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Damage Control Vascular Surgery

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

Purpose of Review

Exsanguination is one of the most fearsome sequelae of trauma and is responsible for a large portion of both civilian and military mortality. The concept of damage control surgery is a critical development in the field of trauma largely driven by the growing understanding that coagulopathy and physiologic derangements are the primary cause of death in critically ill trauma patients. Damage control vascular surgery focuses on the rapid temporization of vascular injuries.

Recent Findings

Balloon occlusion can be utilized for rapid hemorrhage control (REBOA, foley catheter, retrohepatic caval balloon, etc.). In the setting of damage control, most veins can and should be ligated. Consideration of shunting should be made regarding the suprarenal inferior vena cava, the portal vein, and the superior mesenteric vein. The named arteries should be shunted and repaired when possible; however, redundant arterial beds can be safely ligated. Vessels of all sizes can be safely shunted with commercially available or improvised devices. Systemic heparinization is not necessary to maintain patency. More recently, the concept of using endovascular stents as long-term shunts has gained attention. These can be deployed traditionally under angiographic guidance or using the novel direct site endovascular repair (DSER) technique.

Summary

The rapidly evolving field of endovascular trauma management has afforded a host of new management strategies for the physiologically deranged critically ill trauma patient.

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References

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

  1. Peitzman AB, et al. Hemorrhagic shock. Curr Probl Surg. 1995;32(11):925–1002.

    CAS  PubMed  Google Scholar 

  2. Kauvar DS, Lefering R, Wade CE. Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations. J Trauma. 2006;60(6 Suppl):S3–11.

    PubMed  Google Scholar 

  3. Eastridge BJ, et al. Died of wounds on the battlefield: causation and implications for improving combat casualty care. J Trauma. 2011;71(1 Suppl):S4–8.

    PubMed  Google Scholar 

  4. Davis JS, Satahoo SS, Butler FK, Dermer H, Naranjo D, Julien K, et al. An analysis of prehospital deaths: who can we save? J Trauma Acute Care Surg. 2014;77(2):213–8.

    PubMed  Google Scholar 

  5. Roberts DJ, Ball CG, Feliciano DV, Moore EE, Ivatury RR, Lucas CE, et al. History of the innovation of damage control for management of trauma patients: 1902–2016. Ann Surg. 2017;265(5):1034–44.

    PubMed  Google Scholar 

  6. Hermreck AS. The history of cardiopulmonary resuscitation. Am J Surg. 1988;156(6):430–6.

    CAS  PubMed  Google Scholar 

  7. Rhee PM, et al. Survival after emergency department thoracotomy: review of published data from the past 25 years. J Am Coll Surg. 2000;190(3):288–98.

    CAS  PubMed  Google Scholar 

  8. HUGHES CW. Use of an intra-aortic balloon catheter tamponade for controlling intra-abdominal hemorrhage in man. Surgery. 1954;36(1):65–8.

    CAS  PubMed  Google Scholar 

  9. Mattox KL, Allen MK, Feliciano DV. Laparotomy in the emergency department. JACEP. 1979;8(5):180–3.

    CAS  PubMed  Google Scholar 

  10. Feliciano DV, Burch JM, Mattox KL, Bitondo CG, Fields G. Balloon catheter tamponade in cardiovascular wounds. Am J Surg. 1990;160(6):583–7.

    CAS  PubMed  Google Scholar 

  11. Ball CG, Wyrzykowski AD, Nicholas JM, Rozycki GS, Feliciano DV. A decade’s experience with balloon catheter tamponade for the emergency control of hemorrhage. J Trauma. 2011;70(2):330–3.

    PubMed  Google Scholar 

  12. Moore LJ, Brenner M, Kozar RA, Pasley J, Wade CE, Baraniuk MS, et al. Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage. J Trauma Acute Care Surg. 2015;79(4):523–30 discussion 530-2.

    PubMed  Google Scholar 

  13. Romagnoli AN, Teeter W, Wasicek P, Gamble WB, Hu P, Stein D, et al. No wire? No problem: resuscitative endovascular balloon occlusion of the aorta can be performed effectively and more rapidly with a wire-free device. J Trauma Acute Care Surg. 2018;85(5):894–8.

    PubMed  Google Scholar 

  14. Brenner M, et al. Resuscitative endovascular balloon occlusion of the aorta and resuscitative thoracotomy in select patients with hemorrhagic shock: early results from the American Association for the Surgery of Trauma Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery Registry. J Am Coll Surg. 2018.

