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Vascular Trauma—Open or Endovascular

  • Vascular Trauma (C Cribari, Section Editor)
  • Published:
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Abstract

Purpose of Review

This review discusses the trends in management of vascular trauma comparing open management with endovascular strategies.

Recent Findings

Endovascular vascular approaches to vascular trauma has evolved significantly in the past several decades, providing an option for reduced morbidity and mortality in the carefully selected trauma patient. While open surgery is a critical skill to maintain, there are strategies more than ever before that can be applied to a hemorrhaging trauma patient which include stent-graft placement, the use of temporary vascular shunts, and vascular balloon occlusion.

Summary

Vascular trauma management has evolved over the last several decades, introducing promising endovascular treatment strategies, particularly in junctional and torso hemorrhage.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Joint trauma system clinical practice guideline (JTS CPG). Available at: http://www.usaisr.amedd.army.mil/cpgs.html. Accessed April 1, 2019.

  2. Scott DJ, Arthurs ZM, Stannard A, Monroe HM, Clouse WD, Rasmussen TE. Patient-based outcomes and quality of life after salvageable wartime extremity vascular injury. J Vasc Surg. 2014;59:173–9.

    Article  PubMed  Google Scholar 

  3. Perkins ZB, Yet B, Glasgow S, Marsh DWR, Tai NRM, Rasmussen TE. Long-term, patient-centered outcomes of lower-extremity vascular trauma. J Trauma Acute Care Surg. 2018 Jul;85(1S Suppl 2):S104–11.

    Article  PubMed  Google Scholar 

  4. •• Faulconer ER, Branco BC, Loja MN, Grayson K, Sampson J, Fabian TC, et al. Use of open and endovascular surgical techniques to manage vascular injuries in the trauma setting: a review of the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Trial registry. J Trauma Acute Care Surg. 2018;84(3):411–7 This registry demonstrated the increasing use of endovascular treatment in vascular trauma as well as an association with improved survival and lower blood transfusion requirements.

    Article  PubMed  Google Scholar 

  5. Branco BC, DuBose JJ, Zhan LX, Hughes JD, Goshima KR, Rhee P, et al. Trends and outcomes of endovascular therapy in the management of civilian vascular injuries. J Vasc Surg. 2014;60(5):1297–1307.e1.

    Article  PubMed  Google Scholar 

  6. DuBose J, Recinos G, Teixeira PG, Inaba K, Demetriades D. Endovascular stenting for the treatment of traumatic internal carotid injuries: expanding experience. J Trauma. 2008;65(6):1561–6.

    PubMed  Google Scholar 

  7. Jindal G, Fortes M, Miller T, Scalea T, Gandhi D. Endovascular stent repair of traumatic cervical internal carotid artery injuries. J Trauma Acute Care Surg. 2013;75(5):896–903.

    Article  PubMed  Google Scholar 

  8. du Toit DF, van Schalkwyk GD, Wadee SA, Warren BL. Neurologic outcome after penetrating extracranial arterial trauma. J Vasc Surg. 2003;38(2):257–62.

    Article  PubMed  Google Scholar 

  9. Reva VA, Pronchenko AA, Samokhvalov IM. Operative management of penetrating carotid artery injuries. Eur J Vasc Endovasc Surg. 2011;42(1):16–20.

    Article  CAS  PubMed  Google Scholar 

  10. Pham MH, Rahme RJ, Arnaout O, Hurley MC, Bernstein RA, Batjer HH, et al. Endovascular stenting of extracranial carotid and vertebral artery dissections: a systematic review of the literature. Neurosurgery. 2011;68(4):856–66.

    Article  PubMed  Google Scholar 

  11. Burlew CC, Biffl WL, Moore EE, Pieracci FM, Beauchamp KM, Stovall R, et al. Endovascular stenting is rarely necessary for the management of blunt cerebrovascular injuries. J Am Coll Surg. 2014;218(5):1012–7.

    Article  PubMed  Google Scholar 

  12. Spanos K, Karathanos C, Stamoulis K, Giannoukas AD. Endovascular treatment of traumatic internal carotid artery pseudoaneurysm. Injury. 2016;47(2):307–12.

