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x List o f C on tributors
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Tom Woolley, MD, FRCA, MBBS
Defence Professor
Anaesthetics and Critical Care
Academic Department Military Anaesthesia and Critical
Care
Royal Centre for Defence Medicine
Birmingham, United Kingdom
Jeniann A. YI, MD, MSCS
Senior Fellow
Department of Surgery
University of Colorado Anschutz Medical Campus
Aurora, Colorado
Foreword
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EMILY MAYHEW*
Imperial College London, 2021
HARRY PARKER**
London, 2021
One day, this comprehensive, up to date, and carefully
refreshed (see Preface) account of the management of vascular trauma in the second decade of the 21st century will
move from the shelves of volumes that constitute the medical school curricula around the world to the quieter library
stacks of medical history. The emerging hot topics explored
on its pages will have been resolved and incorporated into
the clinical mainstream. The innovations and new assessments described in each of its chapters will have become
common practice, and the evolving systems will have
been consolidated and implemented as standard. The calls
for new management strategies to ll the gaps in current
capabilities will have been answered. Vascular surgery, the
youngest of the 10 surgical specialties, will have grown into
all its potential.
Rich’s Vascular Trauma, in this current and three previous editions, provides the textual infrastructure that
has enabled this remarkable disciplinary growth. When,
eventually, it is replaced by successor volumes, its value
will be transformed. Its contents will assume a different
responsibility: that of providing a definitive historical
record of the creation of vascular surgery in the modern
era. Each revised edition contributes to the challenging
task of focused and sustained tracking of an intricate,
highly technical surgical specialty that has developed
at extraordinary speed. Additionally, this fourth edition
contributes a truly international dimension, drawing on
testimony and evidence from vascular specialists with
regional and national specificities in their provision that
has contributed to the global development of the discipline and its community of practice.
The features that make this work essential for vascular
specialists also secure its particular interest for medical
historians. It pays respectful attention to the practices of
the past that would eventually coalesce into the discipline
of vascular surgery and the formal management of vascular injury. The historical review picks up the rst signs of
the integration of military and civilian medical practice
in vascular repair to show that it is a fascinating constant
of vascular surgery that alliances forged by military medics in times of war were consolidated in peace. Despite the
unprecedented scale and pace of military casualty, lessons
from eld surgery were learned, transmitted, and applied
consistently in civilian practice. Within the medical sector,
it is rare to see progress maintained and stabilized across
periods of transition. A key consequence of this extraordinary success is that both clinician and patient expectations of survivability were revised signicantly, and remain
undiminished. This work provides evidence and exemplar
of disciplinary progress and good historical practice, as well
as a crucial reminder that there are responsibilities to be
respected when the stakes of survival are renegotiated.
One element will never change no matter the century
or the mechanism of vascular injury. Survivors, whether
unexpected or anticipated, will seek to understand the
process by which their lives were secured. This is a useful
dimension of the work that we suggest might receive additional consideration. Rich’s Vascular Trauma is a resource
that enables professional development, historical reection,
and, above all, answers to that most important and complicated question asked by the patient from their life beyond
survival: “what happened to me?”
* Emily Mayhew is Historian in Residence in the Centre for Blast Injury Studies, Department of Bioengineering at Imperial College London. She is the author of
Wounded: From Battlefield to Blighty, 1914-1918 published by Vintage and The Four Horsemen: War, Pestilence, Famine and Death and the Hope of a New Age,
published by Riverrun.
** Harry Parker is a writer and artist and lives in London. He joined the British Army when he was 23 and served in Iraq in 2007 and Afghanistan in 2009 as a
Captain in 4th Battalion The Rifles. His debut novel, Anatomy of a Soldier is published by Faber and Faber.
xi
Preface to the Fourth Edition of
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Rich’s Vascular Trauma
NORMAN M. RICH and KENNETH J. CHERRY
The rst two decades of the 21st century saw the military
surgical communities of the United States of America, the
United Kingdom, and other allied counties respond with
determination and innovation to the challenges faced by
those caring for patients with life-and-limb threatening
vascular trauma. Air superiority during the Afghanistan
and Iraq Wars, combined with sophisticated eld and enroute treatment protocols, allowed rapid evacuation of
the injured to denitive surgical centers within the theater of war. Stabilized patients were repatriated rapidly to
military hospitals back home, half-way around the world
from their original point of injury. Deployed teams cared
for patients who, in previous conicts, may never have
reached surgical care alive. Killed-in-action and casefatality rates decreased as clinical experience and new
systems of care and innovative approaches and products
were applied.
