, etal. Adjunctive use of hepatic
angioembolization following hemorrhage control laparotomy. J
Trauma Acute Care Surg. 2020;88(5):636–643. 2020.
29. Green CS, Bulger EM, Kwan SW. Outcomes and complications of
angioembolization for hepatic trauma: a systematic review of the
literature. J Trauma Acute Care Surg. 2016;80(3):529–537.
30. Erlich T, Kitrey ND. Renal trauma: the current best practice. Ther Adv
Urol. 2018;10(10):295–303.
31. Coccolini F, Moore EE, Kluger Y, etal. Kidney and uro-trauma: WSES-
AAST guidelines. World J Emerg Surg. 2019;14(1):54.
32. van der Wilden GM, Velmahos GC, Joseph DK, etal. Successful non-
operative management of the most severe blunt renal injuries: a
multicenter study of the research consortium of New England Centers for Trauma. JAMA Surg. 2013;148(10):924–931.
33. Mohsen T, El-Assmy A, El-Diasty T. Long-term functional and mor-
phological effects of transcatheter arterial embolization of traumatic
renal vascular injury. BJU Int. 2008;101(4):473–477.
34. Sarani B, Powell E, Taddeo J, etal. Contemporary comparison of sur-
gical and interventional arteriography management of blunt renal
injury. J Vasc Interv Radiol. 2011;22(5):723–728.
35. Huber J, Pahernik S, Hallscheidt P, etal. Selective transarterial embo-
lization for posttraumatic renal hemorrhage: a second try is worthwhile. J Urol. 2011;185(5):1751–1755.
36. Breyer BN, McAninch JW, Elliott SP, Master VA. Minimally invasive
endovascular techniques to treat acute renal hemorrhage. J Urol.
2008;179(6):2248–2253.
37. Breyer BN, Master VA, Marder SR, McAninch JW. Endovascular man-
agement of trauma related renal artery thrombosis. J Trauma—Inj
Infect Crit Care. 2008;64(4):1123–1125.
38. Lee JT, White RA. Endovascular management of blunt traumatic
renal artery dissection. J Endovasc Ther. 2002;9(3):354–358.
39. Zarzaur BL, Dunn JA, Leininger B, et al. Natural history of
splenic vascular abnormalities after blunt injury: A Western
Trauma Association multicenter trial. J Trauma Acute Care Surg.
2017;83(6):999–1005.
40. Eberle BM, Schnüriger B, Inaba K, et al. Thromboembolic prophy-
laxis with low-molecular-weight heparin in patients with blunt
solid abdominal organ injuries undergoing nonoperative management: current practice and outcomes. J Trauma Inj Infect Crit Care.
2011;70(1):141–147.
41. Heetveld MJ, Harris I, Schlaphoff G, Balogh Z, D’Amours SK, Sugrue
M. Hemodynamically unstable pelvic fractures: recent care and new
guidelines. World J Surg. 2004;28(9):904–909.
42. White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic
fractures. Injury. 2009;40(10):1023–1030.
43. Salazar GMM, Walker TG. Evaluation and management of acute vas-
cular trauma. Tech Vasc Interv Radiol. 2009;12(2):102–116.
44. Salcedo ES, Brown IE, Corwin MT, Galante JM. Pelvic angioemboliza-
tion in trauma – indications and outcomes. Int J Surg. 2016;33(Part
B):231–236.
45. Matsushima K, Piccinini A, Schellenberg M, etal. Effect of door-to-
angioembolization time on mortality in pelvic fracture: every hour of
delay counts. J Trauma Acute Care Surg. 2018;84(5):685–692.
46. Ding A, O’Toole RV, Castillo R, etal. Risk factors for early reoperation
after operative treatment of acetabular fractures. J Orthop Trauma.
2018;32(7):E251–E257.
47. Rehwald R, Schönherr E, Petersen J, etal. Prognostic factors in endo-
vascular treated pelvic haemorrhage after blunt trauma. BMC Surg.
2017;17(1):1–13.
48. Monson DO, Saletta JD, Freeark RJ. Carotid vertebral trauma. J Trauma.
1969;9(12):987–999.
49. Wang K, Peng X, Liu A, etal. Covered stenting is an effective option
for traumatic carotid pseudoaneurysm with promising long-term outcome. J Korean Neurosurg Soc. 2020:1–8.
50. Grigorian A, Kabutey NK, Schubl S, et al. Blunt cerebrovascular
injury incidence, stroke-rate, and mortality with the expanded Denver
criteria. Surg (United States). 2018;164(3):494–499.
51. Arthurs ZM, Sohn VY, Starnes BW. Vascular trauma: endovas-
cular management and techniques. Surg Clin North Am. 2007;
87(5):1179–1192.
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