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Vascular Management & Damage Control

Control hemorrhage while preserving salvageable organ and limb perfusion. During reconstructive surgery, obtain temporary control, improve exposure and call the appropriate vascular, trauma or pelvic surgical team early. Definitive repair is appropriate when it can be completed promptly in a stable patient; abbreviated damage-control surgery is reserved for physiology or injury complexity that makes continued reconstruction unsafe.[1][2]

ESVS 2025 explicitly excludes iatrogenic injuries from its formal scope. Its abdominal recommendations are often based on low-certainty evidence and expert consensus.[2]

Immediate priorities​

  1. Communicate and obtain temporary control. Stop the injuring maneuver without moving abruptly or releasing the tissue being held or retracted; losing the established exposure makes reidentifying the injury harder and increases blood loss. Avoid sustained active suction directly on an uncontrolled vessel; use suction beside the injury to clear the field while maintaining pressure. During laparoscopy, excessive suction can diminish pneumoperitoneal tamponade; after repair, gradually lower insufflation pressure to detect bleeding masked by gas pressure.[29][30] Apply directed pressure, usually with a finger, and escalate to sponge-stick compression and then laparotomy-pad packing with external compression if manual compression is insufficient or cannot be maintained. Activate the major-hemorrhage response when indicated, summon experienced help, and tell the scrub, nursing and anesthesia teams that bleeding has occurred, specifying any additional instruments needed. Avoid blind clamps or sutures in a blood-filled field.
  2. Expose the injury and secure vascular control. Enlarge or convert the operative approach when necessary. Identify the vessel, adjacent ureter, bowel and nerves, and appropriate inflow and outflow control before releasing tamponade or opening a contained hematoma.
  3. Resuscitate while controlling the source. Anesthesia and the blood bank manage blood products, temperature, ionized calcium and coagulation alongside the operation.
  4. Choose repair, endovascular treatment, shunting or ligation according to anatomy and physiology. The fastest technically possible maneuver may sacrifice an organ or limb; make that tradeoff explicit. Do not postpone an achievable definitive repair simply because the injury is called “damage control.”[1][2][3]

A negative FAST examination does not exclude abdominal or retroperitoneal bleeding. Use CT angiography when the patient can safely undergo it; unstable ongoing hemorrhage requires a control strategy that does not wait for imaging. Fracture pattern alone cannot identify the bleeding vessel or determine the need for embolization.[1][2][4]

When to stage the operation​

Damage-control surgery interrupts worsening shock, hypothermia, acidosis and coagulopathy when definitive reconstruction would impose an intolerable additional burden. Its phases are:[1][2]

  • Abbreviated source control: secure bleeding and contamination, preserve perfusion with a temporary shunt when necessary, and use temporary closure if definitive closure is unsafe.
  • Physiologic recovery: restore perfusion, temperature and hemostasis; reassess for ongoing bleeding, ischemia and abdominal compartment syndrome.
  • Planned completion: remove or revise packing, replace temporary shunts, assess bowel or organ viability and complete repair and closure as soon as the patient's condition permits.

There is no universal “under 90 minutes, then wait 24–36 hours” prescription. Persistent hemorrhage, threatened perfusion or compartment syndrome requires earlier intervention. Conversely, opening a recently controlled field according to a fixed clock may be inappropriate. Document the reason for staging and the findings that will trigger return to the operating room.[1][2]