Implementing a process that the National Academy of
Medicine referred to as focused empiricism, military surgeons
managed a once-in-a-generation burden of vascular injury
within a new and evolving global trauma system.1 Newly
designed tourniquets, balanced transfusion of blood products, damage control surgery, including the use of temporary vascular shunts, and selective venous and tibial artery
repair were among the approaches that became standard
during the wars. For the rst time a closed, negative pressure wound dressing technology was used to control soft
tissue injuries associated with vascular trauma and endovascular devices were applied to select injury patterns in
frontline surgical hospitals.
Unable to perform traditional randomized, controlled
research on these approaches, surgeons relied on registrybased study and international collaboration to develop
real-world evidence that was applied within a system
of data-driven performance improvement. Throughout
this period, military techniques and protocols for vascular trauma were scrutinized, adjusted based on the best
available evidence, and shared with civilian surgeons, as
part of the constructive exchange of breakthroughs that
accompanies the unearthing of fresh knowledge in either
setting.
in vascular trauma care made since the beginning of this
century; progress that the Third Edition of Rich’s Vascular
Trauma did much to capture when it was published in
2015, toward the closure of the Iraq and Afghanistan
Wars. Six years on, this carefully refreshed Fourth Edition is
a commendable addition to the toolbox required to address
that ever-urgent task of avoiding the so-called Walker Dip2;
where peacetime or inter-war periods see atrophy of military
1
The challenge now is to preserve and sustain the progress
surgical readiness, with the cost of that inertia shored up
and eventually born by those injured in wars of the future.
More than ever, we are convinced that the answer to this
conundrum lies in purposeful collaboration and shared
endeavors across all stakeholders charged with the responsibility of surgical care: civilian and military surgical communities, trauma and vascular surgeons, prehospital and
in-hospital specialists, global health, humanitarian and
military providers, and across international borders.
We are delighted to see that, in the Fourth Edition, the
Editors have again assembled contributions from an array
of talented practitioners and leaders who have wedded
state-of-the-art technical insight to hard-won wisdom,
divined from a range of practice settings: an approach
which sees the Fourth Edition endorsed and adopted by
the Society for Vascular Surgery. Todd Rasmussen of the
United States Air Force and Uniformed Service University
has been an effective leader, role model, and respected
mentor in all of this experience, forging an effective partnership with his counterpart Nigel Tai of the British Army
and UK Defence Medical Services—a partnership borne
out of the recent wars that has now served two Editions
of this textbook.
These two Editors continue the important work of
forerunners Frank Spencer, Ken Mattox, and Asher
Hirschberg, whose foundational Editorship proved to be
the shoulders upon which subsequent editions rest. The
work of the contributors within these pages consolidates
and continues the themes and perspectives that Michael
E. DeBakey, Carl W. Hughes, and others took from their
respective service in World War II, the Korean Conict,
and Vietnam, and that Colonels Todd Rasmussen3 and
Nigel Tai took from theirs.
Finally, with the publication of this Fourth Edition we
would like to acknowledge our friend and military surgical
colleague Surgeon Vice-Admiral Alasdair Walker CB OBE
QHS FRCS, who died in 2019. Admiral Walker completed
his surgical research fellowship at the Uniformed Services
University and was a key mentor and contributor to the
Third Edition of this textbook. As Surgeon General to
the UK Armed Forces, Admiral Walker worked tirelessly to
mitigate the insidious effects of the phenomenon that he
dened (The Walker Dip). Admiral Walker was a lion of
military surgery who had immense character and unrivaled experience in a career spanning the 1982 War in
the South Atlantic to the 2009 ghting season in Helmand Province, Afghanistan. Despite daunting bona des
and ascension to the highest levels of military leadership,
Admiral Walker was unpretentious in conversation, reassuring in mentorship, and ever the advocate for the next
xii
Preface to the Fourth Edition of Rich’s Vascular Trauma xiii
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generation of physician and surgeon. His untimely death
is a loss to current and future generations of surgeons and
those whom they serve.
