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"handoff delays”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. The UK-REBOA randomized clinical trial (RCT) found that the addition of REBOA to standard care in patients with exsanguinating hemorrhage actually increased mortality (54% vs 42%), suggesting that its use may be harmful in certain emergency department settings or patient populations [@jansen2026-emergency]. Furthermore, meta-analyses indicate that survival benefits associated with REBOA remain inconsistent, highlighting the need for rigorous patient selection and specialized team training within the hybrid environment [@castellini2021].

Noncompressible torso hemorrhage (NCTH) represents the primary indication for hybrid operative strategies. Contemporary reviews emphasize that the distinction between "compressible" and "noncompressible" hemorrhage is not always binary; evolving endovascular and hybrid techniques continue to expand the range of injuries amenable to minimally invasive control, and the hybrid environment is best positioned to adapt to this spectrum [@zhang2024] [@maegele2024].

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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] A large registry-based cohort study of hemodynamically unstable pelvic fractures found that the combination of hemorrhage control interventions — including angioembolization and surgical packing — was associated with improved survival, reinforcing the value of integrated hybrid approaches for this injury pattern [@anand2026].

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