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Vascular Trauma in Finland
PIRKKA VIKATMAA
Introduction
Europe covers a land area of 10 million km2 and has a
population of 750 million people in 45 independent countries with a signicant variability in the standard of living,
culture, religion, ethnics, and politics. Despite a history of
wars, the continent has seen long periods of peace and a
gradual increase in wealth and stability. The European
Union (EU) has 27 member countries after Brexit in 2020
and has, during its existence, functioned as a signicant
organ for peace, increased equality, and improved standardization in many areas of society, including health care and
education. The Nordic countries form a relatively uniform
area concerning politics and public health-care funding.
They have small populations in a geographically large area
(except for Denmark), standardized education systems, and
good availability of modern technologies.
Finland as a Northern European
Example in Trauma and Trauma
Care
Finland, a country with 5.5 million inhabitants and an area
similar to Germany (357 000 km2 and 83 million inhabitants), is divided into ve university hospital districts, with
an increasingly active trend to centralize the health-care
system. Major trauma is treated exclusively in publicly
funded hospitals and all citizens are covered by national
insurance. The largest trauma center, Helsinki University
Hospital Trauma unit, covers most of Southern Finland
with a catchment area of little short of 2 million inhabitants and a transportation range of 200 km. Although most
medical emergency transfer is taken care of by ground
transportation, helicopter emergency medical services
(HEMS) are available in all parts of the country, including,
most importantly, in the difcult-to-reach archipelago and
sparsely populated northern areas.
Similar to many countries with an aging population,
trauma is the fourth leading cause of death in Finland,
after cardiovascular diseases, tumors, and dementia. In
2017, 4% of all deaths were due to trauma. A decrease
in fatal trafc accidents, but a recent increase in deaths
from falls of the elderly has occurred. In females, the
incidence of traumatic deaths has been stable at around
30/100,000 inhabitants since 1970, whereas the incidence has declined in men from 85/100,000 in 1970 to
55/100,000 inhabitants in 2017 (Statistics Finland, stat.
). Rural areas with longer distances, more socioeconomic
problems, and a higher proportion of home and leisuretime injuries suffer from a higher incidence of prehospital
deaths due to trauma.
1,2
Alcohol and drug consumption play a role in traumatic
deaths both in trafc accidents and violence. Alcohol consumption increased steadily until 2007 and has declined by
20% since then, but is still high at greater than 10 L/year/
capita (expressed in terms of 100% ethanol) in the over
15-year-old population. The drug statistics are less reliable,
but the frequency of “tested during lifetime” answers is
small at less than 5% in the 15- to 69-year-old age group for
all drugs except cannabis, which has tested at 24% according to a 2018 national survey.3 Finland has the fourth highest death rate by unintentional injury in the EU, almost
twice the European average and higher than in the other
Nordic countries (stat.).
In 2016, 186 rearm deaths were recorded, a 50%
decline from 1990, when 366 rearm deaths were seen.
Ninety percent of these were suicidal, 7% were homicides,
and 3% were accidental. In comparison with the rest of
Europe, the number of rearms in Finland is high—1.5
million or 0.27/inhabitant (1.2/inhabitant in the United
States)—and almost all rearms are registered, mostly for
recreational hunting. A high registration rate overestimates
the number of rearms in international comparisons. The
highest per capita rearm density is seen in rural areas with
strong hunting traditions, e.g., 1.6 guns/inhabitant in the
Åland island, Kumlinge, where seabird hunting is common,
but only 0.1 guns/inhabitant in the capital, Helsinki. Since
1950, 13 mass murders (i.e., more than two victims) have
taken place, killing 58 persons and injuring 200. These
include three school shootings (1989, 2007, and 2008)
with 22 deaths.
Most homicides and serious penetrating vascular trauma
are typically caused by stabbing. The causes of death have
been registered in Finland since 1754 and the year 2017
recorded the lowest homicide incidence since 1782, with
1.11 victims/100,000 inhabitants. Despite positive changes
in society and a decline in many risk factors, stabbings still
happen, usually in private apartments, between middleaged, unemployed, alcohol-addicted men who are known
to each other. Both the victim and the stabber typically
have 1 to 3 mg/mL of alcohol in their blood (ndikaattori.
/en). Assaults against police ofcers are rare. In the Helsinki region with roughly 1 million inhabitants, 22 ofcers
have been killed, including all causes, in the 103 years since
independence. In the 21st century, two ofcers have been
killed in Finland. The police red 122 times between 2003
and 2013 and seven persons were killed in these incidents
(poliisi./en).