The success that we have no doubt will accompany this
latest edition of Rich’s Vascular Trauma was, to a large
degree, set by Admiral Walker’s tireless groundwork in
strengthening and renewing the bonds of surgical kinship
between his country’s military, ours, and that of countless
allies along the way. He leaves us a rich legacy of union and
friendship, upon which this and future Editions of this textbook will surely capitalize in the pursuit of ever-better outcomes for our deserving patients.
References
1. National Academies of Sciences, Engineering, and Medicine. A National
Trauma Care System: Integrating Military and Civilian Trauma Systems to
Achieve Zero Preventable Deaths After Injury. Washington, DC: National
Academies Press; 2016.
2. Expounded on at the 2013 meeting of the Military Health Services Research Symposium meeting in Fort Lauderdale, FL using the
example of the Crimean War to illustrate his point. The phenomenon can be found in almost all historical antecedents. Military Med.
2014;179:477–482.
3. Rich NM, Carl W, Hughes CW, De Bakey ME. Recognition of Air
Force surgeons at Wilford Hall Medical Center-supported 332nd
EMDG/Air Force Theater Hospital, Balad Air Base, Iraq. J Vasc Surg.
2007;46(6):1312–1313.
Alasdair Walker qualied from the University of Glasgow in 1979. He deployed to the South Atlantic during the Falklands
War in 1982 and led Commando Forward Surgical Goup 2 during the Iraq War in 2003. He was Senior Surgeon in the
Role 3 Hospital at Camp Bastion in 2009. Subsequent appointments included Medical Director (2009), Director of Medical
Policy and Operational Capability for the Surgeon General (2011), Assistant Chief of the Defence Staff for Health (2014),
Medical Director General (Navy), and Surgeon General in 2015. He retired from the Royal Navy in May 2019 as Surgeon
Vice-Admiral.
The portrait above was taken during his time as International Scholar in the Department of Surgery at Uniformed Ser-
vices University of Health Sciences, Bethesda, Maryland, United States in 1992.
Vice-Admiral Alasdair Walker, CB, OBE, QHS, FRCS, RN
22 June 1956–1 June 2019
Table of Contents
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Surgical Trainee’s Perspective, 1
ALEXANDER KERSEY and ALEXIS LAURIA
SECTION 1
Setting the Stage, 11
1 The Vascular Injury Legacy, 12
NORMAN M. RICH and KENNETH J. CHERRY
2 Epidemiology of Vascular Trauma, 23
PETER GOGALNICEANU, TODD E. RASMUSSEN, and NIGEL R.M. TAI
3 Systems of Care in the Management of Vascular
Injury, 34
DONALD H. JENKINS, DOUGLAS M. POKORNY, and PHILIP M.
EDMUNDSON
4 Training Paradigms for Vascular Trauma, 42
PAUL W. WHITE and JAMES B. SAMPSON
SECTION 2
Immediate Management and Diagnostic
Approaches, 55
5 Prehospital Management of Vascular Injury, 56
ROBERT H. JAMES and JASON E. SMITH
6 Damage Control and Immediate Resuscitation for
Vascular Trauma, 70
TOM WOOLLEY, RAVI CHAUHAN, and ALLAN PANG
7 Diagnosis of Vascular Injury, 82
MICHAEL J. SISE
8 Imaging for the Evaluation and Treatment of
Vascular Trauma, 91
DAVID L. DAWSON
SECTION 3
Emerging Technologies and New Approaches
to Vascular Trauma and Shock, 107
9 Endovascular Suites and the Emergency Vascular
Service, 108
JOSEPH A. HERROLD, THOMAS M. SCALEA, and JONATHAN J.