Resuscitation: keep the indication explicit​

MeasurePractical interpretation
Blood pressureEuropean trauma guidance recommends an SBP target of 80–90 mmHg during early uncontrolled traumatic bleeding without clinical evidence of brain injury. For severe traumatic brain injury, it recommends MAP at least 80 mmHg.[1]
Blood productsActivate the local major-hemorrhage protocol. Trauma guidance supports initial plasma/red-cell or factor-based strategies with platelet support, followed by laboratory or viscoelastic guidance. It does not require a fixed 1:1:1 regimen throughout every hemorrhage.
TXAEuropean 2023 trauma guidance recommends TXA as early as possible and within three hours of injury for adults bleeding or at risk of significant bleeding: 1 g IV over ten minutes, then 1 g over eight hours (Grade 1A).[1] EAST 2025 conditionally recommends routine TXA for injured patients at risk of hemorrhage in prehospital and in-hospital settings.[32] Do not wait for viscoelastic testing.[1]
Fibrinogen and coagulation factorsIdentify and treat the relevant deficit. Trauma guidance supports fibrinogen replacement for functional deficiency or a Clauss level at or below 1.5 g/L. Empiric PCC or high-dose cryoprecipitate for every injured patient is not supported by the trials below. Anticoagulant reversal is a separate indication.
Temperature, calcium and fluidsPrevent hypothermia, measure and correct low ionized calcium, and avoid excessive crystalloid dilution. These measures accompany prompt hemostasis; calcium correction alone has not been shown to confer a mortality benefit.
[1][6][7][8][9]

Major trials that change how to interpret resuscitation claims​

Trial and populationMain findingImplication
PATCH-Trauma, 2023: prehospital TXA in advanced trauma systems; 1,310 randomized, 1,131 with the primary outcome determinedFavorable six-month functional survival 53.7% vs 53.5%, RR 1.00 (95% CI 0.90–1.12). Lower 28-day mortality was a secondary finding.The secondary mortality result was not adjusted for multiple comparisons. [6]
PROCOAG, 2023: empiric 4F-PCC added to ratio-based trauma transfusion; 324 analyzedNo reduction in 24-hour blood-product use. At least one thromboembolic event: 56/161 vs 37/157 (35% vs 24%), RR 1.48 (1.04–2.10).Do not routinely add PCC to trauma transfusion without a specific indication. Patients taking anticoagulants were excluded. [7]
CRYOSTAT-2, 2023: early empiric high-dose cryoprecipitate added to a major-hemorrhage protocol; 1,604 randomized28-day mortality 25.3% vs 26.1% in 1,531 with outcome data, center-adjusted OR 0.96 (0.75–1.23).— [9]
FiiRST-2, 2025: fibrinogen concentrate plus PCC replacing plasma in the first two trauma packs; 217 randomized, 137 in the modified intention-to-treat analysisMean 24-hour blood-product use 20.8 vs 23.8 units, ratio 0.87 (one-sided 97.5% CI 0–1.19); superiority was not demonstrated, and recruitment stopped for futility.This was a different strategy from PROCOAG. Neither equivalence nor a survival or safety advantage was established.[8]
TOWAR, 2026: cluster-randomized prehospital whole blood vs components; 993 in primary analysis30-day mortality 25.9% vs 20.5%, adjusted OR 1.24 (0.87–1.76).No demonstrated superiority of the initial whole-blood strategy.[10]
SWiFT, 2026: prehospital whole blood vs components; 942 randomized, 616 with the primary composite determinedDeath or massive transfusion by 24 hours 48.7% vs 47.7%, RR 1.02 (0.80–1.31).Also no demonstrated superiority. Its composite endpoint and analysis population differ from TOWAR. Neither trial establishes equivalence or the optimal subsequent hospital regimen.[11]
[6][7][8][9][10][11]

These are treatment-strategy comparisons. Trial-specific blood-product “unit” definitions, exclusions and follow-up differ.

Vaginal and perineal hemorrhage​

Identify the source: a visible laceration, expanding hematoma, operative pedicle, diffuse coagulopathic bleeding and bleeding tumor require different definitive treatment. Adequate light, exposure and analgesia or anesthesia are needed. Apply directed pressure while arranging repair or embolization; repeated blind deep sutures can injure the bladder, ureter, rectum or pelvic vessels.[2][12][13]

Direct suture ligation of an identified vessel is the usual first operative step. The vaginal branches of the uterine artery and the internal pudendal artery are common sources. Figure-of-eight sutures through the vaginal wall control diffuse venous oozing from lacerations. Perineal wounds that cannot be controlled, such as an open pelvic fracture with a perineal wound, can be packed directly with laparotomy pads for tamponade.