The exact incidence of vascular trauma in Finland is
unknown because of the distribution of victims to different
hospitals and the lack of a dedicated registry that includes
all vascular-trauma victims. Validated trauma registries
do not include all these patients as an injury severity score
(ISS) of greater than 15 is required.6 The national hospital
4,5
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discharge registry, based on ICD-10 coding, gives rough
estimates, but not more detailed information and, although
validated for other vascular diseases,7 their reliability in
detecting vascular trauma has not been evaluated. Finnvasc,
glob ally among the rst vascular registries with national
coverage, was founded in 1989, but was reduced to regional
registries due to data privacy issues. It is currently regaining national coverage. The national vascular registry will,
as regards vascular injury, still suffer from the fact that
vascular trauma is treated by many different hospitals and
surgeons do not systematically report all incidents to the
registry. In the second largest hospital, Tampere University
Hospital, 143 noniatrogenic vascular trauma patients were
treated between 2006 and 2010, giving an incidence of
5.8/100,000 inhabitants. Of these patients, 58% (n = 85)
sustained injuries to the upper arm. Penetrating mechanism was more common in men than women (83% vs 17%).
Sixty-ve percent of the vascular injuries were treated with
open surgery, 11% by endovascular means, and 24% without vascular intervention. Two (12%) of the lower limb vascular injuries led to amputation. The 30-day mortality was
zero, but this did not include prehospital deaths.
Iatrogenic vascular injuries are today by far the most common type of vascular trauma, obviously caused by the huge
increase in cardiac, neurovascular, and vascular interventions. In Sweden, 1/6000 knee prosthesis operations lead to
a popliteal artery injury (32 injuries in 24 years), whereas
a total of 888 iatrogenic vascular injuries were registered
during the same time period, mostly from endovascular procedures.9 The proportion of iatrogenic injuries amongst all
injuries increased progressively from 57% in 1987–93 to
79% in 2002–05.
10
8
Vascular and Trauma Surgery
Finland became independent in 1917 and the early years
of trauma surgery were proled by military surgery due to
unrest both in the region and internationally. The founding
father of Red Cross Finland, a prominent military surgeon
who served in seven major conicts from the Russo-Japanese War to the Second World War, was Richard Faltin
(1867–1952). In his honor, the Finnish Surgical Society
still annually acknowledges prominent national and international surgeons with a Faltin prize and lecture (including
Norman M. Rich in 2013). From the early days of surgical
training in Finland, doctors have realized the importance of
international collaboration and many vascular and trauma
surgeons have earned their expertise in the international
scene.
Vascular surgery became an independent specialty in Finland in 1997 when it ofcially separated from cardiothoracic
surgery, and a national training program was dened with
3 years general surgical training in all surgical specialties,
followed by 3 years of vascular surgical training. In Sweden,
vascular surgery evolved from general surgery, became a
branch specialty in 2006, and a monospecialty in 2015.
Irrespective of the different backgrounds, vascular surgery
in the Nordic countries today may be considered similarly:
an independent specialty performing both open and endovascular surgery. In Finland in 2020, in order to better
adapt to the needs of highly specialized modern surgery, the
manda tory common general surgical period was shortened,
and a 5-year specialty-specic, target-oriented training
program was introduced. From the beginning, endovascular treatment has been a part of the training of vascular
surgeons. It is currently increasing in volume, as hybrid
operation theatres are used primarily by vascular surgeons.
Despite typical problems (as to who takes care of which
patients and performs which procedures), signicant turf
wars have been avoided and today the collaboration between
angioradiologists and vascular surgeons is mostly nonproblematic. This is due to the absence of strong economic incentives to guide patient ow and because public hospitals treat
all patients in their respective regions. Furthermore, there
is no competing angiology specialty and neither neuro nor
cardiac interventionalists perform peripheral interventions.
Trauma surgery has traditionally been practiced by
trauma-oriented orthopedic surgeons, with nonskeletal
trauma managed by general and visceral surgeons (with
the support of plastic, vascular, and cardiothoracic surgeons when appropriate). Embolizations are performed by
angioradiologists and increasingly also by vascular surgeons. Acute care medicine is a new and growing specialty,
yet to dene its role in trauma care.
Vascular and Endovascular Trauma
Surgery Training, Availability, and
Challenges
Due to the generally small numbers of trauma patients in
any given health system, specic trauma-oriented training
programs are essential. The Finnish Trauma Association
(traumasurgery.), founded in 2000, has taken an active
role and introduced several formal training opportunities
since 2008. Currently, the Denitive Surgical Trauma Care
(DSTC), European Trauma Course (ETC) and Advanced
Surgical Skills for exposure in Trauma (ASSET) are almost
mandatory for young surgeons and acute care specialists
who wish to focus on trauma. Many have spent time abroad
in dedicated trauma centers, and simulation training of
trauma teams is routine in many hospitals.
One of the limiting issues in modern trauma care is the
availability of 24/7 endovascular skills. All ve university hospitals can provide this with their on-call systems,
though not necessarily residential in-hospital availability.
Most smaller hospitals have angiology suites and c-arms in
the theatres, but round-the-clock expertise is not as readily
available and depends on committed individuals. In 2001,
Helsinki University Hospital (HUS) built the rst hybrid theatre in Finland—one of the rst in Europe. It took 10 years
for the vascular surgeons to properly learn to utilize this
tool. Up to 2010, less than 100 hybrid operations were performed annually, but in 2019 vascular surgeons performed
386 hybrid procedures (excluding diagnostic or completion angiographies and procedures performed primarily by
angioradiologists). These were undertaken in two hybrid
suites with minimal friction, supported by angioradiologists
—clearly fullling the criteria for modern 24/7 endovascular trauma care capacity (Fig. 30.1). Trauma teams regularly train in simulation activities and hybrid theatre teams
train in endovascular ruptured aneurysm treatment.
