Principles of Damage Control Vascular Surgery

in Vascular Trauma

Applied

Type

Reinforcement

Confidence

85%

Created

Mar 20, 2026

Evidence

1 source

Rationale

The meta-analysis by Castellini et al. (2021) provides high-level evidence reinforcing the use of REBOA as a bridge to definitive care in major trauma. It specifically addresses the comparison between REBOA and resuscitative thoracotomy, which was already a point of discussion in the text. Adding this citation strengthens the evidence base for these recommendations while maintaining the existing structure.

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;16(1):41. PMID: 34384452.
Verified source
PubMedDOI

Content Changes

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**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-b]
   - 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]

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**REBOA: practical safety principles**

- Use REBOA as a **bridge**, not definitive hemorrhage control. [@morrison2014] [@castellini2021-b]
- Registry data demonstrate feasibility but also emphasize complication risk and the need for appropriate indications and rapid definitive hemostasis pathways. [@trauma2016-aorta]
- 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, observational data and meta-analyses suggest outcome differences are highly dependent on patient selection and timing. [@brenner2018-survival] [@castellini2021-b]
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