For sinus-type oozing from an exposed raw fascial surface (for example Colles' fascia) rather than a discrete vessel, a described alternative is a pleating suture: successive bites gather the fascia, the ends are tightened and crossed, and the suture is tied so the fascial edges meet and compress the small oozing vessels.[27]

Vaginal packing can provide temporary tamponade when direct control is incomplete or while definitive treatment is being arranged.[13] Gauze rolls are packed tightly and systematically from the apex distally with the vagina exposed by speculum in lithotomy, and topical hemostatic gauze can be incorporated. Place the pack under visualization, record the material and amount, monitor ongoing loss and physiology, and establish an explicit reassessment and removal plan. Consider urinary drainage when compression prevents voiding or accurate output monitoring is needed.[12][13] Antibiotic use depends on the procedure, infection, contamination and local protocol.[12][13] An open pelvic fracture communicating with a vaginal or perineal wound requires prompt broad-spectrum antibiotics and debridement with the trauma and orthopedic teams.[31]

An expanding or symptomatic deep hematoma may require operative control, angiography or embolization or a combined approach. For an obstetric upper-vaginal hematoma, or a lower-vaginal hematoma with hemodynamic instability, urgent angiography may identify the bleeding source and assess whether embolization is feasible; local surgical control of upper-vaginal bleeding can be difficult.[33] Do not drain a contained collection without a plan to control the resulting hemorrhage. In pelvic-fracture wounds, coordinate with trauma and orthopedic teams because vaginal or perineal bleeding may be only one component of a larger pelvic injury.[2][4]

For malignant vaginal bleeding, coordinate with gynecologic oncology, radiation oncology and interventional radiology, taking prior radiation, anatomy and the patient's goals into account. The 2019 Cochrane review found no eligible controlled comparison of packing, TXA or embolization with radiotherapy.[13] A 2026 single-center retrospective cohort of locally advanced cervical-cancer bleeding reported study-defined hemostatic response (cessation within three days or minimal bleeding by seven days) in 141/150 (94.0%) after pelvic artery embolization versus 78/135 (57.8%) after vaginal packing.[34]

Pelvic-fracture hemorrhage​

In hemodynamically unstable pelvic ring disruption, WSES attributes the main source of acute retroperitoneal hemorrhage to venous plexuses and cancellous bone surfaces in 80–90% of cases; it states that 10–20% of all pelvic bleeding sources are arterial.[4] Arterial bleeding may predominate when instability persists after mechanical stabilization, and when arterial bleeding is present, concomitant venous bleeding is close to universal. Stabilization, packing and embolization address different parts of that problem; no single fixed sequence fits every patient or trauma system.[1][4]

InterventionRole and limitations
Pelvic binder and mechanical stabilizationApply the binder at the greater trochanters, not the iliac crests, for suspected unstable pelvic-ring injury. Monitor skin/pressure effects and replace temporary compression with an appropriate stabilization plan.
Preperitoneal pelvic packing (PPP)Rapid tamponade of predominantly venous/osseous bleeding, particularly when immediate angiography is unavailable or the patient needs operative control. Stabilization improves the counterpressure needed for packing.
Angiography and embolizationTargets arterial bleeding, including CT extravasation or persistent bleeding despite stabilization/packing. Absence of a CT blush does not exclude an arterial injury. Selectivity and embolic agent depend on anatomy, physiology and the interventional team's judgment.
Combined or hybrid carePacking and embolization are complementary. Their order depends on the dominant threat, immediate resources and response to treatment. A patient needing laparotomy for an abdominal injury must not be denied it to preserve pelvic tamponade.
[1][2][4]

