Skip to main content

Vascular Management & Damage Control

Vascular damage control across the vagina, perineum, pelvis, and abdomen is governed by a single overarching principle: hemorrhage kills before ischemia does — the immediate priority is to stop bleeding and break the lethal triad of hypothermia, acidosis, and coagulopathy, deferring definitive vascular reconstruction until physiologic stability is restored.[1][2][3]

Part I: The lethal triad and damage-control philosophy​

Principle 1 — The three-phase damage-control paradigm​

Damage control surgery (DCS), first named by Rotondo and Schwab in 1993, is a staged approach that directly counters the lethal triad:[1][2]

  • Phase 1 — Abbreviated laparotomy. Rapid hemorrhage control (ligation, packing, shunting) and contamination control (stapling of bowel). Temporary abdominal closure. Target operative time: <90 minutes.
  • Phase 2 — ICU resuscitation. Aggressive restoration of physiology — rewarming (target >36°C), acidosis correction (lactate clearance), and coagulopathy (massive transfusion protocol, factor replacement). Typically lasts 24–36 hours.
  • Phase 3 — Planned re-operation. Pack removal, definitive vascular repair, bowel anastomosis, and abdominal closure. Each subsequent operation should occur within 24 hours of the previous one to maximize the chance of primary fascial closure.[2]
Key quote

"Damage-control surgery is now recognized as the standard of care for the most severely injured patients who are undergoing surgery for massive bleeding. Its adoption directly mitigates the vicious cycle of hypothermia, acidosis, and coagulopathy." — David R. King, MD (Massachusetts General Hospital)

Principle 2 — Damage control resuscitation concurrent with surgical control​

Modern damage control extends beyond the OR to include damage-control resuscitation (DCR), which begins in the field and continues through definitive care:[2][4]

  • Permissive hypotension (target SBP 80–90 mmHg) until hemorrhage control is achieved — avoids dilutional coagulopathy and clot disruption.
  • Balanced massive transfusion (1:1:1 ratio of PRBC : FFP : platelets).
  • Early tranexamic acid (within 3 hours of injury) — reduces mortality from hemorrhage.
  • Avoidance of crystalloid over-resuscitation — worsens acidosis, hypothermia, and coagulopathy.
  • Point-of-care coagulation testing (TEG / ROTEM) to guide targeted factor replacement.

Part II: Vaginal and perineal vascular damage control​

Principle 3 — Sources of vaginal and perineal hemorrhage​

Hemorrhage from the vagina and perineum arises from several distinct clinical contexts, each requiring tailored damage control:[5][6][7]

  1. Obstetric trauma — genital-tract lacerations (the most common cause of obstetric hemorrhage after uterine atony), cervical lacerations, high vaginal lacerations, vulvovaginal hematomas.
  2. Pelvic-fracture–associated perineal injury — open pelvic fractures with perineal wounds (mortality 30–50%).
  3. Oncologic hemorrhage — bleeding from advanced cervical, vulvar, or vaginal cancer.
  4. Iatrogenic / surgical hemorrhage — intraoperative bleeding during pelvic reconstructive, gynecologic, or urologic surgery.

Principle 4 — Vaginal packing: the first-line temporizing measure​

Tight vaginal packing is the simplest and most immediately available damage-control technique for vaginal hemorrhage:[6][7]

  • Technique. Patient in lithotomy; speculum used to expose the vaginal apex. Gauze rolls are packed tightly into the fornices, maintaining even circumferential pressure, and placed systematically from the apex distally.
  • Adjuncts. Formalin-soaked packs (4% solution) provide chemical cauterization for tumor-related bleeding. Hemostatic agents (QuikClot combat gauze, topical thrombin, oxidized cellulose) can be incorporated into the packing.
  • Catheterization is mandatory while the pack is in situ (urethral compression prevents voiding).
  • Broad-spectrum antibiotics (including metronidazole) should be administered, particularly with necrotic tumor or contaminated wounds.
  • Packing is a bridge — it buys time for resuscitation, angioembolization, or operative repair.