MORRISON
12 Endovascular Variable Aortic Control, 137
MICHAELA GAFFLEY and TIMOTHY K. WILLIAMS
13 Selective Aortic Arch Perfusion, 144
JAMES E. MANNING and ED B.G. BARNARD
14 Endovascular to Extracorporeal Organ Support
for Vascular Trauma and Shock, 158
KEVIN K. CHUNG, ANDRIY I. BATCHINSKY, and IAN J. STEWART
15 Gathering the Evidence: Clinical Study of New
Technologies, 166
LAURA J. MOORE and JAN O. JANSEN
SECTION 4
The Management of Vascular Trauma, 170
16 Cardiac, Great Vessel, and Pulmonary
Injuries, 171
DAVID V. FELICIANO and JOSEPH J. DUBOSE
17 Blunt Thoracic Aortic Injury, 199
DEMETRIOS DEMETRIADES, PEEP TALVING, and KENJI INABA
18 Abdominal Aortic Trauma, Iliac and Visceral Vessel
Injuries, 212
CHRISTOPHER AYLWIN and MICHAEL JENKINS
19 Inferior Vena Cava, Portal, and Mesenteric Venous
Systems, 226
TIMOTHY FABIAN and STEPHANIE SAVAGE
20 Neck and Thoracic Outlet, 241
GREGORY A. MAGEE and FRED A. WEAVER
21 Upper Extremity and Junctional Zone Injuries, 252
MATTHEW VUONCINO, JOSEPH M. WHITE, and WILLIAM DARRIN
CLOUSE
22 Lower Extremity Vascular Trauma, 273
DAVID S. KAUVAR and BRANDON W. PROPPER
23 Surgical Damage Control and Temporary Vascular
Shunts, 288
DANIEL J. SCOTT and SHAUN M. GIFFORD
24 Considerations for Conduit Repair of Vascular
Injury, 300
NITEN SINGH and REBECCA JOY UR
10 Stent-Grafts, Coils, and Plugs, 114
DAVID SCHECHTMAN and BRANDON W. PROPPER
11 Resuscitative Endovascular Balloon Occlusion of
the Aorta, 126
JENIANN A. YL, CHARLES JAMES FOX, and ERNEST E. MOORE
xiv
25 Management of Pediatric Vascular Injury, 312
MATTHEW A. GOLDSHORE and JEREMY W. CANNON
26 Soft-Tissue and Skeletal Wound Management
in the Setting of Vascular Injury, 321
SHEHAN HETTIARATCHY and JON CLASPER
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27 Vascular Surgery in the Austere
Environment, 332
DAVID M. NOTT
SECTION 5
Global Perspectives on Vascular Trauma, 352
28 Australia and New Zealand, 353
IAN D. CIVIL
29 Sri Lanka, 357
AMILA SANJIVA RATNAYAKE, SANJEEWA H. MUNASINGHE, and
SUJEEWA P.B. THALGASPITIYA
30 Vascular Trauma in Finland, 365
PIRKKA VIKATMAA
31 Sweden, 370
TAL M. HÖRER and CARL MAGNUS WAHLGREN
32 Russia, 374
IGOR M. SAMOKHVALOV and VIKTOR A. REVA
33 Serbia, 377
LAZAR B. DAVIDOVIC and MIROSLAV MARKOVIC
34 Israel, 388
EITAN HELDENBERG and ELON GLASSBERG
35 South Africa, 391
KENNETH BOFFARD
36 Colombia: Don’t Dread the Popliteal and Axillary
Fossa, 396
CARLOS A. ORDOÑEZ and MICHAEL W. PARRA
37 Brazil, 401
ROSSI MURILO and RINA PORTA
Index, 407
Surgical Trainee’s Perspective
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ALEXANDER KERSEY and ALEXIS LAURIA
Introduction
The aim of this section is to provide a concise, residentfocused, overview of a select number of chapters in the
textbook. For each of the selected chapters, the topics are
broken down by a general introduction (contextualizing
the subject), surgical approach (detailing patient evalu-
ation and prioritization) and tactics (providing helpful
tips – the “Do’s and Don’ts” of safe surgical care) needed to
get the best outcomes.
The section will be most useful for the busy Resident
needing to quickly review the fundamentals of a vascular
trauma topic, priming them for a later and more comprehensive review of the relevant chapters when their schedule permits.
Subject: Critical First Steps and
Damage Control Resuscitation
(Chapters 5 and 6)
GENERAL
n Damage control resuscitation (DCR) begins in the pre-
hospital arena and is continued via reception into the
Emergency Department (ED), transfer to surgery or
interventional radiology (IR) suite, and within the Critical Care Unit.
n DCR prioritizes use of tourniquets, hemostatic dressings,
temporizing procedures (resuscitative endovascular balloon occlusion of the aorta [REBOA]) and balanced transfusion of blood products to mitigate the consequences of
hemorrhage and shock.
n DCR generates surgical options by restoring physiologi-
cal normality.
