Chapter 4: Basics of Endovascular Trauma Management

INTRODUCTION

Executing safe and effective endovascular trauma management requires the necessary endovascular infrastructure and pre-established local institutional protocols or care pathways established by key stakeholders. These stakeholders include representatives from trauma and acute care surgery, vascular and endovascular surgery, interventional radiology, neurointerventional radiology, diagnostic radiology, and emergency and critical care medicine. Such management also requires careful case preparation, an understanding of available endovascular equipment, and excellent endovascular diagnostic and therapeutic technical skills. This chapter introduces readers to important endovascular case preparation considerations, endovascular resuscitation and trauma management (EVTM),¹ different physical settings for performing endovascular trauma management, vascular access, angiography (i.e., arteriography and venography), and methods of sealing the vascular access site, including percutaneous arterial closure devices. We conclude by summarizing complications specific to angiography and endovascular trauma management. As there have been limited studies conducted on the above issues in trauma patients, some of this information is derived from the vascular and endovascular surgery and interventional radiology or cardiology literature. The types of endovascular equipment available, including sheaths, wires, catheters, balloon occlusion and embolization devices, and stents are summarized in Chapter 5.

CASE PREPARATION

In addition to concomitant injuries, there are a number of factors to consider before beginning an endovascular trauma case. Clinicians should determine whether patients have a history of prior arterial access or endovascular intervention, and whether that access was sealed using a percutaneous arterial closure device. Prior percutaneous arterial closure device use or open vascular surgery (e.g., a cutdown onto the artery) may create scar tissue around the artery to be accessed, which may increase the difficulty of advancing sheaths into the artery. It may also decrease success of percutaneous arterial closure devices. The clinician should also determine if patients have a contrast allergy or concomitant conditions that may increase the risk for contrast nephropathy, including chronic kidney disease, diabetes, acute kidney injury, a recent history of contrast nephropathy, rhabdomyolysis, and renal artery or kidney injuries. It is also important to determine if patients have a history of or are presenting with a coagulopathy or are taking antiplatelet or anticoagulant agents (and the indications for these agents). Endovascular interventions can often be safely performed when the patient is on antiplatelet agents, including dual agents. However, a percutaneous arterial closure device will likely be required to achieve a seal at the arterial access in patients with a coagulopathy or who are therapeutically anticoagulated. A detailed peripheral vascular examination and an examination for puncture or surgical scars should be performed and documented before and after the procedure. Finally, important computed tomography (CT) angiography findings to consider include the patency and diameter of access vessels and vessels along the planned target vessel path (i.e., the path between the vascular access site and the vessel to be treated). Other examinations include vessel tortuosity, arterial calcification and atheroma, intravascular thrombus, the diameters of vessels that are to be treated (to determine whether sheaths ...