Endovascular and hybrid trauma and bleeding management

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Endovascular and hybrid trauma and bleeding management
Other namesEVTM

Endovascular and hybrid trauma and bleeding management is a new and rapidly evolving concept within medical healthcare and endovascular resuscitation. It involves early multidisciplinary evaluation and management of hemodynamically unstable patients with traumatic injuries as well as being a bridge to definitive treatment. [1] [2] [3] It has recently been shown that the EVTM concept may also be applied to non-traumatic hemodynamically unstable patients. [4]

Contents

Principles

The fundamental principles of trauma care are built around advanced trauma life support (ATLS) guidelines using the mnemonic ABCDE for early assessment of the patient and detection of airway and circulatory problems. This way, life-threatening conditions are identified and resuscitation may be initiated, despite the lack of definitive diagnosis. [5] The EVTM concept of acute trauma care incorporates modern endovascular techniques and procedures as additional adjuncts to this well-established protocol. [1] [2] [3] [4] The new suggested algorithm of AABCDE has emerged for EVTM enabled providers. The additional “A” stands for Access, indicating the importance of gaining early vascular access to the femoral artery (and vein), and is fundamental to this concept of trauma care. [6] As with traditional trauma care, vascular access in the peripheral or central veins allows for blood sampling and administration of drugs or fluids. However, for EVTM enabled providers, early femoral arterial access provides the possibility to use potentially lifesaving endovascular diagnostic and therapeutic tools for temporary management and bridge to definitive endovascular or open surgical treatment, in addition to arterial blood sampling and invasive blood pressure monitoring. [1] [7]

One of the major elements of EVTM is the multidisciplinary team approach. By combining the expertise present allows for optimal treatment not just at the time of patient arrival but also in the pre-hospital setting and later in the operating suite. It is all about teamwork with a common goal, to save the patient. It allows for the hybrid use of open surgery and endovascular methods for hemorrhage control and definitive treatment. In a hemodynamically unstable bleeding patient, traditional treatment is laparotomy with abdominal packing, but an EVTM team might simultaneously gain vascular access and perform REBOA for proximal control or embolization as a part in definitive treatment. An EVTM multidisciplinary approach requires complete transparency, good communication and leadership. It is however also important to remember that just because you can, doesn't mean that you should use an EVTM approach. EVTM should always be considered but only used in the optimally selected patient at the right time if the expertise and equipment is present to do it safely. [1] [2] [3] [4] [5] [6] [8]

Vascular access

In the acute setting, the femoral artery is most often the easiest to identify and access thanks to its typically reasonable size. This is however obviously relative to individual anatomical differences and hemodynamic state of the patient. It is in general beneficial to gain early vascular access as the inguinal area is seldom occupied and, if possible, attempt to do this on the contralateral side to a major lower extremity injury. Access may be attempted by ultrasound-guided or blind puncture and surgical cut-down, where ultrasound-guided is the safest and most reasonable alternative for the less experienced. Vascular access is based on the Seldinger technique. After puncturing the vessel with a needle and confirmation of arterial access a wire is advanced, the needle removed and a vascular sheath is introduced. The access is then ready to use. [6]

Endovascular devices

The use of endovascular modalities for bleeding control and treatment on hemodynamically unstable trauma patients is increasing. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for hemorrhage control, angioembolization and stent grafts are highly established tools used for both arterial and venous hemorrhage in both traumatic and non-traumatic patients. [4] [9] [10] [11] To be able to provide an endovascular opportunity for resuscitation requires good organization and a well-established endovascular team. [2] [3]

REBOA

Acute care of a hemodynamically unstable trauma patient is never an ideal task. [12] [13] The emphasis is on stopping blood extravasation and hemodynamic stabilisation without delay, despite if it is pre-hospital, in the emergency department or in a hybrid operating suite. REBOA, also called Aortic Balloon Occlusion (ABO), is a powerful endovascular tool that inflates an intra-aortic balloon occluding the lumen of the vessel and decreased or completely prevents blood flow to the more distal parts. If inflated in the aorta proximal to the identified source of bleeding it may help to diminish or stop blood extravasation, also potentially aiding to increase cardiac afterload. This should increase the central pressure and secure adequate myocardial and cerebral perfusion, hopefully rendering the patient, at least temporarily, more hemodynamically stable. REBOA is used as an endovascular tool for hemodynamic control and as a resuscitation adjunct that may prolong the life of the critical patient. REBOA is not only used from an endovascular resuscitation aspect, but may also to help by allowing more time for definitive treatment. [6] [9] [14] [15] [16] [17] [18] [ excessive citations ]