11
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450
400
350
300
250
200
150
100
50
0
2003 2004 2005 2006 2007 2008 2009
Fig. 30.1 Hybrid procedures performed by vascular surgeons in Helsinki 2003–19. It took almost 10 years for the vascular surgeons to learn how to use
the hybrid theatre effectively in Helsinki University Hospital. Procedures performed in regular operation theatres with a c-arm are not included. In addition, diagnostic and completion angiographies and procedures performed primarily by an angioradiologist or cardiologist (transcatheter valves, etc.) are not
included. In 2013–14, the second hybrid theatre was built.
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Resuscitative balloon occlusion of the aorta (REBOA) is
a controversial hot topic achieving fast worldwide approval
with increasing experience12 and is described in detail in
Chapter 11. In Finland, REBOA is widely trained for and
occasionally used in trauma but is used routinely in ruptured aneurysm surgery (Fig. 30.2). Trauma protocols
in the large hospitals include systematic instructions on
REBOA use and simulation training is used extensively. Inhospital trauma protocols are changing towards including
an early femoral sheath placement to facilitate REBOA, continuing to urgent endovascular treatment, when appropriate. REBOA is not used in the prehospital setting, at least
until more positive data is available.13 Hybrid rooms make
combinations of treatments possible in all university hospitals (Fig. 30.3). In Helsinki, the rst RAPTOR suite (resuscitation with angiography, percutaneous techniques, and
operative repair) with a combination of CT, angiography,
and open surgery possibility, is under construction.
14,15
The wide array of technical possibilities for the treatment
of severely injured patients16 brings pressure to change the
training of physicians and both prehospital and in-hospital
trauma protocols, as well as health-care systems in general,
with a greater need for centralization.
Hand-in-hand with the increase of endovascular skills,
the risk of decline in open vascular reconstruction skills is
inevitable. On the other hand, training programs are much
more systematic now than they were 20 years ago and, in
a study including blunt trauma laparotomies, only 11/89
operations needed a more complex skill set.17 Open vascular
surgery is still readily performed, especially in the lower limb.
Due to an increase in the elderly population, bypass surgery is on the rise despite the fact that many more patients
are treated with endovascular methods (Fig. 30.4). Major
open abdominal surgery is performed in large quantity,
Fig. 30.2 Fluroscopic image of REBOA being undertaken as automated
external cardiac compressions are applied. Resuscitative balloon occlu-
sion of the aorta (REBOA) is most often initially used blindly but is more
controlled when screening fluoroscopy is available. Here an automatic
resuscitating device is used while the REBOA is positioned in the descending thoracic aorta. In order to make vascular puncture easier and safer, it is
recommended to stop the resuscitating device for some seconds.
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Fig. 30.3 Hybrid Theatre. One or more hybrid theatres with a robotic
c-arm are available in the five university hospitals in Finland. Staffing these
on a full-time basis requires large centers with sufficient round-the-clockactivity. A considerable amount of training, including radiation safety, is
mandatory.
and trauma-oriented surgeons train in transplantation and
cardiothoracic surgery. Vascular surgeons are familiar with
large exposures thanks to a substantial increase in oncovascular surgery, where tumor surgery is combined with
vascular reconstructions and justied by improved oncological care. It seems that such interdisciplinary collaboration in the operating theatre is easier today than it was in
the late 20th century.
Summary
Finland and the Nordic countries are stable societies where
noniatrogenic vascular trauma is rare. Trauma systems are
publicly funded, planned, and organized. Economic stability
has made it possible to distribute modern facilities amongst
all parts of the country, but sparsely populated large areas
are a true challenge to the system. The political pendulum is moving towards a more centralized system, leaving
many smaller hospitals with a diminishing role and making longer transportation of even severely injured trauma
patients mandatory. Education, training, and international
collaboration are essential in maintaining and improving
the numbers of skilled vascular trauma surgeons, who
need to be ready to choose and perform the best open,
endovascular, or hybrid approach according to the situation. Furthermore, the “optimized trauma surgeon” should
have excellent collaboration and communication skills—a
challenging training task to tackle.
Fig. 30.4 Open exposure of proximal brachial artery. Open surgery is
still the most common approach to penetrating vascular trauma, as in this
case where a young construction site worker fell 2 m onto a steel pole
which penetrated his right armpit.
References
1. Raatiniemi L, Liisanantti J, Niemi S, etal. Short-term outcome and dif-
ferences between rural and urban trauma patients treated by mobile
intensive care units in Northern Finland: a retrospective analysis.
Scand J Trauma Resusc Emerg Med. 2015;23:91.
2. Kristiansen T, Søreide K, Ringdal KG, etal. Trauma systems and early
management of severe injuries in Scandinavia: review of the current
state. Injury. 2010;41:444–452.
