Part 12/Chapter 66/7-min read

Endovascular Resuscitation and Trauma Management, Resuscitative Endovascular Balloon Occlusion of the Aorta, Aortic Occlusion, and Hybrid Trauma Workflows

Endovascular trauma management is presented as a trained, team-owned hemorrhage-control pathway in which REBOA and aortic occlusion may bridge selected patients to definitive operative, endovascular, or hybrid source control. The chapter keeps EVTM/JEVTM context visible for terminology and implementation background, while clinical recommendations are bounded by current trauma-system, REBOA, registry, target-trial, vascular-guideline, and complications evidence.

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Definition and presentation

Endovascular resuscitation and trauma management (EVTM) integrates vascular access, angiographic assessment and catheter-based treatment with open trauma surgery. The Top Stent manual provides EVTM/JEVTM terminology and implementation background for this hybrid approach, in which endovascular techniques complement surgical haemorrhage control and reconstruction rather than replacing them .

The toolkit includes embolisation to occlude a bleeding arterial target, covered stents or endografts to exclude a suitable injury while preserving arterial continuity, and local balloon occlusion to assist vascular control. Temporary intravascular shunts restore flow when definitive repair must be deferred and are usually placed operatively. Resuscitative endovascular balloon occlusion of the aorta () is a separate, temporary aortic-occlusion adjunct, not definitive treatment of the injured vessel .

Presentation ranges from a stable focal vascular injury to threatened limb or organ perfusion, ongoing haemorrhage and profound shock. Treatment selection depends on the injury, perfusion deficit, bleeding source and urgency of definitive control .

Treatment decision and pathway

Treatment selection integrates the suspected bleeding source, response to resuscitation, associated injuries requiring exploration, and immediately available surgical and endovascular capability. Damage-control resuscitation proceeds alongside source control. Open and endovascular treatments may be combined or sequenced; gaining arterial access or arranging angiography must not postpone an indicated operation .

Selected stable, non-occlusive extremity arterial injury
  • Treatment choice and purpose
    Observation with serial assessment and appropriate imaging
    Important boundary
    A vascular injury does not automatically require catheterisation, stenting or open repair.
    Citation

  • Ongoing abdominal haemorrhage with non-response to resuscitation or another indication for laparotomy

    Treatment choice and purpose
    Operative control; abbreviated damage-control surgery and packing where required
    Important boundary
    Packing may be temporary. Persistent arterial bleeding after operative control can require embolisation; a catheter procedure does not address every venous injury or associated surgical problem.
    Citation

  • Haemodynamically unstable pelvic-fracture bleeding

    Treatment choice and purpose
    Pelvic stabilisation with preperitoneal packing and/or arterial embolisation, according to the bleeding pattern and immediate capability
    Important boundary
    Preperitoneal pelvic packing is distinct from intraperitoneal abdominal packing. Ongoing bleeding may require both packing and embolisation.
    Citation

  • A suitable arterial bleeding target, without an overriding need for immediate surgical exploration

    Treatment choice and purpose
    Embolisation with coils or other agents selected for the vessel and bleeding pattern
    Important boundary
    The intended arterial occlusion and its tissue-perfusion consequences must be acceptable; embolisation is not treatment of all non-arterial bleeding.
    Citation

  • Suitable injury of an artery whose continuity should be preserved

    Treatment choice and purpose
    Covered stent or endograft; open repair remains an alternative
    Important boundary
    Access, the ability to bridge and seal the lesion, branch preservation and associated injuries determine feasibility.
    Citation

  • Threatened distal perfusion when definitive reconstruction is not currently feasible

    Treatment choice and purpose
    Temporary intravascular shunt followed by definitive repair
    Important boundary
    A shunt is a flow-restoring damage-control measure, not a completed reconstruction.
    Citation

  • Difficult exposure requiring temporary local vascular control

    Treatment choice and purpose
    Local balloon occlusion as an adjunct to exposure or repair
    Important boundary
    Local vessel control is distinct from aortic REBOA and does not itself repair the injury.
    Citation

REBOA within this pathway

REBOA is not the default response to a plausible bleeding source below the diaphragm. ESVS 2025 recommends against routine REBOA in exsanguinating torso trauma . EAST conditionally recommends against its use in haemodynamically unstable traumatic subdiaphragmatic bleeding and pelvic-fracture populations. Its conditional preference for REBOA over resuscitative thoracotomy applies to established traumatic cardiac arrest from suspected subdiaphragmatic bleeding, without another thoracotomy indication; it does not establish the same recommendation for impending arrest .