Principle 5 — Surgical control of perineal vascular injuries​

When packing fails or the bleeding source is arterial, surgical intervention is required:[5][7]

  • Direct suture ligation of identifiable bleeding vessels — the vaginal branches of the uterine artery and internal pudendal artery are the most common sources.
  • Figure-of-eight sutures through the vaginal wall at the bleeding site — effective for diffuse venous oozing from lacerations.
  • Exploration and drainage of expanding hematomas. Vulvovaginal hematomas that are rapidly expanding or causing hemodynamic instability require incision, clot evacuation, identification and ligation of bleeding vessels, and closure with or without drain placement. ACOG notes that a single bleeding source is often not identified when a hematoma is incised, and packing may still be needed.[5]
  • Perineal pressure packing. For uncontrollable perineal hemorrhage (e.g., open pelvic fracture with perineal wound), direct packing of the perineal wound with laparotomy pads provides tamponade.

Part III: Pelvic vascular damage control​

Principle 6 — Understanding pelvic hemorrhage sources​

The pelvis presents a unique vascular challenge because hemorrhage arises from three simultaneous sources:[8][9]

  • Venous bleeding (80–90%) — presacral venous plexus, paravesical venous plexus, and internal iliac venous tributaries. Low-pressure, high-volume bleeding that is the dominant source in most pelvic fractures.
  • Osseous bleeding — cancellous bone surfaces of sacral and iliac fractures, concurrent with venous.
  • Arterial bleeding (10–20%) — branches of the internal iliac artery (superior gluteal, internal pudendal, obturator, lateral sacral). Less common but more frequently associated with hemodynamic instability.

When arterial bleeding is present, the likelihood of concomitant venous bleeding approaches 100%.[9] This dual-source hemorrhage is the fundamental reason no single intervention controls all pelvic bleeding.

Principle 7 — The pelvic-hemorrhage control algorithm​

Management of hemodynamically unstable pelvic fractures follows a stepwise, multimodal algorithm:[10][11][9]

Step 1 — Pelvic binder / circumferential compression.

  • Applied in the field or ED as the first temporizing measure.
  • Reduces pelvic volume, approximates fracture fragments, and tamponades venous / osseous bleeding.
  • Must be positioned at the level of the greater trochanters (not the iliac crests).
  • Posterior compression can be augmented with rolled surgical towels placed under the binder at the sacroiliac joints.

Step 2 — Determine the dominant bleeding source.

  • CT angiography (if hemodynamically permissive) — sensitivity 80–90%, specificity 85–98% for arterial bleeding.[12]
  • FAST ultrasound — rules out intraperitoneal hemorrhage (which takes priority over pelvic hemorrhage control).
  • Pelvic radiograph — fracture pattern predicts arterial-injury risk (vertical shear > combined mechanism > high-grade LC / APC).[12]

Step 3 — Definitive hemorrhage control.

Two primary interventions exist, and the choice depends on institutional resources, patient physiology, and bleeding source.

A. Preperitoneal pelvic packing (PPP) addresses the dominant venous / osseous bleeding (80–90% of pelvic hemorrhage):[9][13]

  • Technique. 6–8 cm vertical or Pfannenstiel incision. The preperitoneal space (space of Retzius) is entered without opening the peritoneum (opening the peritoneum releases tamponade and worsens hemorrhage). Three laparotomy pads are placed on each side of the bladder, directed posteriorly toward the sacroiliac joints and pelvic sidewalls. Fascia is closed over the packs.
  • Timing. Can be performed in <20 minutes.[9][14]
  • Pack removal. Within 48–72 hours.[9]
  • WSES recommends PPP especially in hospitals without angiography services (Grade 1C).[9]

B. Pelvic angioembolization (AE) addresses arterial bleeding and is first-line at most high-volume trauma centers:[12][15]