3. Obstbaum Y. Kannabikseen suhtautumisessa eroja Pohjoismaissa. (In
Finnish) Haaste. 2019;19:12–13.
4. Rikander H. Voimankäyttöselvityshankkeen loppuraportti (In
Finnish, English abstract). Police academy report. 2016:124.
5. Niemi H. Rikollisuustilanne 2017. University of Helsinki, Institute for
criminology and justice politics. Report 29. English summary. Crime
trends in Finland, 2018.
6. Brinck T, Handolin L, Paffrath T, Lefering L. Trauma registry com-
parison: six-year results in trauma care in Southern Finland and
Germany. Eur J Trauma Emerg Surg. 2015;41:509–516.
7. Taha AG, Vikatmaa P, Albäck A, Aho PS, Railo M, Lepäntalo M. Are
adverse events after carotid endarterectomy reported comparable in
different registries? Eur J Vasc Endovasc Surg. 2008;35:280–285.
8. Pöyhönen R, Suominen V, Uurto I, Salenius J. Non-iatrogenic civilian
vascular trauma in a well-dened geographical region in Finland. Eur
J Trauma Emerg Surg. 2015;41:545–549.
9. Bernhoff K, Rudström H, Gedeborg R, Björck M. Popliteal artery
injury during knee replacement: a population-based nationwide
study. Bone Joint J. 2013;95:1645–1649.
10. Rudström H, Bergqvist D, Ogren M, Björck M. Iatrogenic vascular
injuries in Sweden. A nationwide study 1987-2005. Eur J Vasc Endo-
vasc Surg. 2008;35:131–138.
11. Aho P, Vikatmaa L, Niemi-Murola L, Venermo M. Simulation train-
ing streamlines the real-life performance in endovascular repair
of ruptured abdominal aortic aneurysms. J Vasc Surg. 2019;69:
1758–1765.
12. Borger van der Burg BLS, van Dongen TT, Morrison JJ, etal. A system-
atic review and meta-analysis of the use of resuscitative endovascular
balloon occlusion of the aorta in the management of major exsanguination. Eur J Trauma Emerg Surg. 2018;44:535–550.
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13. Bulger EM, Perina DG, Qasim Z, etal. Clinical use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in civilian trauma systems in the USA, 2019: a joint statement from the American College of
Surgeons Committee on Trauma, the American College of Emergency
Physicians, the National Association of Emergency Medical Services
Physicians and the National Association of Emergency Medical Technicians. Trauma Surg Acute Care Open. 2019;4(2019):e000376. https://
doi.org/10.1136/tsaco-2019-000376. eCollection.
14. Kirkpatrick AW, Vis C, Dubé M, et al. The evolution of a purpose
designed hybrid trauma operating room from the trauma service
perspective: the RAPTOR (Resuscitation with Angiography Percutaneous Treatments and Operative Resuscitations). Injury. 2014;45:
1413–1421.
15. Kinoshita T, Yamakawa K, Yoshimura J, etal. First clinical experiences
of concurrent bleeding control and intracranial pressure monitoring
using a hybrid emergency room system in patients with multiple injuries. World J Emerg Surg. 2018;13:56.
16. Faulconer ER, Branco BC, Loja MN, etal. Use of open and endovascu-
lar surgical techniques to manage vascular injuries in the trauma setting: a review of the American Association for the Surgery of Trauma
PROspective Observational Vascular Injury Trial registry. J Trauma
Acute Care Surg. 2018;84:411–417.
17. Kosola J, Brinck T, Leppäniemi A, Handolin L. Blunt abdominal trauma
in a European trauma setting: need for complex or non-complex skills
in emergency laparotomy. Scand J Surg. 2020;109(2):89–95. https://
doi.org/10.1177/1457496919828244. Epub 2019 Feb 20.
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Sweden
TAL M. HÖRER and CARL MAGNUS WAHLGREN
Introduction
The management of severe traumatic injury has undergone
major changes over the last 20 years, as Advanced Trauma
Life Support (ATLS), the concept of damage control, massive transfusion protocols, new technological innovations,
and improved intensive care have been implemented across
the world.1 Even in the eld of vascular trauma, there have
been developments in hemostatic resuscitation and vascular damage control including the use of tourniquets, vascular shunts, endovascular occlusion balloons, endografts
(i.e., stent grafts), and embolization to rene operative
techniques.
is regarded as the rst line of investigation for all patients
with suspected vascular trauma with no immediate indication for operative intervention.6 This review will provide
insights into current Swedish vascular trauma practice but
also discuss new nationwide trends in treatment modalities
and their implementation.
2–5
Computed tomography angiography (CTA)
The Swedish Trauma System
Sweden is the largest and most populated Scandinavian
country with a total population of 10.2 million (Swedish
government agency, 2019), and the fth largest country
in Europe by area. It has a low population density of 22
inhabitants per square kilometer (57/sq. mile) and about
85% of the population live in urban areas (about 40% in
the metropolitan areas of Stockholm, Gothenburg, and
Malmö). The country has several hard-to-reach areas,
mountainous, forested, and coastal, and a harsh winter
climate which imposes heavy demands on the prehospital
organization. These facts point out that the conditions for
trauma care differ within the country. There are currently
7 university hospitals and 57 emergency hospitals in Sweden. The university hospitals (Fig. 31.1) have resources
that might meet the criteria for a level-1 or level-2 trauma
center, with access to 24/7 general and vascular surgery, neuro- and thoracic surgery, and also intensive care
units. There has been an increasing trend towards trauma
care centralization in recent years, with severely injured
patients being transferred to major university hospitals
when possible.
