Endovascular Trauma Management

Background

Origins: Developed and formalized by Hörer and colleagues in Örebro, Sweden, beginning in the early 2010s, EVTM led to the foundation of the EVTM Society and the launch of the Journal of EndoVascular Resuscitation and Trauma Management (JEVTM) ^[1].

Scope: 16EVTM does not replace open surgery but integrates endovascular resuscitation and bleeding control, enabling tailored, patient-specific trauma management ^[2]. For foundational principles of 15vascular trauma management, see the Vascular Trauma chapter.

Core Philosophy: Access early, control early, resuscitate endovascularly, and treat bleeding with a hybrid toolbox ^[2].

Pathophysiology of Endovascular Resuscitation

Hemorrhagic shock produces progressive oxygen debt and a self-reinforcing cycle of hypoperfusion, acidosis, hypothermia, and coagulopathy (“lethal triad/lethal diamond”). Early hemorrhage control and damage control resuscitation (DCR) are therefore time-critical. ^{[3] [4]}

Where EVTM fits in DCR

EVTM complements DCR by providing rapid proximal or selective hemorrhage control (e.g., REBOA, selective balloon occlusion, embolization, covered stents/stent-grafts) that can shorten time-to-hemostasis and reduce the duration of profound shock while definitive surgical/IR control is arranged. ^{[5] [2]}

Physiologic principles of aortic balloon occlusion

• Complete occlusion (cREBOA): maximizes proximal perfusion but risks severe distal ischemia and reperfusion injury; use the shortest feasible occlusion time and transition quickly to definitive control. ^[6]
• Partial/intermittent REBOA (pREBOA/iREBOA): titrated deflation can preserve some distal flow and attenuate metabolic burden compared with continuous complete occlusion, especially as a bridge when definitive hemostasis is not yet achieved. ^[7]

Endovascular hemostasis and preservation of perfusion

Covered stents and stent-grafts can exclude arterial disruption while maintaining in-line flow, which is particularly valuable for junctional vessels (subclavian/axillary/iliac) that are difficult to expose surgically in unstable patients. ^[8]

Embolization provides distal/branch control (e.g., pelvic arterial bleeding, solid organ injury) and is commonly integrated into pelvic hemorrhage pathways alongside packing and/or REBOA depending on physiology and resource availability. ^[9]

For surgical damage control concepts (packing, abbreviated laparotomy, open abdomen strategy), see Damage Control Surgery and Open Abdomen. ^[10]

Femoral Access

Femoral arterial and venous access is the practical “gateway” to 16EVTM—it enables REBOA, diagnostic angiography, embolization, covered stents/stent-grafts, and high-flow resuscitation lines. ^[2]

Access standards (trauma-ready and complication-aware)

• Ultrasound-guided common femoral artery (CFA) puncture is preferred to reduce high/low sticks and access-site complications. ^{[6] [11]}
• Use a micropuncture-first technique when feasible, then upsizing over a confirmed wire.
• Confirm intraluminal wire position (fluoroscopy when available; otherwise pressure tracing and ultrasound) before placing large-bore sheaths.

Sheath size and device planning

• Use the smallest effective arterial sheath; contemporary REBOA systems commonly allow 7 Fr access, which may reduce limb ischemia and access morbidity compared with larger legacy systems. ^[6]
• Plan early for: (1) exchange length wires, (2) compatible covered stents/balloons, and (3) a defined end-point (hybrid OR, IR, or OR).

Venous access

• Large-bore femoral venous access supports rapid transfusion during DCR and may facilitate extracorporeal support in select scenarios. Coordinate line placement to avoid compromising future surgical exposure.

Hemostasis/closure strategy

• For large-bore arterial access, plan for device closure vs surgical repair based on sheath size, CFA quality, anticoagulation/coagulopathy, and available expertise. ^[11]

See also Vascular Access for standardized access technique, complication management, and closure options. ^[11]

REBOA

REBOA is a temporizing technique for noncompressible torso hemorrhage (NCTH) in profoundly unstable patients, intended as a bridge to definitive hemorrhage control (OR, hybrid OR, or IR). Appropriate systems require training, governance, and time targets. ^[6]

Table 15.1. REBOA Aortic Zones and Deployment Guidelines ^[6]

Patient selection (systems-level safety)

• Consider REBOA when: profound shock with suspected NCTH and an immediately available pathway to definitive hemostasis (hybrid OR/OR/IR). ^[6]
• Avoid/strongly caution when: major thoracic bleeding proximal to Zone I, suspected aortic rupture/dissection, or when definitive control is not rapidly achievable (risk of prolonged ischemia). ^{[6] [12]}

