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Injuries to zone III of the carotid artery, located between the angle of the mandible and the skull base, are uncommon, associated with a high risk of adverse neurologic events and mortality, and challenging to treat. These lesions are difficult to access and treat surgically due to their anatomic location. Therefore, endovascular and hybrid open and endovascular techniques have emerged as a minimally invasive, and in many cases, safer and more effective alternative to open surgery. Endovascular techniques for use in this anatomical region include balloon catheter tamponade, embolization, balloon angioplasty, and endovascular stenting. Selection of the most appropriate treatment strategy is dependent on the: 1) concomitant injuries of the patient, 2) location (external versus internal carotid artery) and nature (intimal tear, dissection, pseudoaneurysm, transection, occlusion, or arteriovenous fistula) of the injury, and 3) whether the operating surgeon believes it is necessary to revascularize or sacrifice the injured carotid artery. The purpose of this article is to review the present endovascular and hybrid open and endovascular therapies available for zone III penetrating and blunt carotid trauma. We begin by describing the clinical presentation and diagnosis of these injuries and then discuss management of an undifferentiated zone III vascular injury. This is followed by a discussion of the management of zone III external and then internal carotid artery injuries. We conclude by describing postoperative management, follow up, and future directions.

Axillosubclavian injuries (ASI) comprise a small proportion of vascular injuries, yet their morbidity and mortality is high. This is often attributable to non-compressible bleeding in the apical thorax, hemodynamic instability, and the anatomically challenging location of these vessels making them difficult to access and control quickly. While the traditional management of ASI was with open surgical repair (OSR), recent years have seen an evolution towards less invasive endovascular repair (EVR). In patients with these injuries, EVR may be a safer alternative that achieves similar immediate results with significantly lower complication and mortality rates than the highly morbid open surgical option. In this article, we review and compare the two approaches, providing an overview of patient selection, anatomic considerations, techniques, postoperative management, and outcomes. With the advent of EVTM and more trauma team members capable of endovascular management of vascular trauma, a paradigm shift towards EVR for ASI is taking place.

In patients undergoing emergent operation for trauma, surgeons must decide whether to perform a definitive or damage control (DC) procedure. DC surgery (abbreviated initial surgery followed by planned reoperation after a period of resuscitation in the intensive care unit) has been suggested to most benefit patients more likely to succumb from the “vicious cycle” of hypothermia, acidosis, and coagulopathy and/or postoperative abdominal compartment syndrome (ACS) than the failure to complete organ repairs. However, there currently exists no unbiased evidence to support that DC surgery benefits injured patients. Further, the procedure is associated with substantial morbidity, long lengths of intensive care unit and hospital stay, increased healthcare resource utilization, and possibly a reduced quality of life among survivors. Therefore, it is important to ensure that DC laparotomy is only utilized in situations where the expected procedural benefits are expected to outweigh the expected procedural harms. In this manuscript, we review the comparative effectiveness and safety of DC surgery when used for different procedural indications. We also review recent studies suggesting variation in use of DC surgery between trauma centers and the potential harms associated with overuse of the procedure. We also review published consensus indications for the appropriate use of DC surgery and specific abdominal, pelvic, and vascular DC interventions in civilian trauma patients. We conclude by providing recommendations as to how the above list of published appropriateness indications may be used to guide medical and surgical education, quality improvement, and surgical practice.

Non-compressible torso hemorrhage (NCTH) (i.e. bleeding from anatomical locations not amenable to control by direct pressure or tourniquet application) is a leading cause of potentially preventable death after injury. In select trauma patients with infra-diaphragmatic NCTH-related hemorrhagic shock or traumatic circulatory arrest, occlusion of the aorta proximal to the site of hemorrhage may sustain or restore spontaneous circulation. While the traditional method of achieving proximal aortic occlusion included Emergency Department thoracotomy (EDT) with descending thoracic aortic cross-clamping, resuscitative endovascular balloon occlusion of the aorta (REBOA) affords a less invasive option when thoracotomy is not required for other indications. In this article, we review the innovation, pathophysiologic effects, indications for, and technique of EDT and partial, intermittent, and complete REBOA in injured patients, including recommended methods for reversing aortic occlusion. We also discuss advantages and disadvantages of each of these methods of proximal aortic occlusion and review studies comparing their effectiveness and safety for managing post-injury NCTH. We conclude by providing recommendations as to when each of these methods may be best, when indicated, to manage injured patients with NCTH.

Background: The objective of this study was to investigate changes in the diameters of major arteries in trauma patients at the time of severe intravascular volume depletion. Methods: Patients admitted from January 2008–June 2017 in extremis or in arrest who had an immediate computed tomography (CT) scan in the resuscitation period and at least one subsequent CT scan after hemodynamic stabilization and admission to the intensive care unit were included. Diameter in millimeters (mm) of the common carotid, subclavian, common iliac, external iliac, common femoral arteries, and aorta at the following locations were obtained: ascending, proximal descending, and mid-descending thoracic and supra-celiac, renal, and aortic bifurcation. Results: Fourteen patients (93% male) were included. Mean injury severity score was 37 ± 8 and age 36 ± 18 years. Ten patients received a resuscitative endovascular balloon occlusion of the aorta and four patients received a resuscitative thoracotomy prior to the first CT. A maximum increase of the aorta of 63.6%, and 116.9% in the common carotid, subclavian, common iliac, external iliac, and common femoral arteries was observed. For patients aged 18–39 years, increases in diameter were statistically significant (p < 0.05) at all locations except the peri-renal aorta and left subclavian. Patients ≥40 years had a less robust change, with a significant diameter increase only with the proximal descending aorta (p = 0.02). Conclusions: Large arterial diameters in the setting of severe hemorrhage are significantly reduced particularly in younger patients. This has significant implications for emergent placement of endovascular devices such as introducer sheaths, balloon catheters, and stent grafts where the determination of arterial diameter is critical.

Background: Patients who receive resuscitative endovascular balloon occlusion of the aorta (REBOA) for temporization ofexsanguinating hemorrhage may have occult injuries sustained to the iliac arteries or aorta which may pose increased risks in performing REBOA. Caution is essential in performing REBOA in these patients as the injuries are not clearly defined on admission. REBOA is currently performed in select centers without fluoroscopy, leading to blind placement of devices and an essential reliance on tactile feedback. Methods: Patients admitted between February 2013 and July 2017 at a tertiary center who had a successful or unsuccessful blind placement of a REBOA catheter or wire through a damaged iliac artery or aorta were included. Results: Three patients were identified. Two patients had successful placement of the REBOA catheter; one sustained injury to the external iliac artery and the other sustained injury to the abdominal aorta. Confirmation of catheter placement was obtained before balloon inflation, and the damaged vessels were identified upon immediate operative intervention. One patient had unsuccessful placement of the REBOA catheter during cardiac arrest despite accurate access of the common femoral artery (CFA). Conclusions: Emergent, blind placement of wires and catheters past arterial injuries is possible but may result in procedural abandonment and/or arterial injury. Physical exam and/or tactile feedback should alert the surgeon to the possibility of arterial injury. Imaging confirmation should precede balloon inflation if at all possible.