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 runs in parallel with source-control interventions. Balanced blood product transfusion, hemorrhage protocol activation, hypothermia prevention, and correction of coagulopathy are initiated immediately AAST/ACS-COT 2024. Massive transfusion targets a balanced 1:1:1 plasma:platelet:RBC ratio. For suspected pelvic ring injuries, non-invasive pelvic binder placement is the first procedural step. Before hemorrhage is controlled, target a systolic pressure of 80 to 90 mmHg (mean arterial pressure 50 to 60 mmHg) in patients without traumatic brain injury; with severe TBI (GCS 8 or below), maintain mean arterial pressure at 80 mmHg or above (SBP at least 110 mmHg) European Trauma Guideline 2023. Resuscitation maneuvers do not substitute for mechanical source control, and decisions regarding operative or endovascular interventions are made concurrently with physiologic stabilization ESVS 2025.

64.3Treatment-choice decision

Definitive hemorrhage control is achieved through laparotomy, pelvic stabilization, extraperitoneal packing, angioembolization, or open vascular repair. Resuscitative endovascular balloon occlusion of the aorta (REBOA) functions as a selective, restrictive bridge to these definitive maneuvers rather than an isolated resuscitation therapy EAST 2025 · WTA 2022. When definitive control is not available locally, temporary aortic occlusion may bridge a controlled transfer to a higher-capability center, but only when occlusion is maintained safely for the duration of transfer and the receiving team is ready to proceed to definitive control on arrival ESVS 2025. 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. 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) is explored for penetrating injury or expanding and pulsatile hematomas, but stable non-expanding blunt hematomas are left undisturbed. 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

Broad efficacy in undifferentiated trauma: The UK-REBOA randomized clinical trial demonstrated that routine endovascular aortic occlusion in the emergency department for undifferentiated exsanguinating trauma does not improve survival and alters system timing adversely UK-REBOA (2023). This restricts the intervention to highly selected, anatomically defined bridge scenarios.

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.

Endovascular trauma management (EVTM) provenance: The integration of endovascular adjuncts into acute trauma pathways originated closely with the EVTM society and specific centers ESVS 2025 · Hörer 2021 · Hörer 2017. The application of this hybrid paradigm across broader trauma systems remains debated, as its success is highly dependent on institutional choreography, immediate hybrid suite availability, and multidisciplinary rehearsed access.