Embolization

Embolization is a minimally invasive technique used in EVTM of selected hemodynamically unstable patients with both traumatic and non-traumatic injuries. It is the artificial creation of a thrombus by the introduction of various substances to intentionally occlude a vessel with the aim to stop or diminish blood extravasation and is a critical part of the modern management of arterial injuries. [6] [19]

Stent grafts

Stent grafts, or endo-grafts, are a more permanent solution in the hemodynamically unstable patient and are an important part of the tool kit for EVTM. They are self-expanding artificial reconstructions of vessels with fabric coating deployed inside the original vessel and help to gain temporary control, stop the hemorrhage and repair the damaged vessel wall. They can be used and positioned, by an experienced surgeon, in every major vessel in the body. [6] [11] [20] [21] [22]

JEVTM

The Journal of Endovascular Resuscitation and Trauma Management (JEVTM) is an open access platform for publishing peer-reviewed research regarding endovascular hybrid hemorrhage control. The first issue was published August 2017 with continued publications quarterly. The editorial board is made up by clinicians and scientists who are experts within the field. [7]

Related Research Articles

<span class="mw-page-title-main">Aortic dissection</span> Injury to the innermost layer of the aorta

Aortic dissection (AD) occurs when an injury to the innermost layer of the aorta allows blood to flow between the layers of the aortic wall, forcing the layers apart. In most cases, this is associated with a sudden onset of severe chest or back pain, often described as "tearing" in character. Vomiting, sweating, and lightheadedness may also occur. Damage to other organs may result from the decreased blood supply, such as stroke, lower extremity ischemia, or mesenteric ischemia. Aortic dissection can quickly lead to death from insufficient blood flow to the heart or complete rupture of the aorta.

<span class="mw-page-title-main">Aneurysm</span> Bulge in the wall of a blood vessel

An aneurysm is an outward bulging, likened to a bubble or balloon, caused by a localized, abnormal, weak spot on a blood vessel wall. Aneurysms may be a result of a hereditary condition or an acquired disease. Aneurysms can also be a nidus for clot formation (thrombosis) and embolization. As an aneurysm increases in size, the risk of rupture, which leads to uncontrolled bleeding, increases. Although they may occur in any blood vessel, particularly lethal examples include aneurysms of the circle of Willis in the brain, aortic aneurysms affecting the thoracic aorta, and abdominal aortic aneurysms. Aneurysms can arise in the heart itself following a heart attack, including both ventricular and atrial septal aneurysms. There are congenital atrial septal aneurysms, a rare heart defect.

<span class="mw-page-title-main">Interventional radiology</span> Medical subspecialty

Interventional radiology (IR) is a medical specialty that performs various minimally-invasive procedures using medical imaging guidance, such as x-ray fluoroscopy, computed tomography, magnetic resonance imaging, or ultrasound. IR performs both diagnostic and therapeutic procedures through very small incisions or body orifices. Diagnostic IR procedures are those intended to help make a diagnosis or guide further medical treatment, and include image-guided biopsy of a tumor or injection of an imaging contrast agent into a hollow structure, such as a blood vessel or a duct. By contrast, therapeutic IR procedures provide direct treatment—they include catheter-based medicine delivery, medical device placement, and angioplasty of narrowed structures.

<span class="mw-page-title-main">Vascular surgery</span> Medical specialty, operative procedures for the treatment of vascular disorders

Vascular surgery is a surgical subspecialty in which vascular diseases involving the arteries, veins, or lymphatic vessels, are managed by medical therapy, minimally-invasive catheter procedures and surgical reconstruction. The specialty evolved from general and cardiovascular surgery where it refined the management of just the vessels, no longer treating the heart or other organs. Modern vascular surgery includes open surgery techniques, endovascular techniques and medical management of vascular diseases - unlike the parent specialities. The vascular surgeon is trained in the diagnosis and management of diseases affecting all parts of the vascular system excluding the coronaries and intracranial vasculature. Vascular surgeons also are called to assist other physicians to carry out surgery near vessels, or to salvage vascular injuries that include hemorrhage control, dissection, occlusion or simply for safe exposure of vascular structures.

