The Decade in Vascular Trauma
The developments and data that have shaped modern vascular trauma care and what the next decade may hold.
For years, the literature surrounding trauma embolization was limited to technical notes and case series; however, in the last decade, the role of trauma embolization has come into much better focus. This is not surprising, given the ongoing difficulties in conducting clinical research in patients with limited capacity.1 There is, fortunately, an increase of high-quality clinical evidence and more sophisticated multispecialty consensus documents that are clarifying the indications, potential complications, and expected outcomes of embolization in blunt and penetrating trauma.2 The lack of high-quality data still limits the widespread use of some procedures, such as arterial embolization for pelvic fractures in which rigorous comparisons to surgical alternatives are lacking and late neurovascular complications, which are only potentially related to embolization, are pointed to as a cause of patient disability.3
It is worth reviewing the progress made in the endovascular management of trauma, focusing on the most frequent sites of trauma-related endovascular therapy. In this article, we also attempt to identify future trends in trauma diagnosis and endovascular management.
Nowhere in the field of trauma embolization has the role of embolization increased more or been studied as carefully as with splenic embolization. Splenic embolization for trauma was first reported more than 40 years ago.4 For years, splenic embolization was the procedure trauma centers had to provide, but rarely considered first-line therapy. Improvements in embolization technology and the increasing evidence that proximal embolization is efficacious, have made this procedure well accepted (Figure 1). Many centers now have clear indications for splenic embolization based on CT and clinical presentation.5 Previous concerns about late hemorrhage and splenic abscess have largely been disproven.6,7
The role of angiography and embolization in pelvic fractures remains in flux. There are unstable pelvic fractures in which embolization provides the only viable method to control arterial hemorrhage. Therefore, pelvic angiography with embolization will remain an essential tool in the management of pelvic trauma. At the same time, there are no adequate studies comparing embolization to fixation or pelvic packing, both of which may be more effective in controlling venous bleeding. An ongoing challenge in pelvic trauma embolization is the broad spectrum of vascular findings on angiography.8 Indirect signs of arterial injury on angiography are common, potentially leading to nonselective or broad-area embolization (Figure 2); however, this practice may be associated with more complications, including claudication.9 There is a trend toward more microcatheter superselective embolization. Embolization in which only active extravasation is treated using superselective embolization may lead to fewer complications with improved control of bleeding.
The biggest change in practice, which is just now being defined, is the role of CT angiography (CTA) in pelvic trauma. It seems likely that CTA may be the best tool to determine not only who should have endovascular arterial intervention, but also to define the appropriate vessels to embolize.10 The other important trend in pelvic arterial injury embolization is that it is more widely available with shorter response times. Improved training of an enlarging group of specialists is making the procedure available to more patients.
In our practice, we are seeing less open repair than we did 10 years ago because of advances in covered stents and embolization. Nationally, the trend in extremity arterial injury management has been toward endovascular therapies, particularly in blunt trauma and in patients with high injury severity scores.11
The introduction of low-profile, self-expanding covered stents has made it technically possible to rapidly seal many ruptured femoropopliteal and subclavian arteries. Peripheral embolization is still essential for management of small muscular branches and other noncritical branches. A series of improvements in microcatheters and embolization coils has led to better outcomes and shorter procedure times.12
Obtaining a CTA is now a near-essential step on the way to the angiography suite or operating room.8,13 Time to definitive (often multispecialty) treatment is very important.14 Hybrid (angiography-enabled) operating rooms, increasingly popular in the last several years for the treatment of peripheral vascular disease, speed the time to treatment in trauma,15,16 and the ability to perform peripheral embolization and orthopedic fixation or pelvic packing in the same room is in increasing demand.17 The time to embolization is still limited by the time required for CTA and patient transfers.
In the next few years, the first change we hope to see is hybrid rooms that have CTA capability, enabling us to make a diagnosis and deliver complex therapies in the shortest possible amount of time. The second change we should see in the next few years is the increasing use of covered stents to preserve medium and even small arteries.18 For example, it is entirely feasible that the use of covered stents could become routine in the treatment of superior gluteal or profunda artery pseudoaneurysms (Figure 3). The third, and most important change we hope to see, is data-driven algorithms that define when and how embolization or covered stents should be used in specific types and sites of vascular injury.19 The time is right for endovascular procedures to become part of almost every trauma center’s protocol manual, with care delivered in a setting of rapid CT diagnosis and cutting-edge multispecialty care.
John Fritz Angle, MD, is Professor of Radiology, Department of Radiology at the University of Virginia Health System in Charlottesville, Virginia. He has disclosed that he is a consultant for Medtronic and Terumo and speaker for Gore & Associates and Cook Medical. Dr. Angle may be reached at (434) 924-9279; email@example.com.
James Forrest Calland, MD, is Associate Professor of Surgery, Department of Surgery at the University of Virginia Health System in Charlottesville, Virginia. He has stated that he has no financial interests related to this article. Dr. Calland may be reached at (434) 982-4278; firstname.lastname@example.org.
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