PPP exposure: enter the preperitoneal space through a short lower abdominal incision (midline in the modified technique WSES describes) to the space of Retzius without opening the peritoneum. Place three laparotomy pads on each side of the bladder, packed below the pelvic brim toward the iliac vessels and the sacroiliac joints. In experienced hands this can take under 20 minutes. WSES advises that pelvic-fracture patients with hemodynamic instability always be considered for PPP (Grade 1C), especially in hospitals without an angiography service. Keep the packing compartment separate from an abdominal operative field when feasible. If abdominal exploration is needed, a separate laparotomy can preserve the packing compartment. Document pack location and number. WSES describes revision or removal at 48–72 hours, but ongoing bleeding, infection, compartment effects or other urgent findings require reassessment sooner; timing is individualized.[4]

Comparative data are confounded by selection. In the AAST multicenter cohort of 524 patients, pelvic angiography with or without embolization (PAE) without PPP was used in 74.4%, PPP without PAE in 13.0% and both in 12.6%. Patients who received PPP had higher Injury Severity Scores (41 vs 34) and lower nadir systolic pressures (62 vs 74 mmHg), and higher in-hospital mortality (47.1% vs 18.5%); the authors attribute this to more severe shock and suggest embolization as first-line therapy where endovascular access is rapid.[19] A systematic review of PPP versus angioembolization could not draw a conclusive comparison because of bias and heterogeneity, and found that 27% of PPP patients needed subsequent embolization for hemorrhage control.[20] In an 18-year two-center retrospective series, 79% of 61 primary-PPP patients received adjunct embolization; bilateral unselective embolization was associated with more potentially ischemic in-hospital complications than other embolization approaches, including one case of gluteal necrosis.[21]

Internal iliac artery ligation is a selective rescue option when repair or embolization is unsuitable or unavailable. It can fail because of collateral supply and does not reliably control venous or osseous bleeding. Identify the ureter, iliac vein and arterial branches before ligation. Bilateral arterial sacrifice carries gluteal, pelvic-organ and bowel ischemia risk despite small survivor series reporting no local complication.[2]

The classical method isolates the vessel circumferentially, which is difficult and risks iliac vein injury. A simplified technique described by Sanders and colleagues spreads right-angle forceps parallel to the anterior division to create a few millimeters of space on either side, then clips that division with two large vascular clips without circumferential dissection.[14] In a series of 20 unstable pelvic-fracture patients treated with bilateral internal iliac artery ligation and PPP, the median time from emergency-department arrival to completion of ligation was 65.5 minutes; iliac-vein injury during dissection occurred in 3/20, and anatomic hemostasis was achieved in 18/20.[15] A 77-patient series of temporary bilateral ligation after blunt trauma reported no gluteal necrosis, iatrogenic injury or wound infection, with 70% mortality reflecting the severity of the cohort.[16]

REBOA: a restricted rescue strategy​

Resuscitative endovascular balloon occlusion of the aorta temporarily reduces distal arterial flow. ESVS 2025 does not recommend routine REBOA for temporary control of exsanguinating torso hemorrhage in trauma (Class IIIb, Level B).[2] The 2025 EAST guideline conditionally recommends against REBOA for hemodynamically unstable trauma with suspected subdiaphragmatic bleeding or pelvic fracture.[28] For traumatic cardiac arrest with suspected subdiaphragmatic bleeding, it conditionally favors REBOA over resuscitative thoracotomy when there is no other indication for thoracotomy; it makes no recommendation for the combined arrest-or-impending-arrest population versus thoracotomy. For hemodynamically stable patients with anticipated bleeding from placenta accreta spectrum, it conditionally supports prophylactic catheter placement before cesarean; balloons were inflated after delivery in the included studies. Evidence certainty was very low.[28] In a 90-patient observational series that mixed traumatic hemorrhage, arrest and nontraumatic hemorrhage, systolic pressure rose from 68 to 131 mmHg in the 29 patients with traumatic hemorrhage, and overall 30-day mortality was 62%.[2][5][26]

In UK-REBOA, 90 patients were randomized to a REBOA strategy plus standard care or standard care alone. Ninety-day mortality was 25/46 versus 18/43; Bayesian OR 1.58 (95% credible interval 0.72–3.52), with an 86.9% posterior probability of increased mortality. Among patients who died, bleeding was the recorded cause in 8/25 assigned to the REBOA strategy and 3/18 assigned to standard care. Not every patient assigned to the strategy received a balloon.[5]

