Hybrid Trauma and Endovascular Surgery

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Hybrid trauma and endovascular surgery integrates **open damage control surgery** with **immediate angiography/endovascular control**, minimizing time lost to transfers and enabling physiology-driven sequencing (control hemorrhage first, then definitive repair). [@trauma2016-endovascular] [@rutherford2018-rutherford]

**Why hybrid matters in endovascular trauma management (EVTM)**

- Enables **simultaneous** laparotomy/thoracotomy with resuscitative endovascular balloon occlusion of the aorta (REBOA) management, embolization, and covered stent deployment.
- Reduces “handoff delays” for unstable patients who cannot tolerate transport to interventional radiology (IR).
- Supports iterative damage control: packing/temporary closure → angioembolization → reassessment → staged definitive repair. [@wses2018]

While REBOA is a core component of the EVTM toolkit, recent high-quality evidence has introduced important caveats.caveats regarding its use in noncompressible torso hemorrhage (NCTH). The UK-REBOA randomized clinical trial (RCT) found that the addition of REBOA to standard care in patients with exsanguinating hemorrhage actually increased 90-day mortality (54% vs 42%), suggesting that its use may be harmful in certain emergency department settings or patient populations [@jansen2026-emergency].[@jansen2026-d]. Furthermore, meta-analyses indicate that survival benefits associated with REBOA remain inconsistent, with no significant overall mortality reduction and high levels of study heterogeneity, highlighting the need for rigorous patient selection and specialized team training within the hybrid environment [@castellini2021].[@castellini2021-resuscitative].

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**Table 16.5. Location of Care for Unstable Hemorrhage (Practical Framework)**

| **Setting** | **Best for** | **Limitations** |
| --- | --- | --- |
| **Hybrid OR** | Unstable noncompressible torso hemorrhage (NCTH) needing possible laparotomy + endovascular control | Resource-intensive; requires trained team |
| **IR suite** | Stable or transient responders needing embolization | Transport risk; limited access to open surgery |
| **Standard OR** | Rapid laparotomy/packing when no endovascular capability | Delayed pelvic/branch arterial control |

**Pelvic hemorrhage integration**

Hybrid capability is particularly valuable for pelvic fracture hemorrhage where pathways commonly combine binder/preperitoneal pelvic packing (PPP), selective REBOA (Zone III), and angioembolization depending on physiology and resource timing. [@coccolini2017-wses] [@bulger2019] [@castellini2021][@castellini2021-resuscitative]

See also: [[Pelvic Trauma Hemorrhage]] and [[Vascular Trauma|Ch. 15]].