  • Indications. Contrast extravasation on CT, hemodynamic instability with excluded thoracic / abdominal sources, persistent hemorrhage after PPP.
  • Technique. Selective catheterization of bleeding internal iliac branches with coil or gelfoam embolization. Bilateral nonselective embolization with gelfoam is used in the most unstable patients but carries higher ischemic-complication risk.[13]
  • Efficacy. The 2026 AAST multicenter study (524 patients) found AE used in 74.4%, PPP in 13%, and both in 12.6%. PAE was associated with significantly lower mortality at 3 hours (0.5% vs. 27.9%) and 6 hours than PPP, though PPP patients were significantly sicker (ISS 41 vs. 34, lowest SBP 62 vs. 74 mmHg).[15]
  • Limitation. AE does not address venous or osseous bleeding — hence the need for combined approaches in the most severe cases.

Principle 8 — Combined PPP + AE: the hybrid approach​

For the most severely injured patients, a combined sequential approach is increasingly advocated:[13][14][9]

  1. PPP + external fixation performed first (addresses venous / osseous bleeding, buys time).
  2. Transfer to angiography suite for AE (addresses arterial bleeding).
  3. Return to OR for pack removal and definitive fixation.

Hundersmarck et al. (18-year experience) found that 79% of primary PPP patients underwent adjunct AE, performed bilaterally in 77% and nonselectively with gelfoam in 72%. Exsanguination-related deaths occurred in 11% of PPP patients, with no exsanguination deaths in the primary AE group.[13]

The meta-analysis by McDonogh et al. found no significant mortality difference between PPP and AE in dual-arm studies, but noted that 27% of PPP patients required subsequent AE to achieve hemorrhage control — reinforcing the complementary nature of these interventions.[14]

Principle 9 — Internal iliac artery ligation (IIAL)​

Bilateral internal iliac artery ligation is a surgical alternative when angioembolization is unavailable or has failed:[16][17][18][19]

  • Mechanism. Ligation of the anterior division reduces pelvic arterial perfusion pressure by ~50%, converting arterial flow to a low-pressure system that promotes clot formation.
  • Technique. The classical approach requires extensive retroperitoneal dissection with circumferential vessel isolation. Sanders et al. described a simplified contemporary technique using vascular clips applied after limited dissection parallel to the vessel, avoiding circumferential isolation and reducing risk of iliac-vein injury.[17]
  • Combined with PPP. Choi et al. reported bilateral IIA ligation + PPP in 20 patients with severe hemodynamic instability (median SBP 68.5 mmHg, lactate 11.05 mmol/L). Anatomic hemostasis was achieved in 90% (18/20), with completion time ~65 minutes.[18]
  • Complications. Schellenberg et al. (77 patients, 13-year experience) found zero cases of gluteal necrosis, iatrogenic injury, or surgical site infection after temporary BIIAL — dispelling the longstanding concern about gluteal ischemia. Overall mortality was 70%, reflecting the extreme severity of selected patients.[19]
  • Limitations. ACOG / SMFM notes that hypogastric artery ligation may be ineffective due to collateral circulation and can be difficult and time-consuming.[20]

Part IV: Resuscitative endovascular balloon occlusion of the aorta (REBOA)​

Principle 10 — REBOA as a bridge to definitive hemorrhage control​

REBOA is a percutaneous transfemoral balloon technique that provides temporary aortic occlusion to control noncompressible hemorrhage below the diaphragm:[2][4][21]

Aortic zones for balloon placement:

  • Zone I (left subclavian to celiac trunk) — for infradiaphragmatic hemorrhage (abdominal, combined abdominal–pelvic). Provides afterload support and limits distal hemorrhage. Visceral ischemia limits occlusion to <30 minutes.[2]
  • Zone II (celiac trunk to lowest renal artery) — never occluded; carries risks of Zone I without benefits over Zone III.
  • Zone III (lowest renal artery to aortic bifurcation) — for isolated pelvic or junctional hemorrhage. Better tolerated than Zone I (no visceral ischemia).[2]

