I would like to thank the organization for allowing me to present Damage Control Vascular Surgery. I don't have anything to disclose. I would like to start with this great statement where it says great minds discuss ideas, average minds discuss events, and small minds discuss people from Eleanor Roosevelt. The reason I put this is because we need to start thinking out of the box in order to improve outcomes in patients with severe hemorrhage, specifically for vascular injuries. So going back to the incident of the Hartford consensus where my mentor Nora Maxson was instrumental in its development, it is important to understand that damage control vascular surgery doesn't start in the hospital but rather it starts on the first contact with the patient. And that's what is described in the fundamental concept of the Hartford consensus where it states clearly that no one should die from uncontrolled bleeding. So this damage control concept is nothing new. This has been discussed from many, many years ago where basically now we are incorporating with the Stop the Bleed campaign pre-hospital damage control vascular injury with the use of tourniquets. And in this group of patients now that we're using tourniquets for severe vascular damage, these patients are arriving to our hospitals alive. And although we might not be able to save their limbs, sometimes it's definitely of consideration in the trauma world, the famous statement of life versus limb. So this is basically one of the principal concepts to remember when we are performing damage control vascular surgery. One of our first studies regarding the use of tourniquets in the pre-hospital arena came out in 2018 where basically we demonstrated a decrease for blood transfusion and limb complications in this group of patients arriving to our level one trauma center after penetrating trauma. It is important to understand that once the patients arrive through our system, through the hospital system, we need to have a vast knowledge of what injuries they have. And obviously when we're talking about vascular trauma, it's not only the arteries but the veins as well. And we subclassify them into extremity injuries, abdominal non-compressible torso hemorrhage, thorax, head, and neck. For the simplicity of the discussion, we're going to stay in line with management, damage control of extremity, and we will be delineating some of the future trends in the endovascular damage control surgery. As we know, the most common causes of trauma that we use damage control vascular surgery are basically penetrating in nature most of them, but we have blunt trauma as well. So extremity vascular injuries are very common. And if we don't act fast on these injuries, we can actually lose the patient. And this is where limb versus life is a famous icon that we always need to remember when we are dealing with complicated extremity soft tissue vascular injuries. It is always important to remember as well the socioeconomic impact of earning capacity for the patient and economic burden. So when the patient arrives, vascular trauma can have hard signs or soft signs. For the purpose of damage control vascular surgery, we're going to stay in focus on the hard signs. When the patient arrives to the emergency department, there's any obvious signs of active bleeding, demonstration of thrills or bruits on the site of the injury, signs of distal ischemia like absent pulse, pain, pale, perishing, cold, paresthesia, paralysis, paresis, and as well as expanding hematoma. These group of patients are classified under the hard signs, and they may need expedite diagnosis and management with surgical interventions. On the other hand, we have soft signs, which are basically a simple hematoma not expanding close to the injury site or close to neurovascular bundles. These kind of patients, we can obviously start working them up with some diagnostic prior to rushing them to the operating room. It is important to remember that even though they have soft signs, they can evolve over time, and it's a dynamic process where closer balance is of the essence. So as mentioned, investigations for vascular trauma in patients with hard signs, the best management is urgent intervention. For soft signs, we are not going to be discussing in detail this because it's very rare that we undergo damage control vascular interventions. So this is the most common dilemma for damage control vascular surgery, where we have a complicated orthopedic femur fracture as an example, and there is evidence of vascular disruption. In this group of patients, the most important item to remember is to make sure that there is great communication between the orthopedic and the vascular surgery team. It is of the essence, and at least in our practice in our trauma center, we like to perform our vascular procedures first with a chunk utilization. Artery? Vein? Thank you. As it was discussed in this case, follow by external fixation of the broken bone. By doing so, it allows the vascular team more time to get the patient into a more physiologic stability when they, after the chunk placement, within 8 to 10 hours max, they take the patient back to surgery, and they perform a preferable reverse saphenous vein interposition graft. In our trauma center, we like to use our Argyle chunks from range of 8 to 14, and this is the best method to do damage control vascular surgery in patients with extremity injuries. There's other brands like the Javitson's and the Pruitt's, but we are very familiar with the Argyle, and it is a great asset to have in your damage control set when you're performing damage control vascular surgery, specifically with orthopedic injuries as well. Now I would like to change a little bit the discussion into what I call an extension of damage control vascular surgery. With the help and assistance from our amazing vascular surgeons, we are now engaging into what is called endovascular damage control, and it is of the essence to understand that with this new technology, patients are not undergoing massive blood loss or massive reconstruction with prolonged ICU length of stay and or intubation. Here is a clear example of what is now very common to see in our trauma centers, where there is a patient with a transected aorta with a distal to the subclavian artery. Patient was involved in a fast, high-speed motorcycle collision with acute deceleration, and on the chest x-ray, patient had white mediastinum. For this reason, the patient underwent a CT scan, and they identified where the transection was. The patient's systolic was kept under 110 and the heart rate less than 90. In this patient, he underwent an endovascular stenting that was successful, and not only that, the patient did not undergo massive transfusion protocol, and actually the patient went from the ICU to the floor within an 8 to 10-day margin. So endovascular damage control is making a big difference in the way we manage patients nowadays. This is a nice, very great example of how endovascular damage control can be utilized in patients with penetrating injuries. This gentleman had a penetrating gunshot wound to the infra-diaphragm, below the diaphragm injury of the aorta, where you can see that there is obvious extravasation that is contained. Because of the location and proximity to the renal arteries, the patient was needed to be taken to the OR for an open repair. So in order to assess and provide some kind of control proximal to the injury site, a REBOA catheter was placed in