The national trauma system in Sweden is currently
being reviewed after a 2015 national trauma investigation
report stated that it is essential for trauma care in Sweden
to be structured through the formation of networks (the
National Board of Health and Welfare, 2015). Such a network consists of a trauma center as hub with fully equipped
acute-care and surgical hospitals for trauma management
as satellites. All emergency activities are centralized at
one command center (“SOS alarm,” or “112”) that directs
units as required, and arranges and controls patient transfers. The majority of severely injured patients in these networks are transported by ground ambulance, but a large
and increasing proportion are transported by helicopter
to university hospitals. Ground ambulances are generally
equipped with basic life-support facilities and ambulance
nurses. Helicopter transport is available in most regions,
but there is no national helicopter service. Some regions of
the country have physician-operated air and ground ambulance services. There is no dedicated trauma-ambulance
service in Sweden.
The Swedish Trauma and Vascular
Registries
There is a national Swedish trauma registry since 2011,
SweTrau, that gathers data on all trauma cases. At present
46 hospitals in Sweden receiving serious trauma are connected to SweTrau. The national Swedish vascular registry,
Swedvasc, has been collecting information on procedures
since the late 1980s, and all cases of trauma that are carried out by vascular surgeons should be recorded in this
registry. All hospitals and vascular units perform endovascular surgery to some extent, but the amount varies according to experience, capabilities, facilities, etc. The Swedvasc
annual report of 2018 showed a clear and increasing trend
in use of endovascular procedures for vascular disease and
vascular injury within the country.
Trauma in Sweden
The amount of major trauma in Sweden has been increasing
as reported in recent SweTrau annual reports. Blunt injury
constitutes more than 90% of all trauma, half of which is
trafc-related, while one-third is due to falls (Fig. 31.2). There
has also been an increase in the number of rearm injuries in
recent years.7 In the largest Swedish trauma center, the proportion of penetrating trauma injuries increased from 5.3%
in 2005 to 12% in 2016, and the proportion of rearm injuries among all penetrating trauma injuries increased from
16% in 2005 to 36% in 2016.8 Injuries from violence are three
times more common among men compared to women, but fall
accidents are seen in a greater proportion among women. The
trauma distribution relating to age and gender in Sweden is
shown in Fig. 31.3. In summary, the mechanisms of injury
are dominated by trafc and falls, but there has been a recent
increase in penetrating injuries. Overall injury mortality over
time remains unchanged in Sweden but, looking at different
subgroups, there is a decline in mortality among children
(boys) and working-age groups, but an increase in mortality
among the elderly.
8
370
31 • Sweden 371
Fall
Traffic
10%
20%
30%
40%
50%
60%
Stab/shot
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Fig. 31.3 Age and gender distribution of trauma injuries in Sweden.
(From The Swedish Trauma Registry—SweTrau 2017, with permission.)
There are many challenges to the optimal management
of a severe injury in a country where trauma has not been
a major issue and where dedicated trauma surgeons are not
at hand. With trauma on the rise, many aspects of training, education, and centralization are constantly being discussed in Sweden. Issues concerning who should care for
trauma patients and how trauma teams should be trained
and maintain capacity are important.
Fig. 31.1 University hospitals in Sweden. Trauma care and vascular
trauma treatment are provided in these centers. All university hospitals
have full emergency-surgery capacity 24/7, with vascular, cardiothoracic, and neurosurgery units.
2013
2015
2017
0%
Fig. 31.2 Trauma injuries in Sweden by mechanism. (From The Swedish Trauma Registry—SweTrau 2017, with permission.)
Blunt object
Other
Vascular Trauma in Sweden
There are 23 vascular surgery units in the country. All university hospitals have endovascular service available 24/7
with vascular surgeons and/or interventional radiologists.
There is also around the clock access to hybrid suites in
many hospitals and, in a few, even to a dedicated hybrid
trauma suite with a trauma surgeon on call. Traditionally,
vascular surgeons have been involved in the management
of severe traumatic injury and for bleeding control, both as
general and vascular surgeon. Since 2010, their involvement has become ever more important, not only because
of trends in embolization and other endovascular methods,
but also because of the growing need for more specialized
surgeons. Interventional radiologists are mainly involved
in embolization procedures, although they vary in number
between hospitals in Sweden.