SURGICAL APPROACH
n Prior preparation in the ED is essential: muster team
members, assign roles, pre rehearse likely scenarios, prepare equipment and drugs, order blood products, don
PPE, forewarn onward destinations (operating room
(OR), IR suite, intensive care unit (ICU), etc.) and anticipated consultants.
n Use C-ABC framework to prioritize immediate steps in
management:
n (C) Control of catastrophic bleeding – tourniquet,
hemostatic dressings, REBOA
n (A) Airway management
n (B) Breathing – ensure adequate ventilation
n (C) Circulation – vascular access, hemorrhage con-
trol, restore circulatory volume
n Replace volume with a 1:1:1 ratio of red cells,
plasma and platelets (6U packed red blood cells
(pRBC), 6U fresh frozen plasma (FFP), 1 pack of
platelets [which contains 6U])
n Consider tranexamic acid (TXA) as part of the resuscita-
tion protocol based on local practice.
n Consider broad spectrum antibiotics and tetanus where
indicated.
n Match anesthesia-induction strategy to patient physiol-
ogy (use cardio-stable induction agents to avoid catastrophic loss of cardiac output).
n Keep patient warm.
SURGICAL TACTICS IN THE ED
n Do:
n Familiarize yourself with the type of tourniquet and
hemostatic dressings used by your prehospital care
providers – how they are applied and released.
n Understand how long the warm ischemia time has
been and ensure it is recorded.
n Release tourniquets only for specic purpose (e.g.,
immediately prior to diagnostic angiography; to assess
likelihood of arterial injury, etc.). If no gross hemorrhage, leave down but be prepared to tighten again if
further hemorrhage occurs.
n Remove dressings if ineffective or if examining wound
will change operative decision-making.
n Re-assess tourniquets/hemostatic dressings after
patient movement to ensure proper function.
n Monitor coagulopathy through early use of thrombo-
elastography (TEG)/rotational thromboelastometry
(ROTEM); monitor physiology through multiple feeds
(trends in hemodynamic variables, lactate, urine output, etc.).
n Rene anticipated management plan as results from
examination and investigations accrue and communicate accordingly.
n Establish and maintain hierarchy of open, closed-
loop communication and task allocation (i.e., identify
team lead but enable all to have a voice).
n Use checklists and regular, formalized brieng
opportunities (SNAP brief, STACK brief, ‘time outs’)
to review progress and before major interventions
(Chapter 6, p. 68)
n Do Not:
n Lose situational awareness and become task xated.
n Become distracted by a prominent injury and fail to
appropriately assess whole patient in stepwise fashion.
n Fail to obtain and document a brief but thorough
extremity motor and sensory examination prior to
intubation if safe to do so.
n Fail to consider ethics issues and/or fail to set ceilings
of care for patients where continued medical intervention is likely to be futile.
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2 • Surgical Trainee’s Perspective
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n Fail to consider requirements of associated members of
the attending trauma team (e.g., Orthopedics) and not
integrate these points in to the overall DCR strategy.
Subject: Injury Identification and
Diagnostic Workup (Chapters 7
and 8)
GENERAL
n Early identication of vascular injury is crucial to pre-
venting long-term morbidity, loss of limb, or loss of life
n Chapter 7, Box 7.1 (Checklist for Prompt Recognition
of Vascular Injury)
n Modalities for diagnosis include detailed injury his-
tory, bedside examinations (pulse examination, Doppler
examination, point-of-care ultrasound, Ankle Brachial
Index (ABI)), radiographic imaging (CT angiography
[CTA]) and formal angiography.
n Approach is based on: (1) patient stability, (2) concom-
itant injuries, and (3) availability/feasibility of diagnostic modalities (i.e., contrast allergies).
