Abdominal and Pelvic Vascular Trauma

64.1Definition and presentation

Abdominal and pelvic vascular trauma presents primarily as hemorrhagic shock secondary to non-compressible torso bleeding. The physiology mandates rapid differentiation between compressible sources and non-compressible sources requiring operative or endovascular control. Compressible external, extremity, and junctional bleeding is managed by direct pressure, local packing, or tourniquet application. Non-compressible abdominal and pelvic bleeding is managed through systemic damage-control resuscitation and rapid operative or endovascular source control. Clinical severity ranges from transiently responsive hypotension to profound exsanguination, coagulopathy, and traumatic cardiac arrest.

64.2Resuscitation and initial stabilization

Damage-control resuscitation proceeds with mechanical source control: activate the major-hemorrhage protocol, give blood products promptly, prevent hypothermia and correct coagulopathy. Restrict crystalloid rather than withholding needed blood. For suspected pelvic ring disruption, apply a pelvic binder promptly.

Before bleeding is controlled, the European guideline recommends SBP 80–90 mmHg, approximately MAP 50–60 mmHg, in patients without brain or spinal injury; severe TBI (GCS 8 or below) instead requires MAP at least 80 mmHg. These are Grade 1B and Grade 1C recommendations, respectively. The hemoglobin target of 70–90 g/L is Grade 1C and must not be used to delay transfusion during active major bleeding European Trauma Guideline 2023.

Initial component therapy follows the local major-hemorrhage protocol, then laboratory or viscoelastic findings. A 1:1:1 plasma:platelet:RBC approach is an option, not the only accepted regimen. In PROPPR, 1:1:1 versus 1:1:2 improved hemostasis and reduced early exsanguination deaths but did not significantly improve the primary 24-hour or 30-day mortality outcomes PROPPR 2015.

64.3Treatment-choice decision

Definitive control uses laparotomy, pelvic stabilization, packing, embolization or vascular repair. During abdominal exploration, direct or supraceliac aortic clamping provides open proximal control; descending thoracic clamping belongs to selected resuscitative-thoracotomy pathways. REBOA is an alternative temporary inflow-control technique for selected subdiaphragmatic bleeding, not a substitute for these operations REBOA 2025. EAST 2025 conditionally recommends against REBOA in hemodynamically unstable trauma with suspected subdiaphragmatic bleeding, but conditionally favors it over resuscitative thoracotomy in traumatic cardiac arrest from suspected subdiaphragmatic bleeding when no other indication for thoracotomy exists; both conclusions have very-low-certainty evidence EAST 2025. Do not assume that an inflated balloon makes interfacility transfer safe. The JTS protocol calls for hemorrhage control and balloon deflation before ordinary transport and prohibits transfer with complete zone 1 occlusion. Its exceptional partial-occlusion or selected short-distance zone 3 transport pathways require specialist personnel, monitoring and a predefined receiving operation; they are not a general civilian transfer recommendation. The decision to deploy an aortic balloon relies on identifying a bleeding territory anatomically compatible with occlusion, confirming safe arterial access, and naming the exact definitive control maneuver before inflation. Occlusion zone must match the bleeding territory. Zone 1 runs from the origin of the left subclavian artery to the celiac axis and is occluded for intra-abdominal or unlocalized infra-diaphragmatic hemorrhage. Zone 2 is the paravisceral segment from the celiac artery to the lowest renal artery, a no-occlusion zone. Zone 3 runs from the lowest renal artery to the aortic bifurcation and is occluded for isolated pelvic or junctional hemorrhage WTA 2022. A transient hemodynamic improvement following occlusion indicates increased afterload and upstream pressure, but accrues downstream ischemic risk and does not constitute definitive hemorrhage control.

The endovascular trauma pathway executes a structured source-control sequence:

1. Identify the bleeding phenotype: Confirm non-compressible torso hemorrhage and failure of initial resuscitation.
2. Define the exit strategy: Select the primary definitive maneuver (laparotomy, pelvic packing, embolization, or vascular repair) prior to securing access.
3. Establish access: Obtain ultrasound-guided common femoral access without delaying operative incision.
4. Deploy and bridge: Position and inflate the endovascular balloon to temporarily reduce inflow while the definitive maneuver is performed.
5. Reassess and deflate: Transition to partial or complete deflation immediately upon achieving definitive surgical or endovascular control.