Vascular injuries in Sweden, in particular iatrogenic ones,
appear to be increasing when two time periods, 1955–84
and 1987–2005, are compared.
of procedures undertaken for the treatment of vascular
injuries increased from 1.2 to 1.6 per 100,000 inhabitants
between 1987 and 2005.
were 48% iatrogenic, 29% penetrating, and 23% blunt
trauma. More recent data show a larger volume of rearmrelated injuries; 17% of patients had major vascular injuries, a proportion that increased over the years.7 The most
commonly injured vascular region is the lower extremity
vessels at 26/54 (48%), followed by vessels in the chest
and abdomen. The femoral artery was the most commonly
injured vessel (24%), followed by the inferior vena cava
(9%), visceral vessels (9%), and iliac arteries (9%).7 Vascular
injuries in children are fortunately relatively un common,
9,10
The annual incidence
8,9
Of all vascular injuries, there
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both in Sweden and globally.
11,12
A survey of Swedvasc
data on injuries in children undergoing vascular surgery,
between 1987 and 2013, showed that boys (148/222) and
blunt trauma were predominant.12 The primary anatomic
locations of vascular injuries in children were the upper
(60%) and the lower extremities (29%), followed by the
abdomen (7.2%). Repair techniques included interposition
graft, patch, primary repair (lateral suture/direct anastomosis), and bypass. Endovascular techniques were used for
only eight children (3.7%). The outcome at 30-days showed
one above-knee and two below-knee amputations as well as
one death, but there were no further deaths at 1-year after
injury. In general, endovascular techniques are being used
with great caution in children, for obvious reasons related
to age and growth, and open surgery remains the method
of choice wherever possible for many injuries.
The national volume of procedures for aortic trauma has
been low and constant in recent years (Fig. 31.4). There
were 81 registered procedures between 2010 and 2017:
mean age 55 years (SD 21), 73% men, 30-day and 90-day
mortality both 12% (Swedvasc annual report, 2018).
Endovascular procedures clearly predominated, and the
anatomic locations were mainly in the arch and descending
thoracic aorta.
New Developments in Vascular
Trauma Management: the Concept
of Endovascular Resuscitation and
Trauma Management (EVTM)
Vascular surgery has undergone major changes since
2000, in both Sweden and most other developed countries. One of the major developments lies in the shift
from open to endovascular surgery, with an exponential
increase in the number of endovascular interventions.
For example, currently about 60% of infrarenal aortic
aneurysms are treated by endovascular aortic repair
(EVAR) with an increasing trend over the last few years
(Swedvasc annual report, 2019). As endovascular and
hybrid methods have advanced, with concomitant developments in the use of CTA, ultrasound, and angiography,
the majority of ruptured aneurysms can now be treated
by endovascular means. Indeed, in some centers, endovascular treatment predominates.13 On a national level
in 2018, 53% of ruptured infrarenal aortic aneurysms
were treated with EVAR (Swedvasc annual report 2019).
Several centers in Sweden have been among the leaders
200
150
100
50
Aneurysm
Dissection
Trauma
Fig. 31.4 The number of registered operations for treatment of aortic aneurysms, dissections, and trauma between 2010 and 2017 (treatment of
infrarenal aorta excluded). (From the Swedish vascular registry—Swedvasc 2018, with permission.)
201002011 2012 2013 2014 2015 2016 2017
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in the endovascular era and paved the way for the use
of endovascular and hybrid tools in trauma and bleeding
management.14 Endovascular balloon occlusion of the
aorta during EVAR for ruptured aneurysms was adopted
at an early stage in Sweden.
13–16
Embolization procedures
for traumatic, gastrointestinal, and obstetric bleeding
have been used not only by interventional radiologists,
but also and increasingly, in some centers solely, by vascular surgeons. Endografts, in relatively small volumes,
for iatrogenic and vascular trauma have been part of
the treatment algorithm in Sweden for many years, and
more recently REBOA (resuscitative endovascular balloon occlusion of the aorta) has been used for suitable
patients in selected centers.
The evolution of technology, in conjunction with the
work of skilled and enthusiastic vascular surgeons, has
laid the foundation for the development of endovascular
and hybrid (combined open and endo) tools for bleeding
and resuscitation. Many different but parallel efforts in
this area around the world have now coalesced under the
name Endovascular Resuscitation and Trauma Management or EVTM.
14,16
With Sweden as the global hub, EVTM
has emerged as a multidisciplinary group of professionals
and an expanding set of technologies applied to the management of the severely ill and injured patient (http://www.
jevtm.com/about/). The EVTM concept is focused on chal-
lenging the dogma of “open surgery always” for unstable
or potentially unstable patients. Some of the tools involved
are early vascular access, REBOA if needed, embolization,
endograft, surgery in a hybrid or semihybrid suite, with an
endo-tool adjunct to open surgery available at all times (Top
Stent Manual, 2017:16). The extent of implementation of
these methods varies from hospital to hospital, but they can
be and are applied in modern centers as well as in austere
environments.
16,17
EVTM is developing as a scientic platform in the Journal of Endovascular and Trauma Management (JEVTM) (www.jevtm.com) and also for collaboration
in endovascular and hybrid procedures for both trauma and
nontrauma cases.