Critical principle: hemorrhage proximal to the balloon must be ruled out before inflation — occlusion distal to a vascular injury accelerates proximal blood loss and death. FAST, chest X-ray, and diagnostic peritoneal aspiration are used to exclude proximal sources.[2]

Evidence: Brenner et al. (90 patients) demonstrated that REBOA improved mean SBP from 68 to 131 mmHg (p<0.001).[21] However, the UK-REBOA randomized trial (stopped early) showed an 86.9% probability of increased 90-day mortality with REBOA vs. standard care, introducing significant uncertainty about routine use.[22] Current consensus restricts REBOA to experienced teams in mature trauma systems with immediate access to definitive hemorrhage control.[4]

Intermittent REBOA (iREBOA): partial or intermittent balloon inflation extends safe occlusion time by allowing some distal perfusion, reducing ischemia-reperfusion injury.[2][23]

Part V: Abdominal vascular damage control​

Principle 11 — Proximal aortic control: the first priority​

In exsanguinating abdominal hemorrhage, proximal vascular control must be obtained before any attempt at definitive repair:[24]

Supraceliac aortic clamping (fastest route):

  • Enter the lesser sac by dividing the gastrohepatic ligament.
  • Retract the stomach inferiorly and esophagus to the left.
  • Divide the diaphragmatic crura to expose the aorta at the hiatus.
  • Apply an aortic clamp directly — total infradiaphragmatic inflow control.
  • The emergency maneuver of choice when the source of hemorrhage is unknown or when the patient is in extremis.

Infrarenal aortic control:

  • Eviscerate the small bowel to the right.
  • Incise the retroperitoneum directly over the aorta at the ligament of Treitz.
  • The left renal vein is the critical landmark — it crosses anterior to the aorta and marks the suprarenal / infrarenal transition.
  • Clamp the aorta below the renal arteries for isolated infrarenal or iliac hemorrhage.

Principle 12 — Damage-control techniques for specific abdominal vessels​

VesselDamage-control techniqueDefinitive repairKey considerations
Abdominal aortaSupraceliac clamping → temporary shunt or rapid primary repairInterposition graft (Dacron / PTFE) or primary repairMortality 29–70%; endovascular repair increasingly used for blunt injuries
Infrarenal IVCDirect pressure → venorrhaphy or ligationPrimary lateral venorrhaphy preferredLigation tolerated infrarenally; DVT (OR 2.83), compartment syndrome (OR 5.23), PE (OR 3.63)
Suprarenal IVCHepatic vascular isolation (Pringle + infrarenal IVC clamp) → repairPrimary repair; ligation 66% mortalityMost lethal IVC segment; endovascular balloon occlusion emerging
Retrohepatic IVCAtriocaval shunt or total hepatic vascular exclusionDirect repair under isolationHistorically >80% mortality; consider liver packing + damage control
Iliac arteriesTemporary intravascular shunt → delayed repairInterposition graft or primary repairShunts maintain distal perfusion; ligation risks limb ischemia
Iliac veinsLigation or lateral venorrhaphyRepair preferred (ligation OR 2.2 for mortality)Repair preferred when feasible; ligation acceptable in extremis
SMA / celiacTemporary shunt (SMA); ligation (celiac tolerated)Interposition graft or primary repairSMA ligation = bowel infarction; celiac ligation usually tolerated (collaterals)
Renal arteriesTemporary shunt or ligation (if contralateral kidney intact)Repair or nephrectomyWarm-ischemia time <60 min for salvage; nephrectomy is damage control
[3][24][25][27][28][29][30][33]

Principle 13 — Temporary intravascular shunts (TIVS)​

TIVS are a cornerstone of vascular damage control, providing immediate restoration of perfusion while deferring definitive repair:[3][34][32][35]

