Endovascular and hybrid trauma and bleeding management
A new concept integrating endovascular techniques into trauma resuscitation.
Endovascular and hybrid trauma and bleeding management (EVTM) is a fast-growing field in medicine that focuses on endovascular resuscitation. It relies on early, team-based assessment and care for hemodynamically unstable trauma patients, often acting as a temporary measure before definitive treatment. More recently, the same approach has proven useful for non-trauma patients who are also hemodynamically unstable.
The core of trauma care follows the ABCDE mnemonic from Advanced Trauma Life Support (ATLS) to quickly spot airway and circulation issues, allowing resuscitation to start even without a firm diagnosis. EVTM adds modern endovascular techniques to this established protocol, leading to a modified algorithm: AABCDE. The extra "A" stands for Access—specifically, early femoral artery (and vein) access. While standard trauma care uses peripheral or central venous lines for blood draws and medication, EVTM providers use early femoral arterial access to deploy life-saving endovascular tools. These tools help with temporary control and act as a bridge to either open surgery or definitive endovascular repair, while also enabling arterial blood sampling and continuous blood pressure monitoring.
A key element of EVTM is a multidisciplinary team. Combining different specialties ensures optimal treatment not only when the patient arrives but also in the pre-hospital setting and later in the operating room. The goal is teamwork with a shared aim: saving the patient. This allows for a hybrid approach, blending open surgery and endovascular methods to control bleeding and provide definitive care. For example, a hemodynamically unstable patient with abdominal bleeding might traditionally undergo a laparotomy with packing. An EVTM team, however, might simultaneously gain vascular access and perform REBOA for proximal control or embolization as part of the definitive treatment. This approach demands complete transparency, good communication, and clear leadership. Still, it is crucial to remember that just because EVTM is possible does not mean it should always be used. It should always be considered, but only applied to the right patient at the right time, when the necessary expertise and equipment are available to do it safely.
In an acute setting, the femoral artery is usually the easiest to access due to its size, though this depends on the patient’s anatomy and
- field
- Endovascular resuscitation and trauma management
- known_for
- Introducing the AABCDE algorithm and integrating endovascular techniques (REBOA, embolization, stent grafts) into trauma care
- key_principles
- Multidisciplinary team approach, early femoral arterial access, hybrid use of open surgery and endovascular methods
Lore & Background
The EVTM concept builds upon advanced trauma life support (ATLS) guidelines, which use the mnemonic ABCDE for early assessment. EVTM extends this by adding an initial 'A' for Access, emphasizing early femoral artery (and vein) access to enable endovascular diagnostic and therapeutic tools. This access allows for arterial blood sampling, invasive blood pressure monitoring, and the use of devices such as REBOA, embolization, and stent grafts for temporary hemorrhage control and as a bridge to definitive treatment.
A major element of EVTM is the multidisciplinary team approach, combining expertise from pre-hospital settings through the operating suite. The team may simultaneously gain vascular access and perform REBOA for proximal control or embolization while traditional laparotomy with abdominal packing is undertaken. The approach requires complete transparency, good communication, and leadership, but it is emphasized that EVTM should only be used in optimally selected patients when expertise and equipment are present to do it safely.
Vascular access in the acute setting typically targets the femoral artery, using ultrasound-guided or blind puncture and surgical cut-down, with ultrasound-guided being the safest for less experienced providers. The Seldinger technique is employed: needle puncture, wire advancement, needle removal, and sheath introduction. Endovascular devices used include REBOA (aortic balloon occlusion) to occlude the aorta and reduce distal bleeding, embolization to artificially create a thrombus, and stent grafts for permanent vessel repair.
Reader's Guide
The significance of EVTM lies in its integration of modern endovascular techniques into the established ATLS protocol, offering new options for hemodynamically unstable trauma and non-trauma patients. By adding early femoral access to the traditional ABCDE algorithm, EVTM enables providers to use REBOA, embolization, and stent grafts for temporary or definitive hemorrhage control. This multidisciplinary approach, combining open surgery and endovascular methods, represents a shift in trauma care that may improve outcomes in selected patients. However, the concept is still evolving, and its application requires careful patient selection, appropriate expertise, and proper equipment. The Journal of Endovascular Resuscitation and Trauma Management (JEVTM), first published quarterly starting August 2017, provides an open-access platform for peer-reviewed research in this field, reflecting the growing interest and development of EVTM.
Did You Know?
- The EVTM concept has recently been shown to be applicable to non-traumatic hemodynamically unstable patients as well as trauma patients.
- The new algorithm for EVTM-enabled providers is AABCDE, where the additional 'A' stands for Access, specifically early femoral artery access.
- REBOA, also called Aortic Balloon Occlusion (ABO), is used to inflate an intra-aortic balloon to occlude the aorta and decrease or prevent blood flow to distal parts.
- The Journal of Endovascular Resuscitation and Trauma Management (JEVTM) first published its inaugural issue in August 2017 and continues quarterly.
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