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The authors do an outstanding job of outlining the diagnosis of these injuries as well as their open management. Where does endovascular management fit in the contemporary care of these injuries? This is an important question that is made all the more important by the rapidly emerging capabilities of endovascular technologies. In order to adequately provide guidance on the potential utility of these approaches, one must present both the potential promise and the paradox of endovascular therapies in the current era.

First, I will touch on the potential of endovascular management for select patients. In a variety of emerging studies using multi-institutional data, patients managed with endovascular modalities versus traditional open approaches for vascular injury at noncompressible locations (including abdominal and iliac vessels) have been shown to have improved outcomes. It is also clear that these modalities are being employed more aggressively in this regard based on these findings.1-3 The technologies are commonly available to modern vascular surgeons, who have become ever more facile with their expedient employment for a variety of vascular pathologies, including trauma.

While these findings are promising, the results of these efforts must be considered in the context of the significant limitations of present endovascular capabilities for trauma management. In outlining these limitations, it must first be acknowledged that the aforementioned promising results have been noted almost exclusively among patients with a major arterial injury confined to the aorta, iliac arteries, and the pelvic vasculature.4 Additionally, these results are largely achieved only at high-volume centers with the right combination of both trauma volume and vascular expertise. Accordingly, the results of these efforts must be considered in context and are not fair to extrapolate to a wider variety of environments. In addition, what are the most significant limitations of endovascular approaches?

First, a stable patient is almost universally required for endovascular management. Advanced imaging capabilities must be employed, appropriate vascular access achieved, specialized technicians to assist with device selection called in, and the appropriate providers summoned. The latter, at present, typically consist of formally trained vascular surgeons or interventionalists who are not present when the unstable patient demanding emergent hemorrhage control arrives. The delays required in mustering these capabilities are neither practical nor appropriate in the care of an unstable patient.

Second, endovascular technologies are not well suited to the care of patients with multiple pressing injuries that demand urgent attention. Open exposure within the abdomen allows for the rapid intervention for a variety of potentially life-threatening injuries. A facile trauma surgeon can pack a liver and remove a spleen in relatively short order. Endovascular procedures are confined to the intravascular space alone and require focus on one portion of the arterial tree at a time. The use of these technologies simply limits the ability to rapidly address multiple injuries in the same fashion as can be achieved by open means.


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