Part 12/Chapter 62/6-min read

Vascular Trauma Systems, Evaluation, Damage Control, and Regional Patterns

Vascular trauma care begins by reading hemorrhage tempo, physiology, and hard or soft signs, then choosing the fastest credible route to source control. Resuscitation, transfer, hybrid-room activation, and aortic occlusion are treated as connected decisions, with exact thresholds kept local and guideline-defined.

Edited by Tal M. Hörer MD, PhD · David T. McGreevy MD, PhD·Reviewed ·5 sections · 12 references

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Emergency handoff / trauma debrief: Urgent but calm: frame the initial recognition, the sequence of decisions, transfer/workflow, and what changes the plan.

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Definition and presentation

Vascular trauma encompasses traumatic injury to major vessels, presenting with varying degrees of hemorrhage and ischemia. Initial assessment prioritizes physiology, mechanism, injury zone, and specific vascular signs . The clinical presentation dictates the diagnostic and management tempo:

  • Exsanguinating: Patients have no physiological reserve, necessitating immediate operative, hybrid, or temporising hemorrhage control without delayed imaging.
  • Unstable but compensating: Patients tolerate a brief diagnostic interval only if it actively advances definitive source control.
  • Stable: Patients with a credible vascular injury permit structured imaging and serial examination.

Clinical presentation is categorized into hard and soft signs, which dictate immediate action:

  • Hard signs: Active pulsatile bleeding, expanding hematoma, absent distal pulses, bruit or thrill, distal ischemia, and shock with a plausible vascular source. These demand immediate hemorrhage control.
  • Soft signs: History of major bleeding, proximity injury, neurologic deficit near the injured vessel, non-expanding hematoma, or an injured but perfused extremity. These permit selective computed tomography angiography, duplex ultrasound, or serial examination while physiological stability is maintained.

Regional systems and pathway activation

Regional trauma networks determine the appropriate location for vascular control by mapping local capability against transfer risk. Transfer is an explicit time-to-control decision based on the patient's capacity to survive the interval until the first effective control maneuver is applied . The transfer threshold is determined qualitatively by local distance, available bridge measures, and physiology, rather than a universal numeric interval . Clinical handovers specify the mechanism, hard and soft signs, suspected anatomical zone, limb perfusion, and established bridge measures.

The receiving center uses a prepared hybrid pathway activated by specific triggers, including unstable hemorrhage with a plausible vascular source, pelvic or junctional bleeding, a named major vascular injury, or transfer-in for vascular control . This pathway requires predefined team roles for vascular access, open exposure, anticoagulation management, and perfusion reassessment. Pathway readiness depends on the immediate availability of equipment, including sheaths, wires, occlusion balloons, covered stents, embolic agents, vascular clamps, temporary shunts, grafts, fasciotomy instruments, completion-imaging capability, warming equipment, and blood products.

Treatment and hemorrhage control

Management integrates concurrent hemorrhage control and damage-control resuscitation. Elective reconstruction is deferred in favor of temporising maneuvers that arrest bleeding, restore minimal perfusion, and preserve life . Temporising surgical options include proximal and distal control before formal debridement, temporary shunting prior to graft selection, packing, balloon tamponade, staged fasciotomy, and abbreviated endovascular control.

Medical therapy operates concurrently as damage-control resuscitation, comprising permissive hypotension, tranexamic acid, balanced component transfusion, active warming, and correction of coagulopathy and hypocalcaemia . Blood-product component therapy is titrated to local massive transfusion protocols, incorporating the findings of PROPPR (2015) regarding plasma, platelet, and red blood cell balance . Tranexamic acid is administered early, with specific timing balanced against traumatic brain injury physiology as demonstrated in CRASH-3 (2019) .

Aortic occlusion, achieved via resuscitative endovascular balloon occlusion of the aorta or open thoracic clamping, serves solely as a temporary bridge to definitive control. It is indicated for exsanguinating hemorrhage where a prepared team can immediately proceed to definitive repair . Feasibility is modified by arrest physiology, imaging access, operator skill, hostile groin anatomy, and operating room availability. Execution requires predefined ownership of access, zone confirmation, occlusion duration, reduction planning, and continuous monitoring of distal perfusion.