<span class="mw-page-title-main">Internal bleeding</span> Medical condition

Internal bleeding is a loss of blood from a blood vessel that collects inside the body, and is not usually visible from the outside. It can be a serious medical emergency but the extent of severity depends on bleeding rate and location of the bleeding. Severe internal bleeding into the chest, abdomen, pelvis, or thighs can cause hemorrhagic shock or death if proper medical treatment is not received quickly. Internal bleeding is a medical emergency and should be treated immediately by medical professionals.

<span class="mw-page-title-main">Aortic aneurysm</span> Excessive enlargement of the human aorta

An aortic aneurysm is an enlargement (dilatation) of the aorta to greater than 1.5 times normal size. They usually cause no symptoms except when ruptured. Occasionally, there may be abdominal, back, or leg pain. The prevalence of abdominal aortic aneurysm ("AAA") has been reported to range from 2 to 12% and is found in about 8% of men more than 65 years of age. The mortality rate attributable to AAA is about 15,000 per year in the United States and 6,000 to 8,000 per year in the United Kingdom and Ireland. Between 2001 and 2006, there were approximately 230,000 AAA surgical repairs performed on Medicare patients in the United States.

<span class="mw-page-title-main">Abdominal aortic aneurysm</span> Medical condition

Abdominal aortic aneurysm (AAA) is a localized enlargement of the abdominal aorta such that the diameter is greater than 3 cm or more than 50% larger than normal. An AAA usually causes no symptoms, except during rupture. Occasionally, abdominal, back, or leg pain may occur. Large aneurysms can sometimes be felt by pushing on the abdomen. Rupture may result in pain in the abdomen or back, low blood pressure, or loss of consciousness, and often results in death.

<span class="mw-page-title-main">Thoracic aortic aneurysm</span> Medical condition

A thoracic aortic aneurysm is an aortic aneurysm that presents primarily in the thorax.

Hemoperitoneum is the presence of blood in the peritoneal cavity. The blood accumulates in the space between the inner lining of the abdominal wall and the internal abdominal organs. Hemoperitoneum is generally classified as a surgical emergency; in most cases, urgent laparotomy is needed to identify and control the source of the bleeding. In selected cases, careful observation may be permissible. The abdominal cavity is highly distensible and may easily hold greater than five liters of blood, or more than the entire circulating blood volume for an average-sized individual. Therefore, large-scale or rapid blood loss into the abdomen will reliably induce hemorrhagic shock and, if untreated, may rapidly lead to death.

<span class="mw-page-title-main">Traumatic aortic rupture</span> Medical condition

Traumatic aortic rupture, also called traumatic aortic disruption or transection, is a condition in which the aorta, the largest artery in the body, is torn or ruptured as a result of trauma to the body. The condition is frequently fatal due to the profuse bleeding that results from the rupture. Since the aorta branches directly from the heart to supply blood to the rest of the body, the pressure within it is very great, and blood may be pumped out of a tear in the blood vessel very rapidly. This can quickly result in shock and death. Thus traumatic aortic rupture is a common killer in automotive accidents and other traumas, with up to 18% of deaths that occur in automobile collisions being related to the injury. In fact, aortic disruption due to blunt chest trauma is the second leading cause of injury death behind traumatic brain injury.

<span class="mw-page-title-main">Endovascular aneurysm repair</span> Surgery used to treat abdominal aortic aneurysm

Endovascular aneurysm repair (EVAR) is a type of minimally-invasive endovascular surgery used to treat pathology of the aorta, most commonly an abdominal aortic aneurysm (AAA). When used to treat thoracic aortic disease, the procedure is then specifically termed TEVAR for "thoracic endovascular aortic/aneurysm repair." EVAR involves the placement of an expandable stent graft within the aorta to treat aortic disease without operating directly on the aorta. In 2003, EVAR surpassed open aortic surgery as the most common technique for repair of AAA, and in 2010, EVAR accounted for 78% of all intact AAA repair in the United States.

<span class="mw-page-title-main">Aortic rupture</span> Rupture or breakage of the aorta, the largest artery in the body

Aortic rupture is the rupture or breakage of the aorta, the largest artery in the body. Aortic rupture is a rare, extremely dangerous condition. The most common cause is an abdominal aortic aneurysm that has ruptured spontaneously. Aortic rupture is distinct from aortic dissection, which is a tear through the inner wall of the aorta that can block the flow of blood through the aorta to the heart or abdominal organs.

