Damage Control Vascular Surgery

Abstract

Exsanguination is one of the most fearsome sequelae of trauma and is responsible for a large portion of both civilian and military mortality. The concept of damage control surgery is a critical development in the field of trauma largely driven by the growing understanding that coagulopathy and physiologic derangements are the primary cause of death in critically ill trauma patients. Damage control vascular surgery focuses on the rapid temporization of vascular injuries. Balloon occlusion can be utilized for rapid hemorrhage control (REBOA, foley catheter, retrohepatic caval balloon, etc.). In the setting of damage control, most veins can and should be ligated. Consideration of shunting should be made regarding the suprarenal inferior vena cava, the portal vein, and the superior mesenteric vein. The named arteries should be shunted and repaired when possible; however, redundant arterial beds can be safely ligated. Vessels of all sizes can be safely shunted with commercially available or improvised devices. Systemic heparinization is not necessary to maintain patency. More recently, the concept of using endovascular stents as long-term shunts has gained attention. These can be deployed traditionally under angiographic guidance or using the novel direct site endovascular repair (DSER) technique. The rapidly evolving field of endovascular trauma management has afforded a host of new management strategies for the physiologically deranged critically ill trauma patient.