    Article  PubMed  Google Scholar 

  13. Fabian TC, Patton JH Jr, Croce MA, Minard G, Kudsk KA, Pritchard FE. Blunt carotid injury. Importance of early diagnosis and anticoagulant therapy. Ann Surg. 1996;223(5):513–22 discussion 522-5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Biffl WL, Moore EE, Ryu RK, Offner PJ, Novak Z, Coldwell DM, et al. The unrecognized epidemic of blunt carotid arterial injuries: early diagnosis improves neurologic outcome. Ann Surg. 1998;228(4):462–70.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Eastridge BJ, Mabry RL, Seguin P, Cantrell J, Tops T, Uribe P, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012;73(6 Suppl 5):S431–7.

    Article  PubMed  Google Scholar 

  16. Demetriades D, Chahwan S, Gomez H, Peng R, Velmahos G, Murray J, et al. Penetrating injuries to the subclavian and axillary vessels. J Am Coll Surg. 1999;188(3):290–5.

    Article  CAS  PubMed  Google Scholar 

  17. • Branco BC, Boutrous ML, DuBose JJ, Leake SS, Charlton-Ouw K, Rhee P, et al. Outcome comparison between open and endovascular management of axillosubclavian arterial injuries. J Vasc Surg. 2016;63(3):702–9 This study presents comparative outcomes of axillosubclavian arterial injuries managed by open or endovascular approaches.

    Article  PubMed  Google Scholar 

  18. Matsagkas M, Kouvelos G, Peroulis M, Xanthopoulos D, Bouris V, Arnaoutoglou E. Endovascular repair of blunt axillo-subclavian arterial injuries as the first line treatment. Injury. 2016;47(5):1051–6.

    Article  PubMed  Google Scholar 

  19. du Toit DF, Lambrechts AV, Stark H, Warren BL. Long-term results of stent graft treatment of subclavian artery injuries: management of choice for stable patients? J Vasc Surg. 2008 Apr;47(4):739–43.

    Article  PubMed  Google Scholar 

  20. • Waller CJ, Cogbill TH, Kallies KJ, Ramirez LD, Cardenas JM, Todd SR, et al. Contemporary management of subclavian and axillary artery injuries-a Western Trauma Association multicenter review. J Trauma Acute Care Surg. 2017;83(6):1023–31 A large multi-center retrospective review of axillosubclavian injuries managed by open, endovascular, and hybrid approaches.

    Article  PubMed  Google Scholar 

  21. DuBose JJ, Rajani R, Gilani R, Arthurs ZA, Morrison JJ, Clouse WD, et al. Endovascular management of axillo-subclavian arterial injury: a review of published experience. Injury. 2012;43(11):1785–92.

    Article  PubMed  Google Scholar 

  22. Gutierrez A, Inaba K, Siboni S, Effron Z, Haltmeier T, Jaffray P, et al. The utility of chest X-ray as a screening tool for blunt thoracic aortic injury. Injury. 2016;47(1):32–6.

    Article  PubMed  Google Scholar 

  23. Azizzadeh A, Valdes J, Miller CC 3rd, Nguyen LL, Estrera AL, Charlton-Ouw K, et al. The utility of intravascular ultrasound compared to angiography in the diagnosis of blunt traumatic aortic injury. J Vasc Surg. 2011;53(3):608–14.

    Article  PubMed  Google Scholar 

  24. • Azizzadeh A, Keyhani K, Miller CC 3rd, Coogan SM, Safi HJ, Estrera AL. Blunt traumatic aortic injury: initial experience with endovascular repair. J Vasc Surg. 2009;49(6):1403–8 This study describes the first grading classification for traumatic aortic injury.

    Article  PubMed  Google Scholar 

  25. Lee WA, Matsumura JS, Mitchell RS, Farber MA, Greenberg RK, Azizzadeh A, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2011;53(1):187–92.

    Article  PubMed  Google Scholar 

  26. Fabian TC, Richardson JD, Croce MA, Smith JS Jr, Rodman G Jr, Kearney PA, et al. Prospective study of blunt aortic injury: multicenter trial of the American Association for the Surgery of Trauma. J Trauma. 1997;42(3):374–80; discussion 380-3.

    Article  CAS  PubMed  Google Scholar 

  27. Demetriades D, Velmahos GC, Scalea TM, Jurkovich GJ, Karmy-Jones R, Teixeira PG, et al. Operative repair or endovascular stent graft in blunt traumatic thoracic aortic injuries: results of an American Association for the Surgery of Trauma Multicenter Study. J Trauma. 2008;64(3):561–70 discussion 570–1.

    PubMed  Google Scholar 

  28. Murad MH, Rizvi AZ, Malgor R, Carey J, Alkatib AA, Erwin PJ, et al. Comparative effectiveness of the treatments for thoracic aortic transection. J Vasc Surg. 2011;53(1):193–9.