DIAGNOSTIC APPROACH
n Any exsanguinating hemorrhage should be temporized
per C-ABC with adjuncts (as described previously).
n Hard signs of vascular injury, CTA or angiography posi-
tive for vascular injury→to the OR
n Chapter 7, Fig. 7.5 (Algorithm of the indications for
immediate operation and the role of imaging modalities)
n Hard signs of vascular injury include:
n Pulsatile hemorrhage
n Expanding hematoma
n Bruit or thrill over area of injury
n Absent pulse
n ABI < 0.9
n Soft signs of vascular injury include:
n History of hemorrhage at scene
n Wounds of neck/extremities with unexplained hem-
orrhagic shock
n Neurologic decit in peripheral nerve in proximity to
vessels
n High risk fracture, dislocation, or penetrating proxim-
ity wound
n Presence of a pulse does not rule out a vascular injury.
Conversely, a normal ABI makes the likelihood of a vascular injury much lower.
n Consider use of checklist adjuncts to “clear” the patient
of vascular injuries in various cavities or prompt further
imaging.
n Chapter 7, Box 7.3 (Clearing Trauma Patients for
Presence of Vascular Injury)
TACTICS
n Do:
n Consider injury mechanism when evaluating for
occult injury.
n Be cognizant of additive use of contrast.
n Discuss injury concerns with radiologist so that vas-
cular workup can be integrated with planned imaging
to avoid multiple trips to the radiology suite.
n Frequently reassess for changes in pulse examination
throughout the resuscitation as hypotension, vasopressors may confound examination.
n Do Not:
n Take an unstable patient to imaging.
n Delay operative intervention for imaging if the imag-
ing will not add to or change decision-making.
n Hesitate to conrm questionable pulse examinations –
either with second provider or Doppler examination.
n Fail to consider the risks associated with each imag-
ing modality (contrast reactions, renal dysfunction,
access site complications, time requirements, risks of
radiation).
Subject: Resuscitative
Endovascular Balloon Occlusion of
the Aorta (REBOA) (Chapter 11)
GENERAL
n Minimally invasive alternative to thoracotomy and aor-
tic clamping for temporization of exsanguinating subdiaphragmatic hemorrhage.
n Carries systemic consequences due to lower body and
visceral ischemia but these are probably less than standard emergency department thoracotomy (EDT) and
cross-clamping. These consequences may be off-set
through the development of partial occlusion or intermittent occlusion techniques.
SURGICAL APPROACH
n The rst step is percutaneous femoral artery cannula-
tion, which should be done under ultrasound (US) guidance to maximize chances of success and minimize
complications.
n The artery is accessed via hollow-needle and wire 2 to 3 cm
below the mid-inguinal ligament. Seldinger technique is
used to place a sheath, which is used to position a guidewire over which a compliant occlusion balloon can be
placed into zone I or III as required, using predetermined
standard insertion lengths (Chapter 11, Fig. 11.1). The
wireless ER REBOA system (Prytime Medical; Chapter 11,
Fig. 11.2) does not require wire guidance and employs a
7-Fr sheath.
n The aorta is divided into three zones; zone I ((left subcla-
vian to celiac), zone II (celiac to lowest renal artery) and
zone III (infrarenal aorta). Chapter 11, Fig. 11.4).
n The length of catheter insertion needed to reach each
zone can be approximated using anatomic landmarks:
n Zone I: femoral access site to sternal notch
n Zone III: femoral access site to umbilicus
n The occlusion balloon is positioned in zone III for pelvic
hemorrhage and distal zone I for intraabdominal bleeding.
n Position of the balloon may be conrmed with plain x-ray.
n The balloon is inated with a contrast/saline mix:
n Inate balloon until recognizable hemodynamic
response (increased central/upper extremity blood
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pressure, absent or decreased distal pulses, step-up in
waveform proximal to balloon)
n Tactile feedback during ination is important in
recognizing aortic wall tension and avoiding injury –
if resistance is met, ination should stop
n The REBOA is secured to prevent balloon migration and
the patient can be taken to the right place to stop the
hemorrhage (IR suite, OR).
n Balloon time must be assiduously tracked. Zone I aortic
occlusion time must be kept to less than 30 minutes to
reduce the chances of spinal cord or visceral ischemia/
tissue infarction. Longer occlusion times may be tolerated for zone III ination.