the hybrid suite proximal to the injury site, providing proximal control of the aorta and minimizing the amount of blood loss. Repair was done easily with a patch graft, and the patient had an uneventful outcome. This is another example of an endovascular damage control surgery, where patients now with presenting subclavial artery injuries that are in hemodynamic stability mode. You can take these patients to the hybrid suite, and in the hybrid suite in this specific patient with a subclavian artery injury, we were able to, from a proximal approach to the radial and distal approach to the femoral, we were able to basically stent the subclavian artery injury. This is something that is being utilized more and more, and it's another asset of endovascular damage control surgery. Minimizing the amount of blood loss and minimizing the potential for an invasive exploration that will keep the patient in the ICU for a prolonged stay. Moving along, unstable pelvic fracture and refractory hemorrhagic shock. This is something that can be very, very problematic in any trauma center when they arrive to the emergency department. In this group of patients that have severe pelvic fracture, also we are very fully aware that 85% can be venous injury, 15% is still arterial in nature. So it is important to understand how or what are the adjuncts that we can utilize in this group of patients to minimize the amount of blood loss and increase survival. I would like to discuss briefly a study that we did with multiple institutions regarding the effect of hemorrhage control adjuncts on outcome in severe pelvic fracture, a multistitutional study. We analyzed the utilization of REBOA, preperitoneal packing, binder, and external fixation. And our goal was to see the incidence and how much blood loss was in every single one of these cases and what intervention helped the most. When we look at all of our patients, it was very interesting that binders was the most common utilized adjunct, followed by preperitoneal packing, external fixation, and REBOA being the least utilized. Now of interest, it is important to recognize that preperitoneal packing and REBOA demonstrated the fastest time to OR and intervention radiology. But of interest, it had the highest blood utilization and mortality rates. When reviewing the data, it was obvious that REBOA and preperitoneal packing were used as last adjunct resort for this kind of patients. Instead of being an upfront intervention adjunct in this kind of patient with hemorrhagic pelvic trauma. So it is imperative that preperitoneal packing and REBOA be used early in the game and not late, like in the study that we just demonstrated. We concluded from our analysis that in patients with unstable pelvic fracture, it is imperative to have a very proactive algorithm within your trauma center. It needs to be an algorithm that includes the utilization of early use of binders with REBOA utilization, followed by the hybrid room utilization, where you can then proceed with the use of preperitoneal packing. REBOA can be taken down during the angioembolization and so forth. This is the algorithm that we propose from our paper, a manuscript that we just discussed. I believe it is something that, if it's done properly, can minimize blood loss and improve outcomes in any trauma center. So what's in the future? As we stated at the beginning, great minds discuss ideas. So where are we now? I would like to maybe take you a little bit into the future of the role of prehospital damage control, and specifically for vascular injury. We look specifically at the impact of times to sardeo mortality in hypotensive patients with non-compressible torso hemorrhage, and a double-AC multicenter prospective study. And in our findings, we demonstrate that in the United States, it takes 74 to 88 minutes to get a non-compressible torso hemorrhage hypotensive patient from the scene to the OR. Not only that, the average time for prehospital patients to arrive to a trauma center is in the range of 30 to 28 minutes, where the peak mortality for non-compressible torso hemorrhage occurs. We analyzed from the T-QIP data that actually there is a total 33 minutes of contact time where EMS is with a patient prior to arrival to the emergency department. And despite the typical misbelief of pressing on the gas to get the patient as fast as possible to the emergency department, 34% of these patients died. And this mortality has not changed since in the 1970s, when Dr. Tronke very nicely and elegantly demonstrated the trimodal death distribution. Because of this, we are proposing the selective prehospital advanced resistive care with the development of a strategy to prevent prehospital death from non-compressible torso hemorrhage. And in this model, what is important is that we are not asking prehospital system to stay and play. That is not the purpose of this, but rather to identify which patients are in that early mortality group within 30 minutes. And once we identify those patients, those patients will be managed with the selective prehospital advanced resistive care, with basically the team being activated and on the scene with the patient. And scoop and control instead of scoop and run, where the patients will receive blood, will receive other interventions, tourniquets, that will increase perfusion and retain volume. Now, I would like to discuss another aspect of what can be coming to our future in the United States. This is... The patient is not moved anymore. The patient is moved to the CT scan position. Within five minutes, they scan the whole body. Then they emerge from there. No visible hematoma in the brain, writ fractures. Pelvic fractures with hemorrhage. After this, the patient pulse is weak and they decide to intubate with circulation first. The patient is being intubated. They are getting ready for perpetual packing. And before the perpetual packing, they are placing on their fluoroscopic guidance, the use of a REBOA. It is placing someone above the diaphragm, limiting perfusion below the diaphragm. The C-arm is moved out. And now they are performing perpetual packing within 28 minutes from arrival. In the emergency room. Packing is performed. Blood pressure now is 140. They close the packing site. And now they are getting ready for angioembolization. And all this was done in their hybrid emergency room. Patient was managed within 40 minutes from arrival. Next, I would like to mention that the next possible step is to do a CT scan of the brain. That will be the Better REBOA catheter, which is basically the SAP-CAR catheter, which is the supraortic arch perfusion catheter, which basically it creates a balloon above the diaphragm, but at the end of the catheter, it gives perfusion to the brain and coronary arteries. This is a model of a cardiac arrest in an animal model, where the balloon was insufflated above the diaphragm and blood, oxygenated blood, bicarb, calcium was infused through the port. And without any cardiac massage, CPR, you will note how this catheter, by increasing perfusion to the coronary arteries and the brain, it increases and it activates contractility, spontaneous contractility in the heart. I think the future is bright. I think the future is near. I would like to thank once again the Society of Critical Care Medicine for the honor to present. Thank you.

damage control vascular surgery

severe hemorrhage

vascular injuries

endovascular damage control surgery

unstable pelvic fractures

preperitoneal packing