Endovascular Trauma Management

Background

Origins: Developed and formalized by Hörer and colleagues in Örebro, Sweden, beginning in the early 2010s, endovascular trauma management (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. (Rotondo 1993)📄 (Spahn 2019)📄

Where endovascular trauma management (EVTM) fits in DCR

Endovascular trauma management (EVTM) complements DCR by providing rapid proximal or selective hemorrhage control (e.g., resuscitative endovascular balloon occlusion of the aorta (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/interventional radiology (IR) control is arranged. (Morrison 2014)📄 [2]📄 However, the clinical benefit of REBOA remains a subject of intense debate; recent evidence from the UK-REBOA randomized clinical trial (RCT) indicated that the addition of REBOA to standard care in the emergency department (ED) did not improve survival and may even increase mortality, potentially due to procedural delays or complications. (Jansen 2023) (Jansen 2026)

Physiologic principles of aortic balloon occlusion

• Complete REBOA (cREBOA): maximizes proximal perfusion but risks severe distal ischemia, reperfusion injury, and procedural complications such as vascular access site injury, arterial thrombosis, or pseudoaneurysm; use the shortest feasible occlusion time and transition quickly to definitive control. (Bulger 2019)📄 (Ribeiro Junior 2024) (Marcelo Augusto 2024)
• 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. (Sadeghi 2018)

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. (Markov 2011)

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. (Coccolini 2017)📄

For surgical damage control concepts (packing, abbreviated laparotomy, open abdomen strategy), see 15Vascular Trauma and 16EVTM. (Coccolini 2018)📄

Femoral Access

Femoral arterial and venous access is the practical “gateway” to 16EVTM—it enables resuscitative endovascular balloon occlusion of the aorta (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. (Bulger 2019)📄 (Schmidli 2018)📄
• 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. (Bulger 2019)📄
• 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. (Schmidli 2018)📄

See also 16EVTM for standardized access technique, complication management, and closure options. (Schmidli 2018)📄

REBOA

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a temporizing technique for noncompressible torso hemorrhage (NCTH) in profoundly unstable patients, intended as a bridge to definitive hemorrhage control (operating room [OR], hybrid OR, or interventional radiology [IR]). (Bulger 2019)📄 (Wagner 2025)

Appropriate systems require training, governance, and time targets. (Bulger 2019)📄

Table 16.1. REBOA Aortic Zones and Deployment Guidelines (Bulger 2019)📄

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). (Bulger 2019)📄 (Wagner 2025)
• 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). (Bulger 2019)📄 (Isselbacher 2022)📄

Technique essentials

• Prefer ultrasound-guided common femoral artery (CFA) access; confirm intraluminal wire position prior to upsizing. (Bulger 2019)📄
• Inflate using physiologic endpoints (proximal blood pressure [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, including partial REBOA (pREBOA) or intermittent REBOA (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. (Sadeghi 2018) (Wagner 2025)

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. (Du 2016)
• 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. (Brenner 2018)📄
• National datasets also suggest substantial practice variability and reinforce the need for protocolized use. (Matsumura 2020)
• Updated systematic reviews and clinical practice guidelines reinforce the role of endovascular resuscitation and trauma management (EVTM) for hemorrhage and associated vascular lesions in severely injured patients, emphasizing protocolized use and multidisciplinary coordination. (Wagner 2025)

See also: 15Vascular Trauma and 16EVTM for coordinated damage control resuscitation (DCR) during balloon occlusion and deflation. (Spahn 2019)📄

Endovascular Stent-Grafts

Covered stents and stent-grafts are core endovascular trauma management (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. (Markov 2011)

Table 16.4. Endovascular Stent-Grafts in Trauma (Practical Use) (Markov 2011)

Traumatic thoracic aorta

Endovascular repair is widely used for BTAI in appropriately selected patients, with guideline support for endovascular-first strategies when anatomy permits. (Riambau 2017)📄 (Isselbacher 2022)📄

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. (Chakf 2020)