Aortic zoneAnatomical extent and use
ILeft subclavian artery to celiac origin; selected subdiaphragmatic abdominal or combined abdominal/pelvic hemorrhage. Occlusion compromises visceral, renal and lower-body perfusion.
IICeliac origin to the lowest renal artery; avoid deployment across these visceral/renal branches.
IIILowest renal artery to aortic bifurcation; selected isolated pelvic/junctional hemorrhage. Proximal visceral branches remain perfused, but lower-body ischemia and reperfusion injury remain substantial risks.
[2][4][5]

If selected by an experienced team, REBOA requires immediate access to definitive hemorrhage control, attention to bleeding above the balloon and monitoring for access injury, migration, ischemia and reperfusion effects. There is no universally safe occlusion duration. Partial or intermittent occlusion may change distal flow but does not guarantee safety or justify delaying hemostasis. A negative FAST scan alone cannot clear a patient for balloon inflation.[1][2][5]

Abdominal vascular control​

Exposure before repair​

Use Operative Exposure for the anatomical approach. Direct pressure or packing may permit controlled extension of the incision and vessel-specific proximal or distal control.[2][3] Supraceliac aortic clamping is a rescue maneuver for selected catastrophic abdominal arterial hemorrhage.[2][3]

  • Supraceliac access: enter the lesser sac through the gastrohepatic ligament, retract the stomach inferiorly and the esophagus to the left, and divide the diaphragmatic crura as needed to expose the aorta at the hiatus. Identify and protect the esophagus, and develop a controlled clamp site. This is one emergency route to supraceliac control; left medial visceral rotation is another, and the injury and available exposure determine the approach. Avoid blind circumferential dissection that can avulse posterior aortic branches.
  • Infrarenal access: eviscerate the small bowel to the right and incise the retroperitoneum over the aorta at the ligament of Treitz; the left renal vein is an important landmark, but identify the actual renal arterial origins and any variants before choosing the clamp site.
  • Right medial visceral rotation provides broad caval, right renal and iliac exposure; left medial visceral rotation provides aortic and visceral-branch exposure. A local Kocher maneuver is not the same as a complete right-sided rotation.[2][3]

Vessel-specific decisions​

InjuryReconstruction and damage-control considerations
AortaObtain controlled inflow/outflow access; choose primary repair, patch, interposition or selected endovascular repair according to the defect. Emergency synthetic reconstruction may be necessary even with bowel injury, but contamination, coverage and subsequent surveillance still matter.
Common/external iliac arteryPreserve limb perfusion by repair or a temporary shunt when definitive reconstruction cannot be completed promptly. Ligation can cause limb-threatening ischemia.
Infrarenal IVC or major iliac veinRepair active bleeding when readily achievable. Ligation may be necessary in extremis, with consequences for venous outflow, thrombosis, limb swelling and compartment pressure. For stable trauma with an IVC injury contained in a nonexpanding, nonbleeding retroperitoneal hematoma, consider close observation and follow-up imaging (ESVS Class IIa, Level C).[2]
Suprarenal/retrohepatic IVCRequires specialist planning and control appropriate to the injured segment. Packing may provide temporary control. Formal total hepatic vascular exclusion requires suprahepatic and infrahepatic caval control plus hepatic inflow control (Pringle); Pringle plus an infrarenal clamp alone is incomplete. ESVS states that atriocaval shunting is not indicated for IVC trauma (Class IIIa, Level C).
SMA/celiac or portal-system vesselsAssess the injured segment, collateral supply and bowel/hepatic viability. Repair, selected endovascular restoration or shunting may preserve perfusion. Neither celiac sacrifice nor loss of a mesenteric branch is automatically harmless. Plan reassessment when bowel viability is uncertain.
Renal vesselsConsider active bleeding, a solitary or bilateral threatened kidney, ischemia duration and reconstructibility. A devascularized unilateral kidney discovered after trauma is a different problem from a freshly recognized, potentially salvageable intraoperative renal artery injury. No single 60-minute rule decides salvage or nephrectomy. Repair renal-vein injury when feasible; left renal-vein ligation near the IVC may be tolerated through collateral drainage, whereas right renal-vein ligation can threaten right renal function.[2]
[2][3]

