Endovascular Approaches

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**Where endovascular therapy adds the most value**

Endovascular techniques are particularly useful for **junctional and torso vessels** where exposure is difficult and time to hemorrhage control is critical, and in patients with severe physiologic derangement where open repair is poorly tolerated. [@trauma2016] [@branco2014]

**Common endovascular options**

- **Covered stent-grafts**

  - Typical targets: subclavian/axillary, iliac, select carotid injuries, and thoracicblunt aortatraumatic aortic injury (BTAI). [@branco2014] [@riambau2017]
  - Key requirement: adequate landing zones and ability to maintain antiplatelet therapy when needed.

- **Embolization (coils/plugs/particles)**

  - Commonly used for pelvic and solid-organ hemorrhage control as part of damage control resuscitation. [@coccolini2017-wses]
  - See [[endovascular trauma management (EVTM)]] for embolization workflows in hybrid trauma systems. [@trauma2016]

- **Balloon occlusion (resuscitative endovascular balloon occlusion of the aorta (REBOA) or selective balloons)**

  - Bridge to definitive hemorrhage control in non-compressible hemorrhage, within system governance standards. [@bulger2019] [@trauma2016-aorta]
  - **Caution**: Recent randomized evidence (UK-REBOA trial) suggests that the addition of REBOA to standard care may increase mortality in some trauma systems, highlighting the necessity for strict patient selection and rapid transition to definitive repair [@jansen2026].

**Patient selection and practical contraindications**

- Avoid delaying hemorrhage control in unstable patients when endovascular capability is not immediately available (conversion to open should be anticipated). [@rutherford2018]
- Consider contamination, soft tissue destruction, and infection risk when selecting stent-grafts in penetrating wounds. (If long-term infection risk is high, open reconstruction may be preferred.) [@esvsvgei2020]

**Traumatic aortic injury (BTAI): current principles (overview)**

- thoracic endovascular aortic repair (TEVAR) is generally preferred for **grade II–IV** injuries when anatomy is suitable, with anti-impulse therapy as early management. [@riambau2017] [@isselbacher2022][@isselbacher2022-isselbacher]
- Grade I injuries (intimal tears) are typically managed conservatively with medical therapy and serial imaging [@isselbacher2022-isselbacher].
- Left subclavian management should be individualized; see [[TEVAR]] and guidance on subclavian coverage strategies. [@matsumura2009]