Technique essentials

• Prefer ultrasound-guided CFA access; confirm intraluminal wire position prior to upsizing. ^[6]
• Inflate using physiologic endpoints (proximal BP response) and confirm position with imaging when available.
• Define the “bridge endpoint” before inflation: (1) laparotomy, (2) pelvic packing + angio, (3) endograft/covered stent, or a hybrid combination. ^[2]

Partial and intermittent REBOA

Titrated balloon deflation (pREBOA/iREBOA) may reduce distal ischemia and reperfusion burden during bridging, particularly when transport or procedural delays occur; it requires continuous hemodynamic monitoring and an experienced team. ^[7]

Evidence and limitations

• Multicenter observational data (e.g., AORTA registry) demonstrate feasibility and define complication profiles, but outcomes are highly dependent on indication, timing, and comparator choice. ^[13]
• Comparative observational analyses versus resuscitative thoracotomy show mixed results and are vulnerable to selection bias; REBOA benefit is most plausible when used early with rapid transition to definitive hemostasis. ^[14]
• National datasets also suggest substantial practice variability and reinforce the need for protocolized use. ^[15]

See also: Damage Control Surgery and Massive Transfusion for coordinated DCR during balloon occlusion and deflation. ^[4]

Endovascular Stent-Grafts

Covered stents and stent-grafts are core EVTM tools for rapid hemorrhage control with preservation of in-line flow, especially in anatomically hostile or unstable scenarios where open exposure is slow or morbid. ^[8]

Table 15.4. Endovascular Stent-Grafts in Trauma (Practical Use) ^[8]

Traumatic thoracic aorta

Endovascular repair is widely used for BTAI in appropriately selected patients, with guideline support for endovascular-first strategies when anatomy permits. ^{[16] [12]}

Antithrombotic and infection considerations

• Trauma patients may have competing bleeding risks; antiplatelet/anticoagulation plans must be individualized and revisited after hemostasis.
• Stent-graft infection is uncommon but catastrophic; contamination, bowel injury, and prolonged bacteremia increase concern. ^[17]

Post-procedure surveillance

When feasible, arrange follow-up imaging (CTA or duplex depending on vascular bed and device) to detect endoleak, stenosis, or thrombosis (practice varies by territory). See Aortic Disease and Follow-up After Endovascular Repair. ^[12]

Endovascular Embolization

Table 15.3. Endovascular Embolization Agents and Applications

Indications: - Pelvic hemorrhage (pelvic ring fractures) ^[9] - Solid-organ trauma (spleen, liver, kidney) - Junctional or retroperitoneal bleeding

WSES Recommendation: Angioembolization as first-line for uncontrolled pelvic bleeding where available, with preperitoneal pelvic packing as complementary when angiography is delayed ^[9].

Temporary Intravascular Shunts

Temporary intravascular shunts (TIVS) are used in extremity vascular trauma to restore perfusion during resuscitation and orthopedic stabilization ^[18]. In the EVTM context, TIVS can be combined with endovascular techniques such as REBOA ^[2] to achieve proximal hemorrhage control while maintaining distal limb perfusion.

Key considerations in EVTM: * Shunt placement may follow REBOA deployment to allow deflation while preserving limb perfusion * Enables staged definitive repair after physiologic optimization * Civilian and combat series report limb-salvage rates >90% with appropriate shunt use

For comprehensive TIVS protocols including indications, shunt selection, fixation techniques, anticoagulation, dwell times, and outcomes data, see 15Ch. 15.

Hybrid Trauma and Endovascular Surgery

Hybrid trauma and endovascular surgery integrates open damage control surgery with immediate angiography/endovascular control, minimizing time lost to transfers and enabling physiology-driven sequencing (control hemorrhage first, then definitive repair). ^{[2] [19]}

Why hybrid matters in EVTM

• Enables simultaneous laparotomy/thoracotomy with REBOA management, embolization, and covered stent deployment.
• Reduces “handoff delays” for unstable patients who cannot tolerate transport to IR.
• Supports iterative damage control: packing/temporary closure → angioembolization → reassessment → staged definitive repair. ^[10]

Table 15.5. Location of Care for Unstable Hemorrhage (Practical Framework)

Pelvic hemorrhage integration

Hybrid capability is particularly valuable for pelvic fracture hemorrhage where pathways commonly combine binder/PPP, selective REBOA (Zone III), and angioembolization depending on physiology and resource timing. ^{[9] [6]}

See also: Pelvic Trauma Hemorrhage and 15Ch. 15.

