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Endovascular Management of Thoracic and Abdominal Trauma

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Endovascular Resuscitation and Trauma Management

Part of the book series: Hot Topics in Acute Care Surgery and Trauma ((HTACST))

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Abstract

Endovascular methods to achieve torso hemorrhage control continue to evolve. Early results suggest that endovascular hemostasis is associated with fewer systemic complications when compared with open repair for many vascular beds. This chapter is designed to outline the contemporary utilization of endovascular techniques in the setting of NCTH as an adjunct to surgery for control and as definitive repair. We will describe developed and refined approaches for hemorrhage associated with axillosubclavian injuries, blunt thoracic aortic injuries, visceral injuries, aortic injuries, and pelvic injuries.

Additionally, endovascular adjuncts are seeing increased use as tools to facilitate open repair, such as with REBOA or selective balloon occlusion prior to an incision.

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Author information

Authors and Affiliations

  1. Division of Vascular and Endovascular Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA

    Ravi R. Rajani & Christopher Ramos

Authors
  1. Ravi R. Rajani
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  2. Christopher Ramos
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Corresponding author

Correspondence to Ravi R. Rajani .

Editor information

Editors and Affiliations

  1. Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden

    Tal Hörer

  2. University of Maryland Medical Center, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA

    Joseph J. DuBose

  3. F. Edward Hebert School of Medicine – “America’s Medical School”, Uniformed Services University of the Health Sciences, Bethesda, MD, USA

    Todd E. Rasmussen

  4. The Department of Surgery at Uniformed Services, University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD, USA

    Joseph M. White

Expert’s Comments by Yoram Kluger

Expert’s Comments by Yoram Kluger

This chapter by Ravi R. Rajani, MD, FACS, and Christopher Ramos, MD, outlines the various angiographic diagnostic and therapeutic tools available for the management of injuries presenting with non-compressible bleeding.

Correctly indicated endovascular methods to achieve torso hemorrhage control continue to advance. The endovascular approach is associated with fewer unwarranted complications than traditional open techniques. Specifically, this chapter describes endovascular approaches associated with axillo-subclavian, blunt thoracic aortic, visceral (liver, spleen, kidney), aortic, and pelvic injuries. Approaching these life-threating injuries with an endovascular technique has revolutionized trauma management and resulted in saving the lives of many patients who would previously have succumbed to their injuries or to complicated surgery in the operating theater.

The proper selection of patients, based on their mechanism of injury, injury pattern, and hemodynamic status, is of utmost importance in the utilization of endovascular techniques to arrest bleeding. The timely availability of expert personnel to carry out diagnostic and therapeutic angiographic maneuvers, of a designated operating room (hybrid operating theater) that will allow management of other injuries, and a coordinated team approach to the injured will result in better outcomes due to early and prompt control of the bleeding vessels or organs. Thereafter, the trauma surgeon will continue with surgery to manage hollow viscus injuries or other injuries as indicated.

The authors of this chapter wish to highlight current knowledge on resuscitative endovascular balloon occlusion of the aorta (REBOA). This approach to resuscitation is becoming more frequently used as an adjunct to the management of patients in profound shock following trauma. However, even with the increasing attention paid to REBOA as a temporary tool to arrest bleeding in trauma patients, Level-1 data is currently lacking. The present guidelines are based on expert opinions and a limited number of case reports only.

In a recent publication [33] on REBOA in selected patients with hemorrhage and shock, Brenner and colleagues indicated that REBOA has a survival advantage over emergency room thoracotomy, predominantly in patients not requiring CPR (REBOA = 44% survived to discharged vs. EDT = 0%, p = 0.008). This cohort is a subset of the American Association for the Surgery of Trauma (AAST) Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery (AORTA) study initiative that did not show any difference in survival between patients who received REBOA and those who underwent emergency room thoracotomy. The authors [33] also conclude that considerable additional study is needed to further recommend this resuscitative approach in the management of subsets of trauma patients.

In this chapter, the authors quote systolic blood pressure of <80 mmHg as a potential indicator for proceeding with resuscitation using REBOA. Obviously, REBOA should not be applied to hemorrhaging injuries in the thorax. It is obvious that intra-aortic balloon occlusion has a place in the armamentarium of the trauma surgeon while dealing with an exsanguinating patient. We should carefully scrutinize the available data and conduct prospective randomized well-controlled trials to define REBOA’s place in resuscitation.

Proper use of REBOA versus abuse is currently a major concern.

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Rajani, R.R., Ramos, C. (2020). Endovascular Management of Thoracic and Abdominal Trauma. In: Hörer, T., DuBose, J., Rasmussen, T., White, J. (eds) Endovascular Resuscitation and Trauma Management . Hot Topics in Acute Care Surgery and Trauma. Springer, Cham. https://doi.org/10.1007/978-3-030-25341-7_4

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  • DOI: https://doi.org/10.1007/978-3-030-25341-7_4

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-25340-0

  • Online ISBN: 978-3-030-25341-7

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