  • Indications. Damage control in physiologically deranged patients (63.4%); staged repair for combined orthopedic-vascular injuries (36.1%).[32]
  • Technique. The injured vessel is debrided to healthy intima. A commercially available shunt (Argyle, Pruitt–Inahara) or improvised conduit (chest tube, feeding tube) is inserted into both ends of the transected vessel and secured with silk ties or vessel loops. Blood flow is restored immediately.
  • Dwell time. <24–72 hours typical; longer durations reported without thrombosis in select cases.[32]
  • Thrombosis rate. 5–6%.[32]
  • Limb salvage. 96.3% in the largest civilian multicenter series (213 injuries).[32]
  • Key finding. Propensity-matched analysis demonstrated that unshunted patients had a 3.6-fold greater likelihood of amputation than shunted patients (OR 3.6, 95% CI 1.2–11.1).[35]
  • Commercial vs. improvised. Noncommercial shunts (chest tube / feeding tube) did not increase thrombosis but were an independent risk factor for subsequent graft failure — commercial shunts are preferred when available.[32]
  • Anticoagulation. Sparsely reported and inconsistently applied; no consensus exists on systemic heparinization during shunting.[34]

Principle 14 — Vessel ligation: when speed trumps perfusion​

Ligation is the fastest hemorrhage-control technique and is appropriate when repair is not feasible or the patient cannot tolerate additional operative time:[3][26]

Vessels that tolerate ligation:

  • Infrarenal IVC — tolerated with acceptable morbidity, though associated with higher rates of DVT, PE, and compartment syndrome vs. repair.[27][28]
  • Internal iliac arteries (bilateral) — tolerated due to extensive pelvic collateral circulation; zero gluteal necrosis in large series.[19]
  • Celiac trunk — usually tolerated due to collateral flow from SMA via pancreaticoduodenal arcades.
  • One renal artery (if contralateral kidney intact) — nephrectomy is the damage-control equivalent.
  • External iliac vein — tolerated with leg elevation and compression; DVT risk elevated.

Vessels that should NOT be ligated:

  • SMA — ligation causes bowel infarction; temporary shunt mandatory if repair is not immediately possible.
  • Common / external iliac arteries — ligation causes limb-threatening ischemia; shunt required.
  • Suprarenal IVC — ligation associated with 66% mortality and renal failure.[30]
  • Portal vein — ligation carries ~50% mortality; repair or shunt preferred.

Principle 15 — IVC injury: repair vs. ligation​

IVC injuries occur in 0.5–5% of penetrating abdominal trauma and carry 42% overall mortality:[29][27][30][28]

  • The PROOVIT registry (140 patients, 19 institutions) found 70% underwent repair and 30% ligation. Suprarenal injuries had 66% mortality vs. 33% for infrarenal.[30]
  • Matsumoto et al. (NTDB, 1,316 patients) found that after propensity matching, mortality was similar between ligation and repair (41.3% vs. 39.0%), but ligation was associated with significantly higher complications: compartment syndrome (OR 5.23), DVT (OR 2.83), PE (OR 3.63).[27]
  • Meta-analysis by Byerly et al. (855 patients) found ligation associated with higher mortality (OR 3.12, p<0.001).[28]
  • Emerging technique. Endovascular balloon occlusion of the IVC provides temporary inflow control without extensive dissection — Howell et al. reported 80% survival in 5 patients with penetrating IVC injuries managed with this hybrid approach.[31]

Clinical decision: repair is preferred when feasible; ligation is reserved for damage control in patients in extremis, particularly for infrarenal injuries where it is better tolerated.[29][27][28]

Part VI: Pelvic hemorrhage in obstetric and gynecologic contexts​

Principle 16 — Abdomino-pelvic packing in OB / GYN​

DCS principles, originally developed for trauma, are increasingly applied to obstetric and gynecologic emergencies:[7][20]