Vascular trauma management and source-control pathways

  • Stable, suspected injury

    Clinical presentation
    Soft signs (history of bleeding, proximity, non-expanding hematoma, perfused extremity)
    Preferred pathway
    Observation and imaging (computed tomography angiography, duplex) with serial examination
    Citation

  • Exsanguinating extremity

    Clinical presentation
    Active pulsatile bleeding, absent distal pulses, expanding hematoma
    Preferred pathway
    Immediate open control (direct pressure, clamping, shunting, fasciotomy readiness)
    Citation

  • Pelvic or junctional hemorrhage

    Clinical presentation
    Unstable torso, pelvic fracture, or junctional wounds
    Preferred pathway
    Hybrid or endovascular control (access, balloon occlusion, embolisation, stent-graft)
    Citation

  • Severe contamination or competing injuries

    Clinical presentation
    Complete definitive repair unsafe in the first sitting
    Preferred pathway
    Damage-control surgery (temporary shunting, packing, balloon tamponade)
    Citation

  • Arrest or near-arrest physiology

    Clinical presentation
    Exsanguinating hemorrhage with a prepared team
    Preferred pathway
    Aortic occlusion (open clamp or endovascular balloon) as a bridge to definitive control
    Citation

  • Prohibitive risk or un-survivable injury

    Clinical presentation
    Transfer outlasts physiological reserve or injury exceeds salvage limits
    Preferred pathway
    No intervention, focusing on care goals and temporising local measures
    Citation

Management follows an ordered sequence:

  1. The hemorrhage tempo is assessed and hard or soft vascular signs are identified.
  2. The source-control route is determined: observation for stable soft signs, open surgery for exsanguinating extremities, or hybrid approaches for pelvic and junctional bleeding.
  3. Concurrent damage-control resuscitation is activated, balancing blood products and administering tranexamic acid.
  4. Prepared bridge measures, including aortic occlusion, are executed when physiology demands, ensuring assigned ownership for access, balloon reduction, and definitive hemorrhage control.
  5. Perfusion and coagulopathy are reassessed following every meaningful event, including tourniquet adjustment, clamping, balloon inflation, and transfusion.

Special populations

Pediatric, pregnant, elderly, anticoagulated, and severely comorbid patients follow the established sequence of rapid hemorrhage control and concurrent damage-control resuscitation. However, exact resuscitation thresholds, blood-product ratios, and specific therapeutic interventions must be drawn from the relevant pediatric, obstetric, hematology, and local protocols rather than extrapolated from adult default values .

Areas of controversy

  • Transfer-time thresholds: While organized trauma systems improve injured-patient care at the population level, strict numerical transfer-time thresholds are not universally applicable. Distance, rurality, blood availability, and interventional staffing alter local capabilities, rendering the boundary between stay-and-control and bridge-and-transfer conditionally dependent on patient physiology .
  • Resuscitation and transfusion ratios: The exact ratios of plasma, platelets, and red blood cells, as well as the universal application of fibrinogen triggers and tranexamic acid timing, remain debated. Flattening landmark evidence such as PROPPR and CRASH-3 into a single unqualified rule for all vascular injuries is contested; exact targets are instead matched to the specific protocol and patient phenotype .
  • Partial and titratable balloon occlusion: Advances in partial aortic occlusion aim to balance proximal perfusion with the mitigation of distal ischemia and reperfusion injury. However, the technique increases the need for complex physiological monitoring. Universal duration thresholds or numerical standards for partial occlusion remain unsettled, requiring mature program structure and strict titration discipline .