Any use requires an immediately actionable definitive-control plan and trained personnel. Major intrathoracic haemorrhage or tamponade requires the appropriate thoracic intervention, not an aortic balloon strategy that leaves the source untreated .

Occlusion strategies

Aortic occlusion dictates a direct trade-off between proximal hemodynamic support and distal ischemia. Techniques vary by the degree of flow reduction:

  • Complete occlusion interrupts antegrade aortic flow. Distal ischaemic risk depends on the occlusion level, duration and preceding shock.
  • Partial occlusion permits some antegrade flow while seeking proximal haemodynamic support. This physiological aim does not by itself establish clinical benefit.
  • Intermittent occlusion alternates periods of inflation and deflation to manage the ischemic trade-off over time.

Proximal pressure improvement alone does not verify balloon position, definitive haemostasis or adequate distal perfusion. Position confirmation and assessment of proximal and distal perfusion remain necessary, particularly during partial or intermittent occlusion .

Complications and surveillance

Aortic occlusion introduces specific iatrogenic risks that alter the survival balance. Primary failure modes include access-site injury, limb ischemia, distal organ ischemia, reperfusion burden, and renal failure . The femoral sheath requires active surveillance and a formal removal or repair plan.

Deflation initiates a period of hemodynamic transition that can unmask recurrent hemorrhage and reperfusion acidosis. The intervention pathway remains active until temporary control, definitive source control, and reperfusion are managed. Post-deflation reassessment includes :

  • Access-site integrity checks to identify bleeding, , arterial , or pseudoaneurysm.
  • Distal limb perfusion assessment utilizing pulses, Doppler signals, and motor-sensory exams.
  • Monitoring of hemodynamics and renal-risk indicators.
  • Confirmation of definitive hemorrhage control to rule out missed, venous, or coagulopathic bleeding.
  • Formal transfer documentation detailing the occlusion course, ongoing risks, and clinical follow-up ownership.

Surveillance also depends on the definitive treatment. After embolisation, reassess for recurrent bleeding and tissue ischaemia. After stent-grafting, consider persistent leakage, thrombosis and device-related failure. Temporary shunts require patency assessment and a plan for conversion to definitive repair. Follow-up should reflect the treated vessel, device and associated injuries rather than a single schedule for all EVTM procedures .

Areas of controversy

Open, endovascular and combined treatment. Comparisons are affected by differences in anatomy, associated injuries, shock and treatment availability. Packing and embolisation may address different components of haemorrhage and can be complementary. Neither “endovascular first” nor “packing first” is a universal rule across abdominal and pelvic injury patterns .

REBOA outcomes. The UK-REBOA randomized trial did not demonstrate a 90-day survival benefit from adding emergency-department REBOA to standard care and raised concern for harm. Its findings should not be replaced by a generic statement that benefit remains unsettled, but neither do they determine the effect in every narrowly defined rescue scenario .

Observational comparisons address different populations and alternatives. The small AT-REBOA matched analysis found no difference in its primary mortality outcome, while the retrospective “enabler of surgery” cohort did not demonstrate improved matched haemostasis timing or survival. These findings do not establish equivalence or successful bridging in an individual patient .

The AORTA study reported an association between partial Zone I REBOA and lower adjusted mortality than complete REBOA or emergency-department thoracotomy. Only 84 of 921 patients received partial REBOA, and treatment was not randomized. This association does not establish superiority of partial occlusion, a safe universal occlusion duration, or benefit from REBOA compared with standard care without aortic occlusion .

Further reading

  • Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): update and insights into current practices and future directions for research and implementation. (2021). REBOA implementation background; predates UK randomized evidence and cannot justify routine use.
  • Management of non-compressible torso hemorrhage: An update. (2021). Noncompressible torso hemorrhage overview and hybrid approaches.

References

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