Principles of Damage Control Vascular Surgery

in Vascular Trauma

Applied

Type

Reinforcement

Confidence

90%

Created

Mar 19, 2026

Evidence

2 sources

Rationale

The integration incorporates a high-level meta-analysis (Castellini 2021) and a significant registry study (Cralley 2026/2023) to reinforce the evidence base for REBOA in damage control surgery. The comparison between REBOA and resuscitative thoracotomy was updated to reflect more recent registry findings, and the abbreviation RT was introduced as per the style guide.

Evidence

Castellini G et al. Resuscitative endovascular balloon occlusion of the aorta (REBOA) in patients with major trauma and uncontrolled haemorrhagic shock: a systematic review with meta-analysis. World J Emerg Surg. 2021. PMID: 34384452.
Verified source
PubMedDOI
Cralley AL et al. Zone 1 Endovascular Balloon Occlusion of the Aorta vs Resuscitative Thoracotomy for Patient Resuscitation After Severe Hemorrhagic Shock. JAMA Surg. 2023. PMID: 36542395.
Verified source
PubMedDOI

Content Changes

<!-- type: treatment -->

**Core concept**

Damage control vascular surgery prioritizes **rapid hemorrhage control and restoration of critical perfusion**, deferring definitive reconstruction until physiology is corrected (hypothermia, acidosis, coagulopathy). [@rotondo1993] [@rutherford2018]

**Stepwise damage-control sequence**

1. **Immediate hemorrhage control (compressible bleeding)**

   - Direct pressure, wound packing, junctional devices, and tourniquets.
   - Early tourniquet application for severe extremity hemorrhage improves survival when used appropriately. [@kragh2009]

2. **Immediate hemorrhage control (non-compressible torso hemorrhage)**

   - **Endovascular balloon occlusion** (e.g., [[endovascular trauma management (EVTM)|resuscitative endovascular balloon occlusion of the aorta (REBOA)]]) as a bridge to definitive hemorrhage control in appropriately selected patients and systems. [@trauma2016] [@morrison2014] [@castellini2021]
   - REBOA practice should follow system-level governance and training standards. [@bulger2019]

3. **Temporize perfusion and shorten operative time**

   - **Temporary intravascular shunts (TIVS)** to restore limb perfusion when definitive repair is unsafe or delayed (polytrauma, ortho fixation first, transfer). [@fox2005]
   - Clamp/ligate selectively when permissible (e.g., select venous injuries) as a last resort for uncontrolled hemorrhage. [@rutherford2018]

4. **Staged definitive reconstruction**

   - Definitive arterial/venous repair after resuscitation endpoints improve (warming, correction of coagulopathy, reduced vasopressor requirement). [@rotondo1993]

<!-- type: treatment -->

**REBOA: practical safety principles**

- Use REBOA as a **bridge**, not definitive hemorrhage control. [@morrison2014]
- Registry data and meta-analyses demonstrate feasibility but also emphasize complication risk and the need for appropriate indications and rapid definitive hemostasis pathways. [@trauma2016-aorta] [@castellini2021]
- Consider **partial or intermittent REBOA** to reduce distal ischemia burden in selected scenarios when expertise and monitoring are available. [@sadeghi2018-partial]
- When comparing REBOA with resuscitative thoracotomy,thoracotomy (RT), observational data and registry analyses suggest outcome differences are highly dependent on patient selectionselection, injury patterns, and timing. [@brenner2018-survival] [@cralley2026]
Go to section in textbookDispute / Submit evidenceAll updates