DAMAGE CONTROL FOR VASCULAR INJURIES

Vascular trauma is often part of the injury complex in patients with exsanguinating hemorrhage who undergo damage control surgery. Vascular injuries in these patients may be either truncal or peripheral. The former usually present an immediate threat to the patient's life, whereas the latter may present either as severe external bleeding or as a threat to limb viability. The central issues in the operative management of vascular trauma are the maintenance of correct priorities and the need for rapid and effective operative maneuvers to prevent exsanguination and maintain perfusion to distal organs. Vascular trauma is especially challenging in the context of damage control because an inherent conflict exists between the need for an elaborate and time-consuming reconstruction and the urgent need to abbreviate the procedure before the patient sustains an irreversible physiologic insult. The coagulopathy and unmanageable bleeding that set in once the patient's physiologic envelope is breached 10 frustrate even the most heroic and technically perfect vascular reconstruction. The aim of this article is to discuss the management of major vascular injuries as an integral component of the damage control strategy. 5,20 The emphasis is on vascular bail-out techniques and the operative strategies designed to maximize the patient's chance for surviving complex multiple injuries. These considerations represent a marked deviation from conventional principles and methods used in the management of vascular injuries in stable patients.