SURGICAL TACTICS
n Do:
n Match the need for REBOA to a good understanding of
patient physiology:
n Physiologically stable patients with potential for
sudden deterioration may have a sheath inserted
as a prelude to REBOA deployment if there is
deterioration.
n Unstable patients may have sheath insertion
and balloon ination to allow safer transfer to
IR/OR.
n Deate the balloon slowly (consider 1–2 mL every
2–3 minutes) to prevent rapid hemodynamic changes
and catastrophic ischemia-reperfusion injury to
the heart, giving plenty of warning to anesthetic
colleagues.
n Consider adding medications or common rescue needs
(bicarb, blood and/or crystalloid, pressors, management of hyperkalemia) in anticipation of reperfusion
injury after balloon deation.
n Employ REBOA as part of a comprehensive DCR
paradigm.
n Do Not:
n Use REBOA as a “bridge” if the destination is not
determined or the hemorrhage control strategy not
clear – always have a plan as to next steps (including
denitive hemorrhage control).
n Persist at multiple attempts at groin cannulation.
Resort to surgical cutdown early if groin cannulation
is not possible.
n Longitudinal incision extending inferiorly from the
midpoint between the pubic symphysis and anterior superior iliac spine (ASIS).
n Use REBOA for intrathoracic hemorrhage.
n Fail to evaluate the patient for complications, particu-
larly lower limb ischemia due to peri-sheath thrombosis, and have a plan for dealing with them.
Subject: Temporary Vascular
Shunts (Chapter 23)
GENERAL
n Use of shunts is a desirable option to bridge damaged
vessels in the extremities, junctional areas, and trunk to
enable early reperfusion of tissue.
n Consider shunting when denitive repair must be
deferred due to:
n physiological instability (i.e., damage control surgery)
n need to complete other life-saving interventions
n requirement to perform skeletal xation
n absence of sufcient expertise or materials
n Shunting is applicable to both arteries and veins.
n Shunt dwell times of 2 to 5 hours are typical; however,
some scenarios require longer times. The goal should be
to remove shunts and perform denitive revasculariza-
tion as early as the patient’s status, resources, and tech-
nical expertise allow.
SURGICAL APPROACH
n Shunts should be used as part of a comprehensive vascu-
lar management plan and require a technically experi-
enced team with adequate resources.
SURGICAL TACTICS
n Do:
n Get the preliminaries right: adequate proximal and
distal vascular exposure; injury denition/débridement; assessment of inow and backow; Fogarty
sweep; heparinized saline ush.
n Ensure that vascular injury downstream of the shunt
has been ruled out to prevent hemorrhage once ow
restored – consider angiography.
n Choose a shunt and position that is right for the vessel
caliber and injury:
n In-line – short segmental defect or small working
area (Chapter 23, Figs. 23.3 and 23.4)
n Looped – long segment defect, large working area
(Chapter 23, Fig. 23.5).
n Remember standard sequencing: [Shunt]→[Fracture
Reduction and Fixation]→[Denitive Vascular
Repair]→[Fasciotomy].
n Have a plan for denitive management, know when/
where necessary resources are available.
n Be aware of and have a plan for shunt-related com-
plications (dislodgement, luminal injury, thrombosis,
kinking, etc.) and communicate this to other relevant
members of the patient care team.
n Do Not:
n Inadequately secure the shunt.
n Fail to consider collaterals and branch points within
the injury/shunt zone and ligate these as needed.
n Fail to give anesthesia colleagues warning of reperfu-
sion prior to shunt clamp removal.
n Routinely employ systemic anticoagulation.
n Routinely use shunts to bridge defects in small vessels
below the elbow or the knee (increased likelihood of
thrombosis).
Subject: Neck Injury (Chapter 20)
GENERAL
n A unique, compacted and congested anatomical zone
with multiple vital structures.
4 • Surgical Trainee’s Perspective
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n Neck trauma is divided into three zones based on ana-
tomic landmarks (Chapter 20, Fig. 20.1):
n Zone I – sternal notch to cricoid cartilage
n Zone II – cricoid cartilage to angle of mandible
n Zone III – angle of mandible to base of skull
n Wide spectrum of presentation from exsanguinating
hemorrhage to subtle clinical or imaging ndings that
can lead to delayed stroke.
n Carotid injuries may present with contralateral
extremity weakness, aphasia, or Horner’s syndrome.
n Vertebral injuries are rarely symptomatic on presen-
tation.
n Increased prevalence of CTA has resulted in more blunt
injuries (blunt carotid and vertebral injury – BCVI) being
identied.
