Over the last three decades vascular surgery has undergone a paradigm shift as the skills, techniques, and thinking have embraced the endovascular approach. Management of vascular injuries has similarly followed suit with large-scale research demonstrating the increasing use of endovascular methods in the management of trauma. A substantial portion of those studies suggest a correlation between the judicious use of endovascular interventions in trauma and a decrease in overall morbidity and mortality.1–3 While there are likely multiple factors contributing to this increase in survival, it is reasonable to postulate that a significant contributor is the speed with which endovascular hemorrhage control can be achieved.
As vascular surgery has incorporated endovascular methods, the boundary between open and endovascular procedures has blurred and hybrid operating rooms and angiographic suites are becoming ubiquitous.4 These operating rooms permit the flexibility of employing endovascular, open, or hybrid surgery without a change of venue or significant increase in operating time and they eliminate delays between angiographic interventions and the operating room.5,6 The most common scenario emphasizing the advantages of this resource is the simultaneous performance of external pelvic fixation and pelvic embolization, with the added benefit of using the same radiographic equipment.7 With the rise in availability of hybrid rooms, a host of innovative techniques specific to trauma have emerged.
In this chapter we endeavor to provide a review of standard endovascular instruments, devices, and techniques through the lens of the trauma surgeon, and in so doing we describe subtle nuances as they pertain to trauma. Unless specifically stated, the following text concerns only devices approved for use in the United States.
ENDOVASCULAR EQUIPMENT AND TECHNIQUES
The sheath is the platform from which all endovascular surgery is deployed, simultaneously enabling and limiting intervention. The three variables of any sheath are the length, inner diameter, and for longer sheaths the shape.
As in non-trauma surgery, the sheath length should provide stability and support at a point close to the site of intervention. The ability to approximate the target is constrained by the tortuosity and diameter of the arteries between the access point and the area of interest. Furthermore, the length of the sheath used immediately limits wire and device options for treatment. For reasons that are clear, a 90-cm sheath is not compatible with a balloon mounted on a 75-cm shaft; a 150-cm sheath cannot be used with a 180-cm wire.
One consideration specific to the trauma setting is the frequent necessity to cross the ostia of branch vessels with the sheath without the ability to heparinize the acutely injured hemorrhaging patient. Thus a large-diameter sheath passing across and partially occluding a vessel orifice (e.g., a sheath crossing from the aortic arch into the right subclavian and traversing the origins of both the carotid and the vertebral arteries) ...