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 thoracic aorta (BTAI).aorta. [@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]
  - Note: Recent randomized evidence (UK-REBOA trial) has suggested that the addition of REBOA to standard care may increase mortality in some trauma settings, emphasizing the need for highly selective use and rapid definitive intervention. [@jansen2026-emergency]

**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)**

- thoracicThoracic endovascular aortic repair (TEVAR) is generally preferred for **grade II–IV** injuriesblunt traumatic aortic injury (BTAI) when anatomy is suitable, with anti-impulse therapy as early management. [@riambau2017] [@isselbacher2022] [@aha2022]
- Grade I injuries (intimal tears) are typically managed conservatively with serial imaging and blood pressure control. [@aha2022]
- Left subclavian management should be individualized; see [[TEVAR]] and guidance on subclavian coverage strategies. [@matsumura2009]