References

  1. 1.
    American College of Surgeons - Advanced Trauma Life Support (ATLS) 10th Edition program page.
    ACS / FACSClinical practice guideline2018
    Source
  2. 2.
    Editor's Choice -- European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular Trauma. 2025.
    PubMed-indexed articleClinical practice guideline2025

    Editor's Choice -- European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular Trauma. 2025. doi:10.1016/j.ejvs.2024.12.018.

    PubMedDOI
  3. 3.
    Organised trauma systems and designated trauma centres for improving outcomes in injured patients. The Cochrane database of systematic reviews. 2025.
    PubMed-indexed articleMeta-analysis / systematic review2025

    Organised trauma systems and designated trauma centres for improving outcomes in injured patients. The Cochrane database of systematic reviews. 2025. doi:10.1002/14651858.cd012500.pub2.

    PubMedDOI
  4. 4.
    The Vascular Interventions and Surgery in Trauma Audit (VISTA): A Prospective National Service Evaluation of Vascular Trauma in the UK. 2026.
    PubMed-indexed articleRegistry / cohort2026

    The Vascular Interventions and Surgery in Trauma Audit (VISTA): A Prospective National Service Evaluation of Vascular Trauma in the UK. 2026. doi:10.1016/j.ejvs.2025.08.040.

    PubMedDOI
  5. 5.
    Endovascular management of haemorrhage and vascular lesions in patients with multiple and/or severe injuries: a systematic review and clinical practice guideline update. 2025.
    PubMed-indexed articleClinical practice guideline2025

    Endovascular management of haemorrhage and vascular lesions in patients with multiple and/or severe injuries: a systematic review and clinical practice guideline update. 2025. doi:10.1007/s00068-024-02719-0.

    PubMedDOI
  6. 6.
    Damage Control for Vascular Trauma from the Prehospital to the Operating Room Setting. Frontiers in surgery. 2017.
    PubMed-indexed articleReview2017

    Damage Control for Vascular Trauma from the Prehospital to the Operating Room Setting. Frontiers in surgery. 2017. doi:10.3389/fsurg.2017.00073.

    PubMedDOI
  7. 7.
    American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma: Clinical protocol for damage-control resuscitation for the adult trauma patient. 2024.
    PubMed-indexed articleClinical practice guideline2024

    American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma: Clinical protocol for damage-control resuscitation for the adult trauma patient. 2024. doi:10.1097/ta.0000000000004088.

    PubMedDOI
  8. 8.
    European guideline on management of major bleeding and coagulopathy following trauma (sixth edition).
    PubMed-indexed articleClinical practice guideline2023

    European guideline on management of major bleeding and coagulopathy following trauma (sixth edition). doi:10.1186/s13054-023-04327-7.

    PubMedDOIOpen PDF
  9. 9.
    Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and Mortality in Patients With Severe Trauma. 2015.
    PubMed-indexed articleRandomized controlled trial2015

    Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and Mortality in Patients With Severe Trauma. 2015. doi:10.1001/jama.2015.12.

    PubMedDOI
  10. 10.
    Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. 2019.
    PubMed-indexed articleRandomized controlled trial2019

    Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. 2019. doi:10.1016/s0140-6736(19)32233-0.

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  11. 11.
    A Western Trauma Association critical decisions algorithm: Resuscitative endovascular balloon occlusion of the aorta. 2022.
    PubMed-indexed articleClinical practice guideline2022

    A Western Trauma Association critical decisions algorithm: Resuscitative endovascular balloon occlusion of the aorta. 2022. doi:10.1097/ta.0000000000003438.

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    A DELPHI CONSENSUS ALGORITHM FOR MODERN REBOA PROGRAMS: EMPLOYING A TITRATABLE CATHETER AND PARTIAL AORTIC OCCLUSION TO ADVANCE THE PROCEDURE. 2025.
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    A DELPHI CONSENSUS ALGORITHM FOR MODERN REBOA PROGRAMS: EMPLOYING A TITRATABLE CATHETER AND PARTIAL AORTIC OCCLUSION TO ADVANCE THE PROCEDURE. 2025. doi:10.1097/shk.0000000000002622.

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