Post-procedure surveillance

When feasible, arrange follow-up imaging (computed tomography angiography (CTA) or duplex depending on vascular bed and device) to detect endoleak, stenosis, or thrombosis (practice varies by territory). See 6Thoracic Aortic and 16EVTM. (Isselbacher 2022)📄

Endovascular Embolization

Table 16.3. Endovascular Embolization Agents and Applications

Indications: - Pelvic hemorrhage (pelvic ring fractures) [@coccolini2017-wses; @wagner2025-d] - Solid-organ trauma (spleen, liver, kidney) (Wagner 2025) - Junctional or retroperitoneal bleeding - Pelvic congestion syndrome (PCS) (Pennec 2025)

WSES Recommendation: The World Society of Emergency Surgery (WSES) recommends angioembolization as first-line for uncontrolled pelvic bleeding where available, with preperitoneal pelvic packing as complementary when angiography is delayed (Coccolini 2017)📄. Recent clinical practice guidelines continue to support endovascular management for hemorrhage and vascular lesions in severely injured patients (Wagner 2025).

Temporary Intravascular Shunts

Temporary intravascular shunts (TIVS) are used in extremity vascular trauma to restore perfusion during resuscitation and orthopedic stabilization (Feliciano 2011)📄. Current guidelines from the Western Trauma Association (WTA) and other international bodies recommend the use of TIVS as a primary component of damage control surgery (DCS) to minimize ischemia time while managing life-threatening hemorrhage and the "lethal triad" of acidosis, hypothermia, and coagulopathy [@rossaint2023; @rossaint2023-e; @feliciano2026]. In the endovascular trauma management (EVTM) context, TIVS can be combined with endovascular techniques such as resuscitative endovascular balloon occlusion of the aorta (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 * Indications for TIVS include physiologic instability, the need for complex orthopedic stabilization before definitive vascular repair, or lack of immediate surgical expertise (Feliciano 2026) * Enables staged definitive repair after physiologic optimization * Civilian and combat series report limb-salvage rates >90% with appropriate shunt use (Feliciano 2011)📄

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]📄 (Rutherford 2018)

Why hybrid matters in endovascular trauma management (EVTM)

• Enables simultaneous laparotomy/thoracotomy with resuscitative endovascular balloon occlusion of the aorta (REBOA) management, embolization, and covered stent deployment.
• Reduces “handoff delays” for unstable patients who cannot tolerate transport to interventional radiology (IR).
• Supports iterative damage control: packing/temporary closure → angioembolization → reassessment → staged definitive repair. (Coccolini 2018)📄

While REBOA is a core component of the EVTM toolkit, recent high-quality evidence has introduced important caveats regarding its application. The UK-REBOA randomized clinical trial (RCT), which evaluated REBOA in the emergency department (ED) setting, found that the addition of REBOA to standard care in patients with exsanguinating hemorrhage actually increased 90-day mortality (54% vs 42%; odds ratio [OR] 1.58, 95% CI 0.98-2.53) (Jansen 2023). This suggests that REBOA may be harmful in certain ED settings or patient populations, potentially due to procedural delays or complications. Furthermore, a systematic review and meta-analysis of 28 studies indicates that survival benefits associated with REBOA remain inconsistent across the literature, highlighting the need for rigorous patient selection and specialized team training within the hybrid environment (Castellini 2021).

Table 16.5. 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/preperitoneal pelvic packing (PPP), selective REBOA (Zone III), and angioembolization depending on physiology and resource timing. (Coccolini 2017)📄 (Bulger 2019)📄 (Castellini 2021)

See also: 15Vascular Trauma and 15Ch. 15.