  • Postpartum hemorrhage. When uterine atony is refractory to uterotonics, B-Lynch suture, and uterine-artery ligation, abdomino-pelvic packing achieves hemostasis in 75–90% of cases with significantly lower mortality than in trauma surgery.[7]
  • Placenta accreta spectrum. The ACOG / SMFM consensus recommends pelvic packing as a damage-control option for uncontrolled hemorrhage, with packs left in for 24 hours (open abdomen, ventilatory support) to allow optimization of clotting.[20]
  • Gynecologic oncology. Pelvic packing is applicable during debulking, exenteration, lymphadenectomy, and for presacral bleeding during sacrocolpopexy.[7]
  • Adjuncts. Early tranexamic acid, topical hemostatic agents (oxidized cellulose, fibrin sealants), and multidisciplinary coordination have transformed packing from a last-resort maneuver into an integrated component of staged hemorrhage control.[7]

Principle 17 — Stepwise escalation for obstetric pelvic hemorrhage​

The ACOG Practice Bulletin outlines a stepwise approach:[5][20]

  1. Identify and repair lacerations — cervical, vaginal, perineal.
  2. Uterine compression sutures (B-Lynch) and uterotonics.
  3. Uterine artery ligation (O'Leary sutures).
  4. Internal iliac (hypogastric) artery ligation — decreases pelvic perfusion pressure; efficacy limited by collateral circulation.[20][17]
  5. Interventional radiology — uterine-artery embolization — especially useful when no single surgical bleeding source is identified.[20]
  6. Pelvic packing — for diffuse coagulopathic bleeding unresponsive to above.
  7. Aortic compression or clamping — reserved for experienced surgical consultants or heroic measures.[20]

Part VII: Combat and austere-environment considerations​

Principle 18 — Damage control in resource-limited settings​

The experience from the war in Ukraine (Sobko et al., 1,407 patients with combat abdominal trauma) provides contemporary data on vascular damage control in austere environments:[26]

  • Retroperitoneal vascular injuries comprised 4.6% of combat abdominal trauma, with IVC (33.9%) and iliac vessels (50.3%) most commonly affected.
  • Ligation was the primary hemostatic method; vessel repair was performed in 58.5% of cases.
  • REBOA and abdominal aortic junctional tourniquet were used prehospitally to stabilize patients for evacuation.
  • Overall mortality was 50.8%, with hemorrhagic shock (classes III–IV) in 77%.
  • Blood lactate and Admission Trauma Score were the most valuable triage tools.

Summary — vascular damage control by region​

RegionPrimary hemorrhage sourceFirst-line damage controlSecond-lineKey metric
VaginaVenous (lacerations, hematomas)Tight vaginal packing ± hemostatic agentsSuture ligation; angioembolizationPacking is a bridge to definitive control
PerineumMixed arterial / venousDirect pressure; perineal packingVessel ligation; hematoma explorationOpen pelvic fracture + perineal wound: 30–50% mortality
Pelvis (fracture)Venous / osseous (80–90%)Pelvic binder → PPP + external fixationAngioembolization (arterial); IIALPPP hemostasis 73–87%; AE for arterial component
Pelvis (obstetric)Uterine / cervical arterial + venousUterotonics → compression sutures → UAEIIAL; pelvic packing; aortic clampingAPP hemostasis 75–90% in OB / GYN
Abdomen (aorta)ArterialSupraceliac clamping → TIVS or primary repairREBOA Zone I as bridgeMortality 29–70%
Abdomen (IVC)VenousDirect pressure → venorrhaphy or ligationEndovascular balloon occlusionRepair preferred; ligation for infrarenal in extremis
Abdomen (iliac)MixedTIVS (arterial); ligation or repair (venous)Definitive graft at re-lookIliac vein: repair preferred (ligation OR 2.2 for mortality)