Surgical Outcomes Analysis & Research, SOAR, is a research laboratory of the Department of Surgery at Boston University School of Medicine and Boston Medical Center with expertise in outcomes research. SOAR investigates surgical diseases and perioperative outcomes. The group focuses on pancreatic cancer, other gastrointestinal and hepatobiliary malignancies, vascular disease, and transplant surgery. SOAR's goal is to examine quality, delivery, and financing of care in order to have an immediate impact on patient care and system improvements. The group members utilize national health services and administrative databases, as well as institutional databases, to investigate and to address factors contributing to disease outcomes and healthcare disparities.

<span class="mw-page-title-main">Acute limb ischaemia</span> Occurs when there is a sudden lack of blood flow to a limb

Acute limb ischaemia (ALI) occurs when there is a sudden lack of blood flow to a limb, within 14 days of symptoms onset. It is different from another condition which is more chronic called critical limb ischemia (CLD). CLD is the end stage of peripheral vascular disease where there is still some collateral circulation (alternate circulation pathways} that bring some blood to the distal parts of the limbs. While limbs in both acute and chronic limb ischemia may be pulseless, a chronically ischemic limb is typically warm and pink due to a well-developed collateral artery network and does not need emergency intervention to avoid limb loss.

An infected aneurysm is an aneurysm arising from bacterial infection of the arterial wall. It can be a common complication of the hematogenous spread of bacterial infection.

Todd E. Rasmussen, MD, FACS is an American professor and Vice Chair for Education in the Department of Surgery at Mayo Clinic, Rochester, and a Senior Associate Consultant in the Division of Vascular and Endovascular Surgery. Prior to joining the Mayo Clinic, he had a 28-year career in the military, retiring as an Air Force Colonel in 2021. His most recent military assignment was as Associate Dean or Research at the Uniformed Services University of the Health Sciences and an attending surgeon at the Walter Reed National Military Medical Center.

<span class="mw-page-title-main">Open aortic surgery</span> Surgical technique

Open aortic surgery (OAS), also known as open aortic repair (OAR), describes a technique whereby an abdominal, thoracic or retroperitoneal surgical incision is used to visualize and control the aorta for purposes of treatment, usually by the replacement of the affected segment with a prosthetic graft. OAS is used to treat aneurysms of the abdominal and thoracic aorta, aortic dissection, acute aortic syndrome, and aortic ruptures. Aortobifemoral bypass is also used to treat atherosclerotic disease of the abdominal aorta below the level of the renal arteries. In 2003, OAS was surpassed by endovascular aneurysm repair (EVAR) as the most common technique for repairing abdominal aortic aneurysms in the United States.

<span class="mw-page-title-main">Resuscitative endovascular balloon occlusion of the aorta</span> Temporary procedure to support blood pressure and stem blood loss

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive procedure performed during resuscitation of critically injured trauma patients. Originally developed as a less invasive alternative to emergency thoracotomy with aortic cross clamping, REBOA is performed to gain rapid control of non-compressible truncal or junctional hemorrhage. REBOA is performed first by achieving access to the common femoral artery (CFA) and advancing a catheter within the aorta. Upon successful catheter placement, an occluding balloon may be inflated either within the descending thoracic aorta or infrarenal abdominal aorta. REBOA stanches downstream hemorrhage and improves cardiac index, cerebral perfusion, and coronary perfusion. Although REBOA does not eliminate the need for definitive hemorrhage control, it may serve as a temporizing measure during initial resuscitation. Despite the benefits of REBOA, there are significant local and systemic ischemic risks. Establishing standardized REBOA procedural indications and mitigating the risk of ischemic injury are topics of ongoing investigation. Although this technique has been successfully deployed in adult patients, it has not yet been studied in children.

Selective aortic arch perfusion (SAAP) is an experimental treatment for haemorrhage-induced traumatic cardiac arrest. It has been shown in animal studies to be superior to Zone 1 REBOA once cardiac arrest has occurred.

<span class="mw-page-title-main">Benjamin Starnes</span> American physician and vascular surgeon

Benjamin Starnes is a vascular surgeon and medical researcher. He holds the Alexander Whitehill Clowes Endowed Chair in Vascular surgery at the University of Washington. He served as a U.S. Army surgeon for 15 years, doing three tours of duty, including in the last M.A.S.H. unit. On the day of the September 11 attacks he was at the Pentagon rendering medical aid to victims, and his experience was later recounted in the book American Phoenix: Heroes of the Pentagon on 9/11. He is among the primary authors of the official guidelines for diagnosis and management of aortic disease adopted by the American College of Cardiology and the American Heart Association.

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