EVTM in Resuscitation Workflows

Table 16.2. Endovascular trauma management (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. (Bulger 2019)📄 (Morrison 2014)📄

Cross-reference: 15Vascular Trauma and 16EVTM. (Rossaint 2023)

Outcomes and Evidence

Evidence landscape

Most endovascular trauma management (EVTM) outcome data are observational (registries, administrative datasets, and single-center series). Interpretation requires attention to indication, timing, comparator selection, and survivorship bias. (Du 2016) (Matsumura 2020)

resuscitative endovascular balloon occlusion of the aorta (REBOA) outcomes

• Registries demonstrate feasibility and define complication patterns; outcome signals vary by indication and practice environment. (Du 2016)
• Comparative observational analyses versus resuscitative thoracotomy (RT) show mixed results and are highly selection-dependent (Brenner 2018)📄. Recent registry data comparing Zone 1 REBOA to RT for patients in severe hemorrhagic shock suggest potential survival benefits in specific cohorts, though the risk of confounding by indication persists in these non-randomized comparisons (Cralley 2026).

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). (Rasmussen 2011)

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. (Mani 2020)📄

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

Complications

Complications of endovascular trauma management (EVTM) arise from (1) large-bore access, (2) ischemia–reperfusion during occlusion, and (3) device-related thrombosis/infection. To facilitate objective comparison of outcomes and quality improvement, complications should be classified using a standardized system such as the Clavien-Dindo classification (Dindo 2004).

Complication prevention bundle

• Access safety: ultrasound-guided common femoral artery (CFA) puncture; avoid high/low sticks; use smallest feasible sheath. (Bulger 2019)📄
• Time discipline: define a definitive control destination before inflation; minimize total occlusion time. (Bulger 2019)📄
• Occlusion strategy: consider partial resuscitative endovascular balloon occlusion of the aorta (pREBOA) or intermittent REBOA (iREBOA) when prolonged bridging is unavoidable and expertise exists. (Sadeghi 2018)
• Post-occlusion readiness: communicate before deflation; anticipate acidosis/hyperkalemia/hypotension and treat proactively within damage control resuscitation (DCR). (Spahn 2019)📄

Table 16.6. Common EVTM Complications and Immediate Responses

Cross-reference: 16EVTM and 16EVTM. (Bulger 2019)📄 (Spahn 2019)📄

Guidelines and Consensus

ACS-COT/NAEMSP Joint Statement (2019) (Bulger 2019)📄: resuscitative endovascular balloon occlusion of the aorta (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) (Coccolini 2017)📄: Angioembolization is recommended as first-line therapy for ongoing pelvic hemorrhage where available, with preperitoneal pelvic packing as a complementary strategy.

endovascular trauma management (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.

Endovascular Management of Hemorrhage in Polytrauma — Guideline Update (2025) (Wagner 2025): A systematic review and clinical practice guideline update addressing endovascular management of hemorrhage and vascular lesions in patients with multiple and/or severe injuries provides updated evidence-based recommendations on patient selection, technique, and integration of endovascular approaches within damage-control resuscitation pathways (Wagner 2025).

References (Expanded)

Hörer TM, et al. Endovascular trauma management (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 (Bulger 2019)📄. Zone I occlusion should be limited to the shortest possible duration, often suggested to be 30 minutes or less (Bulger 2019)📄, while Zone III occlusion is preferably limited to 60 minutes or less. Intermittent or partial resuscitative endovascular balloon occlusion of the aorta (REBOA) should be considered to reduce ischemic burden [@sadeghi2018-partial; @dewey2025].

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

Ultrasound-guided common femoral arterial access should be prioritized (Bulger 2019)📄. The smallest effective sheath, preferably 7 Fr (Bulger 2019)📄 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 (Coccolini 2017)📄. Zone III resuscitative endovascular balloon occlusion of the aorta (REBOA) serves as a bridge to definitive control (Bulger 2019)📄 in patients with profound shock; however, the UK-REBOA randomized clinical trial raised important questions regarding mortality benefit compared with standard resuscitation, and its findings warrant careful consideration when selecting candidates for REBOA deployment (Jansen 2023). Vascular access complications and ischemic sequelae associated with REBOA use should be factored into institutional protocols (Ribeiro Junior 2024). When available, angioembolization provides definitive hemorrhage control (Coccolini 2017)📄. 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 (Bulger 2019)📄, staged or partial deflation techniques, correction of acidosis and hyperkalemia (Sadeghi 2018), and consideration of distal perfusion catheter placement for prolonged Zone III occlusion.