  15. Romagnoli A, Teeter W, Pasley J, Hu P, Hoehn M, Stein D, et al. Time to aortic occlusion: It’s all about access. J Trauma Acute Care Surg. 2017;83(6):1161–4.

    PubMed  Google Scholar 

  16. DuBose JJ, et al. The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA). J Trauma Acute Care Surg. 2016;81(3):409–19.

    PubMed  Google Scholar 

  17. Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma. 2011;71(6):1869–72.

    PubMed  Google Scholar 

  18. Brenner M, Hoehn M, Pasley J, Dubose J, Stein D, Scalea T. Basic endovascular skills for trauma course: bridging the gap between endovascular techniques and the acute care surgeon. J Trauma Acute Care Surg. 2014;77(2):286–91.

    PubMed  Google Scholar 

  19. Assar AN, Zarins CK. Endovascular proximal control of ruptured abdominal aortic aneurysms: the internal aortic clamp. J Cardiovasc Surg. 2009;50(3):381–5.

  20. White JM, Cannon JW, Stannard A, Markov NP, Spencer JR, Rasmussen TE. Endovascular balloon occlusion of the aorta is superior to resuscitative thoracotomy with aortic clamping in a porcine model of hemorrhagic shock. Surgery. 2011;150(3):400–9.

    PubMed  Google Scholar 

  21. Burlew CC, Moore EE, Moore FA, Coimbra R, McIntyre RC Jr, Davis JW, et al. Western Trauma Association critical decisions in trauma: resuscitative thoracotomy. J Trauma Acute Care Surg. 2012;73(6):1359–63.

    PubMed  Google Scholar 

  22. • Pasley J, et al. Resuscitative endovascular balloon occlusion of the aorta (REBOA) for Hemorrhagic shock (CPG ID: 38). 06 Jul 2017 [cited 2019 30 Apr 2019]. Available from: https://jts.amedd.army.mil/assets/docs/cpgs/JTS_Clinical_Practice_Guidelines_(CPGs)/REBOA_%20Hemorrhagic%20Shock_06_Jul_2017_ID38.pdf. US Military Joint Trauma System clinical practice guidelines for resuscitative endovascular balloon occlusion of the aorta utilization (REBOA).

  23. Kalish J, Eslami M, Gillespie D, Schermerhorn M, Rybin D, Doros G, et al. Routine use of ultrasound guidance in femoral arterial access for peripheral vascular intervention decreases groin hematoma rates. J Vasc Surg. 2015;61(5):1231–8.

    PubMed  Google Scholar 

  24. Inagaki E, Farber A, Siracuse JJ, Mell MW, Rybin DV, Doros G, et al. Routine use of ultrasound guidance in femoral arterial access for peripheral vascular intervention decreases groin hematoma rates in high-volume surgeons. Ann Vasc Surg. 2018;51:1–7.

    PubMed  Google Scholar 

  25. Davidson AJ, et al. The pitfalls of resuscitative endovascular balloon occlusion of the aorta: risk factors and mitigation strategies. J Trauma Acute Care Surg. 2018;84(1):192–202.

    PubMed  Google Scholar 

  26. Brenner M, Teeter W, Hoehn M, Pasley J, Hu P, Yang S, et al. Use of resuscitative endovascular balloon occlusion of the aorta for proximal aortic control in patients with severe hemorrhage and arrest. JAMA Surg. 2018;153(2):130–5.

    PubMed  Google Scholar 

  27. Lallemand MS, Moe DM, McClellan JM, Smith JP, Daab L, Marko S, et al. Resuscitative endovascular balloon occlusion of the aorta for major abdominal venous injury in a porcine hemorrhagic shock model. J Trauma Acute Care Surg. 2017;83(2):230–6.

    PubMed  Google Scholar 

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

    Google Scholar 

  29. Reynolds CL, Celio AC, Bridges LC, Mosquera C, OʼConnell B, Bard MR, et al. REBOA for the IVC? Resuscitative balloon occlusion of the inferior vena cava (REBOVC) to abate massive hemorrhage in retrohepatic vena cava injuries. J Trauma Acute Care Surg. 2017;83(6):1041–6.

    PubMed  Google Scholar 

  30. Reilly PM, Rotondo MF, Carpenter JP, Sherr SA, Schwab CW. Temporary vascular continuity during damage control: intraluminal shunting for proximal superior mesenteric artery injury. J Trauma. 1995;39(4):757–60.