    Article  PubMed  Google Scholar 

  29. DuBose JJ, Leake SS, Brenner M, Pasley J, O’Callaghan T, Luo-Owen X, et al. Contemporary management and outcomes of blunt thoracic aortic injury: a multicenter retrospective study. J Trauma Acute Care Surg. 2015;78(2):360–9.

    Article  PubMed  Google Scholar 

  30. • Scalea TM, Feliciano DV, DuBose JJ, Ottochian M, O’Connor JV, Morrison JJ. Blunt thoracic aortic injury: endovascular repair is now the standard. J Am Coll Surg. 2019;228(4):605–10 This analysis describes the current trend in management of blunt thoracic aortic injuries.

    Article  PubMed  Google Scholar 

  31. Azizzadeh A, Ray HM, Dubose JJ, Charlton-Ouw KM, Miller CC, Coogan SM, et al. Outcomes of endovascular repair for patients with blunt traumatic aortic injury. J Trauma Acute Care Surg. 2014 Feb;76(2):510–6.

    Article  PubMed  Google Scholar 

  32. •• Khoynezhad A, Donayre CE, Azizzadeh A, White R, RESCUE investigators. One-year results of thoracic endovascular aortic repair for blunt thoracic aortic injury (RESCUE trial). J Thorac Cardiovasc Surg. 2015;149(1):155–61.e4 A prospective, multi-center trial demonstrating TEVAR outcomes for BTAI.

    Article  PubMed  Google Scholar 

  33. McBride CL, Dubose JJ, Miller CC 3rd, Perlick AP, Charlton-Ouw KM, Estrera AL, et al. Intentional left subclavian artery coverage during thoracic endovascular aortic repair for traumatic aortic injury. J Vasc Surg. 2015;61(1):73–9.

    Article  PubMed  Google Scholar 

  34. Demetriades D, Velmahos GC, Scalea TM, Jurkovich GJ, Karmy-Jones R, Teixeira PG, et al. Blunt traumatic thoracic aortic injuries: early or delayed repair--results of an American Association for the Surgery of Trauma prospective study. J Trauma. 2009;66(4):967–73.

    PubMed  Google Scholar 

  35. Marcaccio CL, Dumas RP, Huang Y, Yang W, Wang GJ, Holena DN. Delayed endovascular aortic repair is associated with reduced in-hospital mortality in patients with blunt thoracic aortic injury. J Vasc Surg. 2018;68(1):64–73.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Chang R, Fox EE, Greene TJ, Eastridge BJ, Gilani R, Chung KK, et al. Multicenter retrospective study of noncompressible torso hemorrhage: anatomic locations of bleeding and comparison of endovascular versus open approach. J Trauma Acute Care Surg. 2017;83(1):11–8.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Shalhub S, Starnes BW, Tran NT, Hatsukami TS, Lundgren RS, Davis CW, et al. Blunt abdominal aortic injury. J Vasc Surg. 2012;55(5):1277–85.

    Article  PubMed  Google Scholar 

  38. Reuben BC, Whitten MG, Sarfati M, Kraiss LW. Increasing use of endovascular therapy in acute arterial injuries: analysis of the National Trauma Data Bank. J Vasc Surg. 2007;46(6):1222–6.

    Article  PubMed  Google Scholar 

  39. Ball CG, Feliciano DV. Damage control techniques for common and external iliac artery injuries: have temporary intravascular shunts replaced the need for ligation? J Trauma. 2010;68(5):1117–20.

    PubMed  Google Scholar 

  40. Asensio JA, Forno W, Roldán G, Petrone P, Rojo E, Ceballos J, et al. Visceral vascular injuries. Surg Clin North Am. 2002;82(1):1–20 xix.

    Article  PubMed  Google Scholar 

  41. Asensio JA, Chahwan S, Hanpeter D, Demetriades D, Forno W, Gambaro E, et al. Operative management and outcome of 302 abdominal vascular injuries. Am J Surg. 2000;180(6):528–33 discussion 533-4.

    Article  CAS  PubMed  Google Scholar 

  42. Teixeira PGR, DuBose J. Surgical management of vascular trauma. Surg Clin North Am. 2017;97(5):1133–55.

    Article  PubMed  Google Scholar 

  43. Cleanthis M, Jenkins M. Abdominal aortic trauma, iliac and visceral vessel injuries. In: Rasmussen TE, Tai NRM, editors. Rich’s Vascular Trauma. Philadelphia: Elsevier; 2016.

