Foreword

Thomas M. Scalea, MD

Physician-in-Chief, Shock Trauma Center

System Chief for Critical Care Services

University of Maryland Medical System

Francis X. Kelly, Professor of Trauma Surgery

Director, Program in Trauma

University of Maryland School of Medicine

Very little has changed as much over the last 50 years as has the care of vascular injuries. As recently as 50 years ago, operative exploration was the diagnostic test used most often in any patient who had a suspicion for vascular injury. Potentially injured vessels were inspected from the outside. If suspicion of injury persisted, they were often opened and then repaired or patched. Diagnostic angiography eventually replaced mandatory exploration. This obviated the need for surgical exploration but it was indiscriminately applied to any patient that had injury anywhere near a blood vessel. The yield of so-called proximity angiography was less than 5%. Many of the injuries identified were located in expendable vessels. More liberal use of angiography did, however, allow us to recognize that there were a number of minimal vascular injuries with non-flow limiting intimal defects. We learned that those could be safely observed and treated with antiplatelet agents. As CT technology continued to improve, we learned we could identify a number of vascular injuries on well-timed CT scans.

CT imaging permitted better identification and characterization of intraparenchymal vascular injuries in new locations such as the cervical vasculature and solid organs, particularly the liver, spleen, and kidneys. New treatment modalities such as transcatheter embolization were developed which greatly extended our ability to offer patient care without laparotomy. Embolization had been used for 15 years to treat pelvic fracture hemorrhage but embolizing solid organs was an exciting new treatment option. While we continue to debate the exact role of embolization, no one would argue against its use in selected patients. During the uptick in violence seen in major cities in America in the late 1980s and early 1990s, the concepts of Damage Control were elucidated. We soon learned that embolization could be a powerful adjunct to open surgical techniques in these desperately ill patients. The need to transport these patients to the interventional radiology suite was anything but appealing initially, but we learned how to do it as safely as possible in order to be able to use these new techniques for hemostasis.

In the early 2000s, stent grafting became an option as a definitive treatment for injuries to large vascular structures. Thoracic Endovascular Aortic Repair (TEVAR) became an alternative to open aortic repair for traumatic aortic injury in the chest and was adopted in many centers almost overnight. Eventually, it was demonstrated to be associated with improved survival. Over the years, TEVAR has almost completely replaced open repair. Stent grafts are now commonly used in a variety of other areas. A very similar migration to stent grafting has been observed for injuries located in the subclavian and axillary vessels, the intra-abdominal aorta, and the pelvic vessels. It seems reasonable to assume that stent grafts will replace open repair in all of these areas. As with peripheral vascular injuries, increased technology allowed us to identify low-grade injuries in major torso vessels that were never diagnosed before. The vast majority of these are treated very nicely with observation. The role of antiplatelet drugs and anti-impulse therapy and low-grade injuries remains a matter of some debate.

More recently the use of Hybrid ORs to treat vascular injuries has become popular in some centers. Leading US centers such as Maryland Shock Trauma and the University of Florida, Gainesville have embraced these new options and demonstrated very good results. Hybrid ORs can be used for definitive care such as the repair of a central vascular injury. Perhaps most importantly, endovascular and open procedures can be performed simultaneously. Rather than taking an unstable patient to the interventional radiology suite, the use of a Hybrid OR allows all care to be delivered in a single location that is used for caring of desperately ill patients. Having anesthesiology assets and OR personnel available at all times almost certainly decrease the time to definitive care.

Endovascular tools have become part of trauma resuscitation. For the last 10 years, transfemoral aortic occlusion (REBOA) has been used as a temporizing inflow control tool in patients with large-volume intra-abdominal and/or pelvic bleeding. Originally, using REBOA involved placing a 12 French sheath into the femoral artery. Many had to be placed via open cut down, particularly in hypotensive patients. All required formal femoral artery repair when the catheter and sheath were removed. Smaller devices are now commercially available with increasing levels of sophistication such as catheters that automatically maintain some degree of flow below the balloon. Discussions are ongoing as we attempt to define the optimal indication for REBOA. Other adjuncts such as balloon occlusion of the vena cava occlusion balloon are now being used as an adjunct to standard open surgical techniques. It seems almost certain that additional tools will become available in the not-too-distant future.

As with many things in Medicine, the pendulum may well have swung too far toward endovascular care. In a number of instances, only an open operation is appropriate. For instance, splenectomy is curative. Bridging unstable patients and transfusing them to do splenic embolization is simply not wise. Without any data to support it, stent grafting is being used in small vessels in the extremities, such as the popliteal artery. While some wish to push the envelope, it is incredibly important to do non-conventional therapy on protocol, collect data, and report the results.

We are now involved in discussions as to who is best positioned to deliver vascular trauma care in the future. Vascular surgeons have expertise in the care of blood vessels. Trauma surgeons understand the complex physiology that governs optimal care for a badly injured patient. These discussions cannot be politically or financially driven. We must do our best for our patients. Not one solution will be the best idea for every location. Vascular and trauma professionals both have a roll. Each institution will need to define what that means.

As this book is being published, there are less than 20 surgeons in the United States that are trained in general surgery, trauma/critical care, and vascular surgery. These individuals who are the editors and authors of a large portion of this book will be the pioneers for the future of vascular injury. I am proud to say that the majority of them have either trained or practiced at the R Adams Cowley Shock Trauma Center. This book is an important reference for anyone who wishes to learn the current state of the art for Vascular Trauma. The subject will continue to evolve and it is my fervent hope that the editors and authors will update this periodically. I have been proud to be part of the vascular and endovascular revolution from the beginning. As my career comes to an end, I cannot think of a better group of people to hand the baton to than the authors of this textbook.