For an infrarenal IVC defect involving less than 50% of the vessel wall, or one that can be closed transversely, Kobayashi et al. describe lateral venorrhaphy with running 4-0 or 5-0 polypropylene. Search for a posterior defect by rotating the IVC or enlarging the anterior injury rather than by blind circumferential dissection. For larger IVC defects, or when primary closure would narrow its lumen by more than 40%, they describe saphenous-vein or prosthetic patch venoplasty. Iliac vein repair also requires preservation of adequate lumen, but these numeric thresholds were reported for the IVC.[3]

Observational comparisons of ligation and repair are heavily confounded by injury severity and physiology. Small hybrid balloon series establish feasibility, not superiority over conventional control.[2]

Of 1,316 eligible National Trauma Data Bank IVC injuries, 310 ligation–repair pairs were propensity matched; in-hospital mortality in the matched groups was 41.3% versus 39.0%.[23] Ligation was associated with more extremity compartment syndrome (OR 5.23), deep venous thrombosis (OR 2.83) and pulmonary embolism (OR 3.63).[23] A meta-analysis of 14 studies (855 patients) associated ligation with higher mortality (OR 3.12), but not specifically for infrarenal injuries (OR 3.13, p = 0.09).[24] In the PROOVIT registry (140 patients), 70% of IVC injuries were repaired and 30% ligated; mortality was 42% overall, 33% for infrarenal and 66% for suprarenal injuries.[25]

Temporary intravascular shunts​

A shunt can restore flow while resuscitation, skeletal stabilization or complex reconstruction proceeds. Select the device and diameter for the vessel; ensure secure fixation without obstruction, confirm flow and reassess for thrombosis, dislodgement and distal ischemia. These are specialist bridging procedures, not definitive repairs.[2]

In a 2016 civilian multicenter series (213 injuries, 94.8% arterial), shunts were placed for damage control in 63.4% and for staged repair of combined orthopedic and vascular injuries in 36.1%. The Argyle shunt was used in 81.2% and Pruitt-Inahara in 9.4%. Shunts were dwelling less than 24 hours in 86.5%. Shunt thrombosis occurred in 5.6% and dislodgment in 1.4%, with no association between dwell time and thrombosis, and limb salvage was 96.3%. A noncommercial conduit (chest tube or feeding tube) did not increase thrombosis but was an independent risk factor for later graft failure.[17] In a propensity-matched multicenter extremity series, unshunted patients had higher odds of early amputation (OR 3.6, 95% CI 1.2–11.1); median follow-up was 12 days in the shunted group and 9 days in controls.[18]

Convert to definitive reconstruction as soon as feasible, ideally during the initial operation; otherwise, ESVS advises removing the shunt when patient status permits, within 12 hours as a practical planning target rather than a validated safety cutoff.[2] Reported shunt patency for many hours is no basis to delay definitive repair. Similarly, the traditional six-hour limb-ischemia concept is not permission to delay revascularization. Systemic anticoagulation, fasciotomy and subsequent antithrombotic therapy depend on bleeding risk, the repair and the limb's condition; none is automatic for every vascular injury.[2]

Obstetric hemorrhage: follow a cause-directed protocol​

Postpartum hemorrhage requires immediate obstetric and anesthesia leadership, resuscitation and assessment for uterine atony, retained tissue, genital-tract trauma and coagulopathy.[12]

Abdomino-pelvic packing has also been described as a damage-control measure for refractory postpartum hemorrhage, placenta accreta spectrum, gynecologic oncology surgery, and presacral bleeding during sacrocolpopexy.[22]

Uterotonics treat uterine atony; they do not close a laceration or repair uterine rupture. When bleeding remains uncontrolled, tamponade, operative repair or compression sutures, devascularization, embolization or hysterectomy are selected according to the cause, clinical trajectory and available expertise. Do not delay definitive surgery, including hysterectomy when required, merely to work through every conservative option.[12]