    CAS  PubMed  Google Scholar 

  31. Hudorovic N. Wartime major venous vessel injuries. Interact Cardiovasc Thorac Surg. 2008;7(1):158–60.

    PubMed  Google Scholar 

  32. Buckman RF, et al. Injuries of the inferior vena cava. Surg Clin North Am. 2001;81(6):1431–47.

    CAS  PubMed  Google Scholar 

  33. Rosengart MR, et al. Prognostic factors in patients with inferior vena cava injuries. Am Surg. 1999;65(9):849–55 discussion 855-6.

    CAS  PubMed  Google Scholar 

  34. Huerta S, Bui TD, Nguyen TH, Banimahd FN, Porral D, Dolich MO. Predictors of mortality and management of patients with traumatic inferior vena cava injuries. Am Surg. 2006;72(4):290–6.

    PubMed  Google Scholar 

  35. Sullivan PS, Dente CJ, Patel S, Carmichael M, Srinivasan JK, Wyrzykowski AD, et al. Outcome of ligation of the inferior vena cava in the modern era. Am J Surg. 2010;199(4):500–6.

    PubMed  Google Scholar 

  36. Mullins RJ, Lucas CE, Ledgerwood AM. The natural history following venous ligation for civilian injuries. J Trauma. 1980;20(9):737–43.

    CAS  PubMed  Google Scholar 

  37. Jones VS, Shun A. Is the inferior vena cava dispensable? Pediatr Surg Int. 2007;23(9):885–8.

    PubMed  Google Scholar 

  38. Percival TJ, Rasmussen TE. Reperfusion strategies in the management of extremity vascular injury with ischaemia. Br J Surg. 2012;99(Suppl 1):66–74.

    PubMed  Google Scholar 

  39. Borut LT, et al. 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 

  40. 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.

    PubMed  Google Scholar 

  41. Chambers LW, Green DJ, Sample K, Gillingham BL, Rhee P, Brown C, et al. Tactical surgical intervention with temporary shunting of peripheral vascular trauma sustained during Operation Iraqi Freedom: one unit's experience. J Trauma. 2006;61(4):824–30.

    PubMed  Google Scholar 

  42. 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.

    PubMed  Google Scholar 

  43. 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 

  44. Hossny A. Blunt popliteal artery injury with complete lower limb ischemia: is routine use of temporary intraluminal arterial shunt justified? J Vasc Surg. 2004;40(1):61–6.

    PubMed  Google Scholar 

  45. McHenry TP, et al. Fractures with major vascular injuries from gunshot wounds: implications of surgical sequence. J Trauma. 2002;53(4):717–21.

    PubMed  Google Scholar 

  46. Granchi T, Schmittling Z, Vasquez J Jr, Schreiber M, Wall M. Prolonged use of intraluminal arterial shunts without systemic anticoagulation. Am J Surg. 2000;180(6):493–6 discussion 496-7.

    CAS  PubMed  Google Scholar 

  47. Inaba K, 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.

    PubMed  Google Scholar 

  48. Oliver JC, Bekker W, Edu S, Nicol AJ, Navsaria PH. A ten year review of civilian iliac vessel injuries from a single trauma Centre. Eur J Vasc Endovasc Surg. 2012;44(2):199–202.

    CAS  PubMed  Google Scholar 

  49. Subramanian A, Vercruysse G, Dente C, Wyrzykowski A, King E, Feliciano DV. A decade’s experience with temporary intravascular shunts at a civilian level I trauma center. J Trauma. 2008;65(2):316–24 discussion 324-6.

    PubMed  Google Scholar 

  50. Hausenloy DJ, Yellon DM. Ischaemic conditioning and reperfusion injury. Nat Rev Cardiol. 2016;13(4):193–209.

    CAS  PubMed  Google Scholar 

  51. Falluji N, Mukherjee D. Critical and acute limb ischemia: an overview. Angiology. 2014;65(2):137–46.

    PubMed  Google Scholar 

  52. Gifford SM, Eliason JL, Clouse WD, Spencer JR, Burkhardt GE, Propper BW, et al. Early versus delayed restoration of flow with temporary vascular shunt reduces circulating markers of injury in a porcine model. J Trauma. 2009;67(2):259–65.

    PubMed  PubMed Central  Google Scholar 

  53. Taller J, Kamdar JP, Greene JA, Morgan RA, Blankenship CL, Dabrowski P, et al. Temporary vascular shunts as initial treatment of proximal extremity vascular injuries during combat operations: the new standard of care at Echelon II facilities? J Trauma. 2008;65(3):595–603.

