Vascular Trauma Consensus

Vascular trauma session offers ischaemia insights

Among the highlights from yesterday’s vascular trauma session were two initial presentations on resuscitative endovascular balloon occlusion of the aorta (REBOA), as well as several short presentations and discussions on blunt cerebrovascular injuries. A concluding talk on opportunities for training in emergency open approaches given by Inova Lee (London, United Kingdom).

Robert Lendrum (London, United Kingdom) opened proceedings with a presentation on the refinement of REBOA for major vessel injury. After this came Megan Foley (Dublin, Ireland), who highlighted the potential complications of REBOA and suggested that further research is needed on what subset of patients benefit from the intervention. She presented a systematic review and meta-analysis of lower extremity vascular complications after arterial access for REBOA.

The analysis drew on 28 studies with 887 patients from 11 countries—though no randomised controlled trials were included. Of those 28, 13 studies had previously been employed in another metaanalysis led by Ramiro ManzanoNunez (Cali, Colombia). Foley et al’s analysis found that up to 10% of patients who undergo REBOA will experience a lower extremity vascular complication. Foley noted the study’s focus on lower limb complications and some source data’s heterogeneity and methodological quality as limitations, and concluded that future research should home in on trauma patients most likely to benefit from REBOA.

Following Foley was Deborah Low (London, United Kingdom), who evaluated endovascular management of penetrating limb trauma, and whose take-home message drew on experience of lower limb trauma in an urban trauma centre. Overall, a small proportion (6%) of all lower limb injuries were suitable for endovascular management. She said that computed tomography angiography (CTA) should be the initial imaging modality for assessing them, before giving examples of endovascular management in pseudoaneurysm and arteriovenous fistula (AVF), the main forms of management for which she outlined as embolisation and stent grafts. A poll after Low’s presentation asking the audience to agree or disagree with the statement “REBOA is an essential tool for vascular trauma management” found 77% agreed and 23% disagreed. Speaking as part of the cerebrovascular trauma phase of the session, Morgan McMonagle (Waterford, Ireland) delivered a talk on the management of penetrating carotid and vertebral injuries. His concluding message was “keep it simple!”, and he advised his audience to focus on protecting the airway, and to consider the zones of the neck with a “no zone” approach. “Always prepare the chest in the field,” he urged, in case proximal control cannot be obtained in the neck itself.

Ligation, meanwhile, was best avoided except when strictly necessary, while repair “will almost always require an interposition graft”, which he said can be a synthetic rather than autologous graft. Finally, he suggested that interventional radiologists may have a role in the management of vertebral injuries, if the patient is well enough.

“Otherwise,” he said, “familiarise yourself with dissecting the vertebral vessels.”

Rounding out the vascular trauma session was a ‘best of abstracts’ section, in which Hannah O’Neill (Aberdeen, United Kingdom) put forward details of a systematic review into endovascular techniques’ role in the management of blunt popliteal artery injury. Considering the popliteal artery’s “relative inaccessibility” and is proximity to neurovascular structures, O’Neill drew on the findings of the review, which analysed data from seven studies, to suggest that open repair “remains the gold standard,” though she said there is a “potential role for endovascular therapy”.

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The Admiral Dr Emma Wilton Vascular Surgery (UK)

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