64.4Pelvic and penetrating injury pathways

Pelvic fracture hemorrhage involves mixed arterial, venous, and cancellous bone bleeding exacerbated by pelvic volume expansion. Aortic occlusion temporarily reduces arterial inflow but does not mitigate pelvic volume, venous bleeding, or bone hemorrhage. Definitive control relies on mechanical stabilization, packing, and selective embolization Houdane 2026 · Ahmed 2024.

Penetrating abdominal vascular trauma presents a distinct anatomical problem defined by direct vessel injury, hollow-viscus contamination, and time-critical surgical exposure. In shocked patients with penetrating injuries, rapid laparotomy remains the primary intervention, with proximal control secured by direct or supraceliac aortic clamping and the injured vessel managed by temporary intravascular shunting, ligation, or definitive repair according to the patient's physiology. At laparotomy the retroperitoneal hematoma zone directs exploration. Zone 1 (central-medial: aorta, IVC, proximal visceral vessels) is explored for both blunt and penetrating mechanisms. Zone 2 (perinephric and flank) requires exploration for expanding or pulsatile hematoma or uncontrolled renal hemorrhage. Stable non-expanding blunt hematomas are generally left undisturbed. Adequately imaged, selected lateral penetrating renal injuries may also undergo nonoperative management; an inadequately assessed penetrating retroperitoneal hematoma, especially with peritoneal entry, still requires exploration WSES-AAST 2019. Zone 3 (pelvic) is explored for penetrating injury; stable blunt pelvic hematomas are not opened and are managed by packing, fixation, and angioembolization ESVS 2025. Endovascular maneuvers are used only when access is immediate and the maneuver accelerates transition to open exposure. Balloon deployment that delays abdominal incision or prolongs resuscitation bay time in penetrating trauma worsens outcomes Hatchimonji 2025 · Nekooei 2025.

High-grade liver injury represents an anatomical boundary phenotype. Hepatic hemorrhage combines arterial, portal venous, and retrohepatic caval bleeding. Altering isolated arterial inflow via aortic occlusion does not control venous or parenchymal exsanguination and is associated with worsened outcomes in registry data Huang 2025.

64.5Post-occlusion management and complications

Reassessment is mandatory following temporary occlusion. The care team monitors continuous physiology, transfusion requirements, and access-site integrity. Occlusion time is tracked explicitly to minimize visceral, spinal, and lower-limb ischemia EAST 2025 · WTA 2022. After hemorrhage control, the common femoral access site requires formal evaluation for repair or closure, and the distal limb undergoes perfusion surveillance. The patient undergoes staged reassessment for secondary operative reconstruction, fasciotomy, damage-control re-exploration, and mitigation of reperfusion injury ESVS 2025 · AAST/ACS-COT 2024.

64.6Areas of controversy

REBOA effectiveness: UK-REBOA randomized 90 severely injured patients aged at least 16 years at 16 UK centers; 89 were analyzed. Ninety-day mortality was 25/46 (54%) with the emergency-department REBOA strategy plus standard care versus 18/43 (42%) with standard care, odds ratio 1.58, 95% credible interval 0.72–3.52; the posterior probability of increased mortality was 86.9%. This does not support routine addition of REBOA and does not establish equivalence to, or superiority over, open aortic clamping UK-REBOA (2023).

Pelvic trauma benefit: Observational data and meta-analyses regarding pelvic fracture hemorrhage remain heavily confounded by selection bias. The survival benefit of temporary aortic occlusion over standard damage-control packing and embolization is unresolved, and temporary occlusion carries a real risk of distal ischemic injury Houdane 2026 · Ahmed 2024 · Chien 2023.

Penetrating mechanism generalization: The application of endovascular bridge concepts to penetrating abdominal injury relies on observational registry data, and definitive causal proof of benefit over immediate laparotomy is lacking Hatchimonji 2025 · Nekooei 2025.

EVTM implementation: Open surgery, packing, embolization, covered stents and selected occlusion techniques belong to a coordinated hemorrhage-control service. The 2017 Top Stent Manual and EVTM implementation literature, within the JEVTM educational context, describe integration, training and procedural readiness. This implementation literature is not comparative evidence of a device-related survival benefit Hörer 2021 · Hörer 2017.

Further reading

• Assessing the role of REBOA in the management of hemodynamically unstable pelvic fractures: a systematic review and meta-analysis. (2026). REBOA in unstable pelvic fracture; synthesis limitations do not establish routine benefit. Houdane 2026