    PubMed  Google Scholar 

  54. Burch JM, Feliciano DV, Mattox KL. The atriocaval shunt. Facts and fiction. Ann Surg. 1988;207(5):555–68.

    CAS  PubMed  PubMed Central  Google Scholar 

  55. Feliciano DV. Pitfalls in the management of peripheral vascular injuries. Trauma Surg Acute Care Open. 2017;2(1):e000110.

    PubMed  PubMed Central  Google Scholar 

  56. Norgren L, et al. Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg. 2007;45(Suppl S):S5–67.

    PubMed  Google Scholar 

  57. Gerhard-Herman MD, et al. 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: executive summary. Vasc Med. 2017;22(3):NP1–NP43.

    PubMed  Google Scholar 

  58. • Faulconer ER, et al. Use of open and endovascular surgical techniques to manage vascular injuries in the trauma setting: a review of the Aast Proovit Registry. J Trauma Acute Care Surg. 2017; Increased utilization of endovascular intervention in blunt trauma, decreased blood transfusion requirement associated with endovascular intervention.

  59. Davidson AJ, Neff LP, DuBose JJ, Sampson JB, Abbot CM, Williams TK. Direct-site endovascular repair (DSER): a novel approach to vascular trauma. J Trauma Acute Care Surg. 2016;81(5 Suppl 2 Proceedings of the 2015 Military Health System Research Symposium):S138–43.

    PubMed  Google Scholar 

  60. Greenberg G, Szendro G, Mayzler O, Ginzburg V, Leytzin A. Use of ViaBahn open revascularisation technique for above-knee femoro-popliteal anastomosis: a technical note. Eur J Vasc Endovasc Surg. 2011;42(2):202–5.

    CAS  PubMed  Google Scholar 

  61. •• Davidson AJ, et al. Comparison of direct site endovascular repair utilizing expandable polytetrafluoroethylene stent grafts versus standard vascular shunts in a porcine (Sus scrofa) model. J Trauma Acute Care Surg. 2017;83(3):457–63 Novel utilization of endovascular stent grafts in open temporizing vascular interventions to create a “suture-less” vascular anastomosis.

    PubMed  Google Scholar 

  62. Holcomb JB, et al. The prospective observational multicenter major trauma transfusion (PROMMTT) study. J Trauma Acute Care Surg. 2013;75(1 Suppl 1):S1–2.

    PubMed  Google Scholar 

  63. Smith A, Ouellet JF, Niven D, Kirkpatrick AW, Dixon E, D’Amours S, et al. Timeliness in obtaining emergent percutaneous procedures in severely injured patients: how long is too long and should we create quality assurance guidelines? Can J Surg. 2013;56(6):E154–7.

    PubMed  PubMed Central  Google Scholar 

  64. Howell GM, Peitzman AB, Nirula R, Rosengart MR, Alarcon LH, Billiar TR, et al. Delay to therapeutic interventional radiology postinjury: time is of the essence. J Trauma. 2010;68(6):1296–300.

    PubMed  Google Scholar 

  65. Schwartz DA, Medina M, Cotton BA, Rahbar E, Wade CE, Cohen AM, et al. Are we delivering two standards of care for pelvic trauma? Availability of angioembolization after hours and on weekends increases time to therapeutic intervention. J Trauma Acute Care Surg. 2014;76(1):134–9.

    PubMed  Google Scholar 

  66. •• Morrison J, et al. A surgical endovascular trauma service increases case volume and decreases time to hemostasis, Dedicated endovascular trauma service, staffed by physicians trained in vascular and trauma surgery decreases time to hemostasis. Ann Surg. 2019.

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Authors and Affiliations

  1. R Adams Cowley Shock Trauma Center, Department of Trauma and Surgical Critical Care, University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD, 21201, USA

    Anna Romagnoli & Joseph DuBose

  2. Riverside University Health System, 26520 Cactus Ave, Moreno Valley, CA, 92555, USA

    Megan Brenner

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  1. Anna Romagnoli
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  2. Joseph DuBose
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  3. Megan Brenner
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Correspondence to Anna Romagnoli.

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Conflict of Interest

Dr. Romagnoli has nothing to disclose. Dr. DuBose has nothing to disclose. Dr. Brenner’s institution received a Department of Defense grant which ended in 2017. Dr. Brenner is a member of the clinical advisory board at Prytime Medical and receives stock options. She has nothing further to disclose.

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Romagnoli, A., DuBose, J. & Brenner, M. Damage Control Vascular Surgery. Curr Trauma Rep 5, 146–153 (2019). https://doi.org/10.1007/s40719-019-00172-8

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