EVTM in Resuscitation Workflows

Table 15.2. EVTM Resuscitation Workflow (Physiology-First, Time-to-Control) ^[2]

Key workflow rule

REBOA and other EVTM tools are not definitive therapy; they are time-buying interventions that must shorten the interval to hemostasis, not prolong it. ^{[6] [5]}

Cross-reference: Damage Control Surgery and Massive Transfusion. ^[4]

Outcomes and Evidence

Evidence landscape

Most EVTM outcome data are observational (registries, administrative datasets, and single-center series). Interpretation requires attention to indication, timing, comparator selection, and survivorship bias. ^{[13] [15]}

REBOA outcomes

• Registries demonstrate feasibility and define complication patterns; outcome signals vary by indication and practice environment. ^[13]
• Comparative observational analyses versus resuscitative thoracotomy show mixed results and are highly selection-dependent. ^[14]

Hybrid/endovascular strategy outcomes (what “success” means)

Beyond survival, meaningful endpoints include:

• Time to hemorrhage control
• Blood product utilization
• Organ failure and ischemic complications (renal/visceral/limb)
• Need for fasciotomy or access repair
• Limb salvage and functional outcome (especially in extremity/junctional trauma). ^[20]

Why registries remain central

Given case heterogeneity and low event frequency at single centers, multi-institution registries are important for benchmarking, governance, and complication surveillance. ^[21]

See also: 15Ch. 15 for extremity injury outcomes and shunt/bypass benchmarks.

Complications

Complications of EVTM arise from (1) large-bore access, (2) ischemia–reperfusion during occlusion, and (3) device-related thrombosis/infection.

Complication prevention bundle

• Access safety: ultrasound-guided CFA puncture; avoid high/low sticks; use smallest feasible sheath. ^[6]
• Time discipline: define a definitive control destination before inflation; minimize total occlusion time. ^[6]
• Occlusion strategy: consider pREBOA/iREBOA when prolonged bridging is unavoidable and expertise exists. ^[7]
• Post-occlusion readiness: communicate before deflation; anticipate acidosis/hyperkalemia/hypotension and treat proactively within DCR. ^[4]

Table 15.6. Common EVTM Complications and Immediate Responses

Cross-reference: 16EVTM and Massive Transfusion. ^{[6] [4]}

Guidelines and Consensus

ACS-COT/NAEMSP Joint Statement (2019) ^[6]: REBOA may be considered for noncompressible torso hemorrhage in systems with appropriate training, governance, and rapid transition to definitive control. The statement emphasizes minimizing occlusion time and appropriate patient selection.

WSES Pelvic Trauma Guidelines (2017) ^[9]: Angioembolization is recommended as first-line therapy for ongoing pelvic hemorrhage where available, with preperitoneal pelvic packing as a complementary strategy.

EVTM Consensus: Endovascular resuscitation encompasses access, embolization, stents, shunts, hybrid surgery, and tailored use of REBOA ^[2]. See 15Vascular Trauma for ESVS Vascular Injuries Guidelines.

References (Expanded)

Hörer TM, et al. EVTM in non-compressible torso hemorrhage: current practice and future directions. JEVTM. 2017. Available at: https://www.jevtm.com/

REBOA Deployment Details: Zones, Occlusion Times, and Techniques

Current guidelines emphasize that Zone II (celiac to lowest renal artery) should be avoided for balloon inflation ^[6]. Zone I occlusion should be limited to the shortest possible duration, often suggested to be 30 minutes or less ^[6], while Zone III occlusion is preferably limited to 60 minutes or less. Intermittent or partial REBOA should be considered to reduce ischemic burden ^[7].

Femoral access specifics for EVTM (arterial and venous): sheath size, ultrasound technique, closure

Ultrasound-guided common femoral arterial access should be prioritized ^[6]. The smallest effective sheath, preferably 7 Fr ^[6] when possible, should be used to reduce limb complications. Arterial closure or repair should be planned at the end of resuscitation. Large-bore venous access should be placed for rapid transfusion and potential extracorporeal membrane oxygenation (ECMO) cannulation.

Pelvic hemorrhage algorithms integrating preperitoneal pelvic packing (PPP), REBOA, and angioembolization

For unstable pelvic ring hemorrhage, pelvic binder application and preperitoneal pelvic packing (PPP) are initial interventions ^[9]. Zone III REBOA serves as a bridge to definitive control ^[6] in patients with profound shock. When available, angioembolization provides definitive hemorrhage control ^[9]. Iterative reassessment is essential for detecting ongoing instability.

Post-occlusion management: reperfusion, metabolic derangements, distal perfusion catheter

Post-occlusion management requires pre-emptive communication before deflation ^[6], staged or partial deflation techniques, correction of acidosis and hyperkalemia ^[7], and consideration of distal perfusion catheter placement for prolonged Zone III occlusion.