Cross-references​

References​

1. Cirocchi R, Montedori A, Farinella E, et al. "Damage control surgery for abdominal trauma." Cochrane Database Syst Rev. 2013;(3):CD007438. doi:10.1002/14651858.CD007438.pub3

2. King DR. "Initial care of the severely injured patient." N Engl J Med. 2019;380(8):763–770. doi:10.1056/NEJMra1609326

3. Aucar JA, Hirshberg A. "Damage control for vascular injuries." Surg Clin North Am. 1997;77(4):853–862. doi:10.1016/s0039-6109(05)70589-2

4. Shaw J, Brenner M. "Resuscitative endovascular balloon occlusion of the aorta: what you need to know." J Trauma Acute Care Surg. 2025;98(6):831–839. doi:10.1097/TA.0000000000004534

5. Committee on Practice Bulletins-Obstetrics. "Practice Bulletin No. 183: postpartum hemorrhage." Obstet Gynecol. 2017;130(4):e168–e186. doi:10.1097/AOG.0000000000002351

6. Eleje GU, Eke AC, Igberase GO, Igwegbe AO, Eleje LI. "Palliative interventions for controlling vaginal bleeding in advanced cervical cancer." Cochrane Database Syst Rev. 2019;3:CD011000. doi:10.1002/14651858.CD011000.pub3

7. Kostov S, Kornovski Y, Yordanov A, et al. "Damage control surgery in obstetrics and gynecology: abdomino-pelvic packing in multimodal hemorrhage management." J Clin Med. 2025;14(20):7207. doi:10.3390/jcm14207207

8. Raniga SB, Mittal AK, Bernstein M, Skalski MR, Al-Hadidi AM. "Multidetector CT in vascular injuries resulting from pelvic fractures: a primer for diagnostic radiologists." Radiographics. 2019;39(7):2111–2129. doi:10.1148/rg.2019190062

9. 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

10. Anand T, El-Qawaqzeh K, Nelson A, et al. "Association between hemorrhage control interventions and mortality in US trauma patients with hemodynamically unstable pelvic fractures." JAMA Surg. 2023;158(1):63–71. doi:10.1001/jamasurg.2022.5772

11. Puchwein P, Hallmann B, Eibinger N. "Bleeding management in pelvic trauma: state of the art." Curr Opin Anaesthesiol. 2025;38(3):323–330. doi:10.1097/ACO.0000000000001478

12. Padia SA, Ingraham CR, Moriarty JM, et al. "Society of Interventional Radiology position statement on endovascular intervention for trauma." J Vasc Interv Radiol. 2020;31(3):363–369.e2. doi:10.1016/j.jvir.2019.11.012

13. Hundersmarck D, Hietbrink F, Leenen LPH, Heng M. "Pelvic packing and angio-embolization after blunt pelvic trauma: a retrospective 18-year analysis." Injury. 2021;52(4):946–955. doi:10.1016/j.injury.2020.11.039

14. McDonogh JM, Lewis DP, Tarrant SM, Balogh ZJ. "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

15. Harfouche MN, Sult L, Sciarretta JD, et al. "To pack or plug: American Association for the Surgery of Trauma multicenter evaluation of hemorrhage control interventions in pelvic fracture management." J Trauma Acute Care Surg. 2026. doi:10.1097/TA.0000000000004856

16. Jeong ST, Kim DW, Kang WS. "Bilateral internal iliac artery ligation in trauma patients with severe pelvic hemorrhage: a systematic review." PLoS One. 2025;20(2):e0303476. doi:10.1371/journal.pone.0303476

17. Sanders AP, Hobson SR, Kobylianskii A, et al. "Internal iliac artery ligation — a contemporary simplified approach." Am J Obstet Gynecol. 2021;225(3):339–340. doi:10.1016/j.ajog.2021.05.003

18. Choi K, Keum MA, Choi B, et al. "Effectiveness and safety of bilateral internal iliac artery ligation with pre-peritoneal pelvic packing for life-threatening pelvic trauma." Injury. 2023;54(2):598–603. doi:10.1016/j.injury.2022.11.003