    Google Scholar 

  44. Mehta M, Darling RC 3rd, Taggert JB, Roddy SP, Sternbach Y, Ozsvath KJ, et al. Outcomes of planned celiac artery coverage during TEVAR. J Vasc Surg. 2010;52(5):1153–8.

    Article  PubMed  Google Scholar 

  45. Fullen WD, Hunt J, Altemeier WA. The clinical spectrum of penetrating injury to the superior mesenteric arterial circulation. J Trauma. 1972;12(8):656–64.

    Article  CAS  PubMed  Google Scholar 

  46. Asensio JA, Petrone P, Garcia-Nuñez L, Healy M, Martin M, Kuncir E. Superior mesenteric venous injuries: to ligate or to repair remains the question. J Trauma. 2007;62(3):668–75 discussion 675.

    PubMed  Google Scholar 

  47. Knudson MM, Harrison PB, Hoyt DB, Shatz DV, Zietlow SP, Bergstein JM, et al. Outcome after major renovascular injuries: a Western trauma association multicenter report. J Trauma. 2000;49(6):1116–22.

    Article  CAS  PubMed  Google Scholar 

  48. Haas CA, Spirnak JP. Traumatic renal artery occlusion: a review of the literature. Tech Urol. 1998;4(1):1–11.

    CAS  PubMed  Google Scholar 

  49. Sangthong B, Demetriades D, Martin M, Salim A, Brown C, Inaba K, et al. Management and hospital outcomes of blunt renal artery injuries: analysis of 517 patients from the National Trauma Data Bank. J Am Coll Surg. 2006;203(5):612–7.

    Article  PubMed  Google Scholar 

  50. Colaco M, Navarrete RA, MacDonald SM, Stitzel JD, Terlecki RP. Nationwide procedural trends for renal trauma management. Ann Surg. 2019;269(2):367–9.

    Article  PubMed  Google Scholar 

  51. Beyer C, Zakaluzny S, Humphries M, Shatz D. Multidisciplinary management of blunt renal artery injury with endovascular therapy in the setting of polytrauma: a case report and review of the literature. Ann Vasc Surg. 2017;38:318.e11–6.

    Article  Google Scholar 

  52. Burch JM, Feliciano DV, Mattox KL, Edelman M. Injuries of the inferior vena cava. Am J Surg. 1988;156(6):548–52.

    Article  CAS  PubMed  Google Scholar 

  53. Yellin AE, Chaffee CB, Donovan AJ. Vascular isolation in the treatment of juxta hepatic venous injuries. Arch Surg. 1971;102:566–73.

    Article  CAS  PubMed  Google Scholar 

  54. Bui TD, Mills JL. Control of inferior vena cava injury using percutaneous balloon catheter occlusion. Vasc Endovasc Surg. 2009;43(5):490–3.

    Article  Google Scholar 

  55. Angeles AP, Agarwal N, Lynd C Jr. Repair of a juxtahepatic inferior vena cava injury using a simple endovascular technique. J Trauma. 2004;56(4):918–21.

    Article  PubMed  Google Scholar 

  56. Rozycki GS, Tremblay LN, Feliciano DV, McClelland WB. Blunt vascular trauma in the extremity: diagnosis, management, and outcome. J Trauma. 2003;55(5):814–24.

    Article  PubMed  Google Scholar 

  57. Kauvar DS, Sarfati MR, Kraiss LW. National trauma databank analysis of mortality and limb loss in isolated lower extremity vascular trauma. J Vasc Surg. 2011;53(6):1598–603.

    Article  PubMed  Google Scholar 

  58. Alarhayem AQ, Cohn SM, Cantu-Nunez O, Eastridge BJ, Rasmussen TE. Impact of time to repair on outcomes in patients with lower extremity arterial injuries. J Vasc Surg. 2018.

  59. Hancock HM, Stannard A, Burkhardt GE, Williams K, Dixon P, Cowart J, et al. Hemorrhagic shock worsens neuromuscular recovery in a porcine model of hind limb vascular injury and ischemia/reperfusion. J Vasc Surg. 2011;53(4):1052–62.

    Article  PubMed  Google Scholar 

  60. Burkhardt GE, Gifford SM, Propper BW, Spencer JR, Williams K, Jones L, et al. The impact of ischemic interval on neuromuscular recovery in a porcine (Sus Scrofa) survival model of extremity vascular injury. J Vasc Surg. 2011;53:165–73.