Education in Vascular Trauma
There has been a traditional emphasis on trauma education in Sweden, in part to offset and prepare for a relatively
low volume of severely injured patients. Both theoretical
and practical courses in vascular trauma have been available for residents in surgery, but also post-specialization in
surgery and vascular surgery. Live-tissue training has been
used to teach and maintain vascular exposure skills, as well
as for the practice of open and endovascular techniques.
The Swedish Surgical Society’s course in Emergency Vascular & Trauma Surgery and the Denitive Surgical Trauma
Care courses (DSTC; International Association for Trauma
Surgery and Intensive Care; IATSIC) have been available for
general and vascular surgeons for many years. There is also
a military version of the DSTC course in Sweden. Wo rkshops
on the EVTM concept and on REBOA are held several times
a year, attracting great interest and participation in Sweden
and from other countries (http://www.jevtm.com/work-
shop/). These courses and workshops including different
level of experience, from residents to senior consultants, aim
to increase knowledge and experience in the management
of vascular trauma. Some of the traditional courses have
adopted the EVTM concept and parts of EVTM are being
incorporated in coming courses (i.e., the DSTC course).
Future Aspects
Vascular trauma in Sweden is likely to increase in the coming years, and proper training for surgical techniques to
control hemorrhage and restore circulation are very important. The early involvement of vascular surgeons in trauma
cases and the implementation of the EVTM concept may
improve results. Continuous registry data evaluation with
critical review of traumatic vascular cases using different
surgical techniques, will help us to improve the outcomes of
challenging vascular injuries.
References
1. Cannon J. Hemorrhagic shock. N Engl J Med. 2018;378:1850–1853.
2. Kalkwarf KJ, Cotton BA. Resuscitation for hypovolemic shock. Surg
Clin North Am. 2017;97(6):1307–1321.
3. Cannon JW, Khan MA, Raja AS, etal. Damage control resuscitation in
patients with severe traumatic hemorrhage: a practice management
guideline from the Eastern Association for the Surgery of Trauma.
J Trauma Acute Care Surg. 2017;82(3):605–617.
4. Inaba K, Siboni S, Resnick S, etal. Tourniquet use for civilian extrem-
ity trauma. J Trauma Acute Care Surg. 2015;79(2):232–237.
5. Gruen RL, Brohi K, Schreiber M, et al. Haemorrhage control in
severely injured patients. Lancet. 2012;380(9847):1099–1108.
6. Patterson BO, Holt PJ, Cleanthis M, etal. Imaging vascular trauma. Br
J Surg. 2012;99(4):494–505.
7. Bäckman PB, Riddez L, Adamsson L, Wahlgren CM. Epidemiology of
rearm injuries in a Scandinavian trauma center. Eur J Trauma Emerg
Surg. 2020;46(3):641–647.
8. Bäckström D, Larsen R, Steinvall I, Fredrikson M, Gedeborg R,
Sjöberg F. Deaths caused by injury among people of working age
(18–64) are decreasing, while those among older people (64+) are
increasing. Eur J Trauma Emerg Surg. 2018;44(4):589–596.
9. Bergqvist D, Helfer M, Jensen N, Tägil M. Trends in civilian vascu-
lar trauma during 30 years. A Swedish perspective. Acta Chir Scand.
1987;153(7-8):417–422.
10. Rudström H, Bergqvist D, Ogren M, Björck M. Iatrogenic vascular
injuries in Sweden. A nationwide study 1987–2005. Eur J Vasc Endo-
vasc Surg. 2008;35(2):131–138.
11. Kayssi A, Metias M, Langer JC, etal. The spectrum and management
of noniatrogenic vascular trauma in the pediatric population. J Pediatr
Surg. 2018;53(4):771–774.
12. Wahlgren CM, Kragsterman B. Management and outcome of pediat-
ric vascular injuries. J Trauma Acute Care Surg. 2015;79(4):563–567.
13. Mayer D, Aeschbacher S, Pfammatter T, etal. Complete replacement
of open repair for ruptured abdominal aortic aneurysms by endovascular aneurysm repair: a two-center 14-year experience. Ann Surg.
2012;256(5):688–695.
14. Hörer TM, Skoog P, Pirouzram A, Nilsson KF, Larzon T. A small case
series of aortic balloon occlusion in trauma: lessons learned from its
use in ruptured abdominal aortic aneurysms and a brief review. Eur J
Trauma Emerg Surg. 2016;42(5):585–592.
15. Malina M, Veith F, Ivancev K, Sonesson B. Balloon occlusion of the
aorta during endovascular repair of ruptured abdominal aortic aneurysm. J Endovasc Ther. 2005;12(5):556–559.
16. Hörer T. Resuscitative endovascular balloon occlusion of the aorta
(REBOA) and endovascular resuscitation and trauma management
(EVTM): a paradigm shift regarding hemodynamic instability. Eur J
Trauma Emerg Surg. 2018;44(4):487–489.
17. Reva V, Hörer TM, Samokhalov I, etal. Femoral arterial closure after
REBOA using the fascia suture technique: rst experiences in a military setting. JEVTM. 2018;2(2):7–76.