n Risk factors for BCVI that should prompt screening
include:
n Head and neck trauma associated with severe neck
hyperextension and rotation or hyperexion
n Lefort II or III fracture
n Basilar skull fracture involving the carotid canal
n Closed head injury consistent with diffuse axonal
injury presenting with Glasgow coma scale (GCS)
score <6
n• Cervical vertebral body or transverse foramen frac-
ture, subluxation, or ligamentous injury at any level or
any fracture of C1–C3
n A seat-belt or other clothesline-type injury with signif-
icant cervical pain, swelling, or altered mental status
SURGICAL APPROACH
n Physical examination is extremely important with iden-
tication of hard vascular signs an indication for airway
control and operative exploration. For stable patients,
CTA is the next step. It is crucial to pick-up pathologic
neurological signs prior to intervention.
n Repair of penetrating carotid trauma in a patient with
neurological decit has attracted controversy, but there
are no absolute contraindications. However, a delay of
more than 3 hours from coma onset and large areas of
cerebral infarct seen on initial CT scan are reasons to
consider what reperfusion is likely to achieve.
n Catheter-based angiography and endovascular stenting
is suited to distal carotid (zone III) hemorrhage where
surgical access is difcult. Similarly, very proximal
lesions (zone I) that would otherwise mandate median
sternotomy for proximal control may be managed via
covered stents.
n Operative positioning and draping should take into
account the potential need to open the chest and possible
vein harvest.
n Carotid injuries are exposed via a standard sternal
notch to mastoid process incision, via a plane that lies
medial to the sternocleidomastoid muscle. The internal jugular vein should be mobilized laterally away
from the carotid; dividing the facial vein facilitates
this. Exposing the upper parts of the internal carotid
(zone III) requires preservation of the XII cranial
nerve, division of the occipital artery, and mobilization
of the posterior belly of the digastric, protecting the IX
and XI cranial nerves.
n Options for carotid repair include:
n Primary repair with monolament suture (rarely
advisable)
n Patch angioplasty with bovine pericardium or vein
graft
n Interposition graft with saphenous vein preferably
or PTFE (graft generally required for >2-cm length
defects)
n Use of a Fogarty occlusion balloon, carefully inated, is a
facile means of gaining distal control in zone III injuries.
If possible, repairs of the internal carotid artery (ICA)
should be undertaken using a shunt to maintain prograde ow. If backow cannot be obtained after gentle
Fogarty thrombectomy, there is little advantage attempting repair and ligation is advisable.
n Vertebral artery injuries are challenging to repair due
to difcult access; management concentrates on injury
denition (CTA), and control of hemorrhage (ligation,
embolization) where this is signicant, accepting the risk
of posterior circulation stroke.
n Injuries to the vertebral artery as it passes through
the transverse processes of the cervical vertebra are
approached by the same route as exposure of the carotid
artery. Hematoma will displace the carotid sheath anteriorly; the carotid artery and internal jugular vein must
be displaced to allow access to the injury tract, longus
colli muscle, and injured vertebral artery. Gaining proximal and distal control requires removal of the anterior
tubercle of the transverse process which is difcult to
accomplish in the midst of hemorrhage.
n Alternatively, tamponading the surgically exposed injury
tract with hemostatic material or the balloon of a Fogarty catheter while addressing balanced transfusion and
judicious use of time may be sufcient to allow bleeding
to stop as a prelude to follow-up catheter-based embolization.
SURGICAL TACTICS
n Do:
n Screen aggressively for BCVI; management is almost
always nonoperative with antithrombotic therapy
and follow-up CTA the mainstay of treatment. Enlarg-
ing pseudoaneurysms that develop during follow-up
can be selectively managed with stenting or coiling.
Grade Description Management
I Intimal injury with <25%
luminal narrowing
II Dissection or hematoma with
>25% luminal narrowing
III Pseudoaneurysm Antithrombotic therapy;
IV Occlusion Antithrombotic therapy
V Transection Operative interven-
n Antithrombotic therapy (either anticoagulation or anti-
platelet) is chosen empirically based on injury pattern,
provider experience, and institutional guidelines.
Antithrombotic therapy
Antithrombotic therapy
consider endovascular
management
tion (endovascular if
inaccessible)
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