    Article  PubMed  Google Scholar 

  61. White JM, Stannard A, Burkhardt GE, Eastridge BJ, Blackbourne LH, Rasmussen TE. The epidemiology of vascular injury in the wars in Iraq and Afghanistan. Ann Surg. 2011;253:1184–9.

    Article  PubMed  Google Scholar 

  62. Patel JA, White JM, White PW, Rich NM, Rasmussen TE. A contemporary, 7-year analysis of vascular injury from the war in Afghanistan. J Vasc Surg. 2018;68(6):1872–9.

    Article  PubMed  Google Scholar 

  63. Howard JT, Kotwal RS, Turner CA, Janak JC, Mazuchowski EL, Butler FK, Stockinger ZT, Holcomb BR, Bono RC, Smith DJ. Use of combat casualty care data to assess the US military trauma system during the Afghanistan and Iraq conflicts, 2001-2017. JAMA Surg 2019. https://doi.org/10.1001/jamasurg.2019.0151.

    Article  PubMed  PubMed Central  Google Scholar 

  64. Seamon MJ, Smoger D, Torres DM, Pathak AS, Gaughan JP, Santora TA, et al. A prospective validation of a current practice: the detection of extremity vascular injury with CT angiography. J Trauma. 2009;67(2):238–43 discussion 243-4.

    PubMed  Google Scholar 

  65. Inaba K, Branco BC, Reddy S, Park JJ, Green D, Plurad D, et al. Prospective evaluation of multidetector computed tomography for extremity vascular trauma. J Trauma. 2011;70(4):808–15.

    PubMed  Google Scholar 

  66. • Rasmussen TE, Clouse WD, Jenkins DH, Peck MA, Eliason JL, Smith DL. The use of temporary vascular shunts as a damage control adjunct in the management of wartime vascular injury. J Trauma. 2006;61(1):8–12 discussion 12–5. This report is one of the earliest and largest studies demonstrating the use of shunts for damage control vascular surgery in combat.

    Article  PubMed  Google Scholar 

  67. Gifford SM, Aidinian G, Clouse WD, Fox CJ, Porras CA, Jones WT, et al. Effect of temporary shunting on extremity vascular injury: an outcome analysis from the global war on terror vascular injury initiative. J Vasc Surg. 2009;50(3):549–55 discussion 555-6.

    Article  PubMed  Google Scholar 

  68. Borut LT, Acosta CJ, Tadlock LC, Dye JL, Galarneau M, Elshire CD. The use of temporary vascular shunts in military extremity wounds: a preliminary outcome analysis with 2-year follow-up. J Trauma. 2010;69(1):174–8.

    PubMed  Google Scholar 

  69. •• Inaba K, Aksoy H, Seamon MJ, Marks JA, Duchesne J, Schroll R, et al. Multicenter evaluation of temporary intravascular shunt use in vascular trauma. J Trauma Acute Care Surg. 2016;80(3):359–64 discussion 364–5. This is the largest, civilian multi-center retrospective review of patients undergoing temporary vascular shunting which demonstrates its safety and favorable outcomes for vascular injuries.

    Article  PubMed  Google Scholar 

  70. Scott DJ, Rasmussen TE. Surgical damage control and temporary vascular shunts. In: Rasmussen TE, Tai NRM, editors. Rich’s vascular trauma. Philadelphia: Elsevier; 2016.

    Google Scholar 

  71. Parry NG, Feliciano DV, Burke RM, Cava RA, Nicholas JM, Dente CJ, et al. Management and short-term patency of lower extremity venous injuries with various repairs. Am J Surg. 2003;186(6):631–5.

    Article  PubMed  Google Scholar 

  72. Williams TK, Clouse WD. Current concepts in repair of extremity venous injury. J Vasc Surg Venous Lymphat Disord. 2016;4(2):238–47.

    Article  PubMed  Google Scholar 

  73. Burkhardt GE, Cox M, Clouse WD, Porras C, Gifford SM, Williams K, et al. Outcomes of selective tibial artery repair following combat-related extremity injury. J Vasc Surg. 2010;52(1):91–6.

    Article  PubMed  Google Scholar 

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Correspondence to Jigarkumar A. Patel.

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Dr. Patel has nothing to disclose. Dr. Rasmussen has patents for REBOA and REBOA-related technologies but has no financial conflicts to disclose.

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Patel, J.A., Rasmussen, T.E. Vascular Trauma—Open or Endovascular. Curr Trauma Rep 5, 137–145 (2019). https://doi.org/10.1007/s40719-019-00167-5

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