32
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Russia
IGOR M. SAMOKHVALOV and VIKTOR A. REVA
Historical Background
Russian surgeons have made signicant contributions to
vascular surgery. After Nikolai Pirogov, one of the founders
of military surgery, investigated vascular trauma and published one of the rst atlases on vascular anatomy, many
Russian surgeons have contributed to the eld of vascular
trauma: the portocaval anastomosis by Nikolai Ekk (1877),
a lateral arterial suture by Alexander Yassinovsky (1899),
blood pressure “sounds” of Nikolai Korotkov (1905),1 rst
suturing of the ascending aorta by Yustin Dzhanelidze
(1913), the rst heart-lung machine by Sergey Brukhonenko (1920), the rst vascular circular-suturing device
by Vasilij Gudov (1945), and kapron temporary intravascular shunts (TS) by Colonel Boris Matveev (1959). After
WWII, vascular centers and units (Boris Petrovsky, Petr
Kupriyanov, Alexander Shalimov, Victor Savel'ev, Anatoly
Pokrovsky, etc.) were established in big cities. Post-WWII
achievements include the rst temporary balloon occlusion
of the internal carotid artery for selective cerebral angiography and detachable balloons by Fedor Serbinenko (1969),
and the invention of the stent graft and its rst implantation for blunt traumatic aortic pseudoaneurysm by Nikolai
Volodos (1987). Endovascular surgery in Russia derived
from vascular surgery and is nowadays a separate specialty
covering all the issues of neuro-, cardiac, and peripheral
interventions. In turn, open vascular surgery has been signicantly improved during recent armed conicts.
Russian military medics provided care to casualties during
the Soviet War in Afghanistan (1979–89; SWA), counterterrorist operations in the North Caucasus region (1994–96,
1999–2002; CO-NC), and lately in Syria (since 2015; CO-S).
Epidemiology
The rate of major vascular injuries has increased from 4.5%
in SWA to 6% in CO-NC to 10% in CO-S, reaching the numbers reported by other investigators. Extremity artery injuries prevailed in all conicts due to “mine war,” accounting
for 80% to 90% of all vascular cases. Carotid artery injuries
occurred in less than 5% of cases, with the remaining 5% to
15% being torso vascular injuries.
During the SWA, a rst-aid kit contained two eld dressings and a rubber tourniquet. Combat medics were equipped
with 15 to 20 eld dressings, 4 or 5 tourniquets, 2 units
of crystalloid, and a supply of drugs for 3 days. Nowadays,
elastic bandages, new tactical tourniquets (ZhK-01/02,
Medplant, Russia), and chitosan-based local hemostatic
agents (Hemoex, Russia and others) are used for prehospital hemorrhage control. There was a reduction in tourniquet application for external bleeding from SWA to CO-NC
from 51% to 32% and then to 22%. This was because for
every second casualty injured in Afghanistan where a tourniquet was applied, extremity amputation was performed
because of prolonged tourniquet times.
For the purpose of achieving skilled casualty tactical
evacuation, advanced airmobile medical teams – consisting of a surgeon, an anesthetist, and an anesthetist-nurse
– were created. Standard anesthesia equipment on board
high-capacity Mil Mi-8 helicopters equipped with a twostretcher special module was used during evacuation (more
than 90% of all evacuations were by air). Average time to
initial surgery decreased from 4 to 6 hours in the SWA to
2.5 to 4 hours in the CO-NC and 2 to 3 hours in the CO-S.
Damage control surgery was provided at role 2/2E forward
medical units in Bagram, Kunduz, Feizabad, and Jelalabad
deployed in wooden detachable modules (SWA), at Mozdok,
Vladikavkaz Harrison military hospitals (CO-NC), and at the
Khmeimim Air Base hospital primarily deployed in inatable tents, and since 2018, in sheltered containers (CO-S).
To provide optimal care for vascular injuries, one military vascular surgeon and one blood bank physician have
been included in every surgical team. In SWA, however, a
group of vascular specialists in the Kabul Army Hospital in
Kabul was established in 1985. Vascular surgeons were also
sent to role 3 during the CO-NC.
Role 2 or 3 facilities had access to air transportation infrastructure, and most of the injured were strategically evacuated within a few postoperative days. This was performed
by an anesthetist-based team on board an Ilyushin IL-76
aircraft equipped with a module for care of the severely
wounded. Denitive surgical care was provided at the Kabul
Army Military Hospital (SWA) and/or in Regional (Rostovon-Don, CO-NC) and Central (Moscow) Military Hospitals or
in the Kirov Military Medical Academy (Saint-Petersburg).
Specific Systems of Care
Modern combat casualty care (CCC) algorithms were
rst implemented during the CO-S. CCC consists now of
5 sequential stages: prehospital care and tactical evacuation
(role 1), primary (damage control) surgery and resuscitation (role 2), denitive in-theater surgery (role 3), strategic
evacuation, and specialized surgical care (role 4 or 5).
374
Specific Considerations for
Diagnosis
Physical examination, single-shot angiography, and vascular exposure were previously used for timely diagnosis. Currently, extensive imaging capabilities have appeared in more
forward hospitals. Hand-held Doppler, portable ultrasound
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