  • Start first-response care concurrently: WHO recommends starting at measured blood loss ≥500 mL, or ≥300 mL with pulse >100/min, shock index >1, systolic pressure <100 mmHg or diastolic pressure <60 mmHg, whichever occurs first within 24 hours of birth. For vaginal birth, begin uterine massage, an oxytocic, TXA, IV fluids, genital-tract examination and escalation together; WHO also recommends the individual components after caesarean birth while noting that bundle evidence is largely from vaginal births.[12] WHO recommends initiating available bundle components promptly, ideally within 15 minutes of diagnosis. For PPH, TXA is 1 g IV over ten minutes within three hours of birth, with a second 1 g if bleeding continues after 30 minutes or restarts within 24 hours after the first dose; this differs from the trauma infusion above.
  • Balloon tamponade has prerequisites: WHO makes a context-specific recommendation for it after vaginal birth for refractory atony when surgery and blood are immediately available, a first-line treatment protocol is implemented, retained tissue or trauma are reasonably excluded, trained personnel are present and monitoring is adequate. WHO advises against intrauterine gauze packing for PPH; this is distinct from vaginal or preperitoneal packing for another bleeding source.[12]
  • Prepare surgery while arranging embolization. Neither transfer to angiography nor repeated conservative attempts should delay necessary operative control. Use an obstetric major-hemorrhage protocol: WHO sets a fibrinogen goal of at least 2 g/L, distinct from the trauma threshold, without specifying an optimal transfusion ratio.[12]

After control: document the unresolved risks​

The handoff should identify the vessel and injury, repair, ligation or shunt performed, clamp and ischemia times, residual perfusion concerns, retained packs, anticipated return to surgery, and the vascular team's surveillance and antithrombotic plan. Continue assessment for recurrent bleeding, bowel or renal ischemia, limb compromise, compartment syndrome and thromboembolism. VTE prophylaxis begins when hemostasis and the wider injury pattern permit.[1][2]

Companion pages​

References​

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2. Wahlgren CM, Aylwin C, Davenport RA, et al. ESVS 2025 Clinical Practice Guidelines on the Management of Vascular Trauma. Eur J Vasc Endovasc Surg. 2025;69:179–237. doi:10.1016/j.ejvs.2024.12.018.

3. Kobayashi LM, Costantini TW, Hamel MG, Dierksheide JE, Coimbra R. Abdominal vascular trauma. Trauma Surg Acute Care Open. 2016;1:e000015. doi:10.1136/tsaco-2016-000015.

4. Coccolini F, Stahel PF, Montori G, et al. Pelvic trauma: WSES classification and guidelines. World J Emerg Surg. 2017;12:5. doi:10.1186/s13017-017-0117-6.

5. Jansen JO, Hudson J, Cochran C, et al. Emergency department resuscitative endovascular balloon occlusion of the aorta in trauma patients with exsanguinating hemorrhage: the UK-REBOA randomized clinical trial. JAMA. 2023;330:1862–1871. doi:10.1001/jama.2023.20850.

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16. Schellenberg M, Gallegos H, Owattanapanich N, et al. Complications following temporary bilateral internal iliac artery ligation for pelvic hemorrhage control in trauma. Am Surg. 2022;88(10):2475-2479. doi:10.1177/00031348221101509.

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18. Polcz JE, White JM, Ronaldi AE, et al. Temporary intravascular shunt use improves early limb salvage after extremity vascular injury. J Vasc Surg. 2021;73(4):1304-1313. doi:10.1016/j.jvs.2020.08.137.

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20. McDonogh JM, Lewis DP, Tarrant SM, et al. Preperitoneal packing versus angioembolization for the initial management of hemodynamically unstable pelvic fracture: a systematic review and meta-analysis. J Trauma Acute Care Surg. 2022;92(5):931-939. doi:10.1097/TA.0000000000003528.

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