19. 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

20. "Obstetric Care Consensus No. 7: placenta accreta spectrum." Obstet Gynecol. 2018;132(6):e259–e275. doi:10.1097/AOG.0000000000002983

21. Brenner M, Teeter W, Hoehn M, et al. "Use of resuscitative endovascular balloon occlusion of the aorta for proximal aortic control in patients with severe hemorrhage and arrest." JAMA Surg. 2018;153(2):130–135. doi:10.1001/jamasurg.2017.3549

22. 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(19):1862–1871. doi:10.1001/jama.2023.20850

23. Webster LA, Little O, Villalobos A, et al. "REBOA: expanding applications from traumatic hemorrhage to obstetrics and cardiopulmonary resuscitation — from the AJR Special Series on Emergency Radiology." AJR Am J Roentgenol. 2023;220(1):16–22. doi:10.2214/AJR.22.27932

24. Warriner Z, Benjamin E, Minneti M, Demetriades D. "Exposure of the abdominal aorta and visceral branches for hemorrhage control: a 2020 EAST Master Class video presentation." J Trauma Acute Care Surg. 2020;89(3):e84–e88. doi:10.1097/TA.0000000000002803

25. Perkins L, Kobayashi L, Coimbra R. "Modern management of abdominal aortic injuries: what you need to know." J Trauma Acute Care Surg. 2026. doi:10.1097/TA.0000000000004984

26. Sobko I, Sivash I, Rogovskyi V, Koval B, Slobodianiuk A. "Surgical management of retroperitoneal vascular injuries in combat abdominal trauma: experience at Role 2 facilities during the war in Ukraine." J Trauma Acute Care Surg. 2025. doi:10.1097/TA.0000000000004716

27. Matsumoto S, Jung K, Smith A, Coimbra R. "Management of IVC injury: repair or ligation? A propensity score matching analysis using the National Trauma Data Bank." J Am Coll Surg. 2018;226(5):752–759.e2. doi:10.1016/j.jamcollsurg.2018.01.043

28. Byerly S, Tamariz L, Lee EE, et al. "A systematic review and meta-analysis of ligation versus repair of inferior vena cava injuries." Ann Vasc Surg. 2021;75:489–496. doi:10.1016/j.avsg.2021.02.032

29. Balachandran G, Bharathy KGS, Sikora SS. "Penetrating injuries of the inferior vena cava." Injury. 2020;51(11):2379–2389. doi:10.1016/j.injury.2020.08.022

30. Stonko DP, Azar FK, Betzold RD, et al. "Contemporary management and outcomes of injuries to the inferior vena cava: a prospective multicenter trial from PROspective Observational Vascular Injury Treatment." Am Surg. 2023;89(4):714–719. doi:10.1177/00031348211038556

31. Howell EC, Kulkarni SS, Walker PF, et al. "Endovascular balloon occlusion of the inferior vena cava in trauma: a single-center case series." J Am Coll Surg. 2023;236(2):e1–e7. doi:10.1097/XCS.0000000000000436

32. Inaba K, Aksoy H, Seamon MJ, et al. "Multicenter evaluation of temporary intravascular shunt use in vascular trauma." J Trauma Acute Care Surg. 2016;80(3):359–364. doi:10.1097/TA.0000000000000949

33. Magee GA, Cho J, Matsushima K, et al. "Isolated iliac vascular injuries and outcome of repair versus ligation of isolated iliac vein injury." J Vasc Surg. 2018;67(1):254–261. doi:10.1016/j.jvs.2017.07.107

34. Laverty RB, Treffalls RN, Kauvar DS. "Systematic review of temporary intravascular shunt use in military and civilian extremity trauma." J Trauma Acute Care Surg. 2022;92(1):232–238. doi:10.1097/TA.0000000000003399

35. 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