Indian Journal of Vascular and Endovascular Surgery

: 2015  |  Volume : 2  |  Issue : 2  |  Page : 75--79

Hybrid Operating Theater Could Increase Role of Endovascular Adjuncts in Peripheral and Thoracic Outlet Vascular Trauma

Shubhabrata Banerjee, Hiten M Patel, Himanshu Verma, VK Sheorain, Tarun Grover, Rajiv Parakh 
 Department of Peripheral Vascular and Endovascular Sciences, Medanta, The Medicity, Gurgaon, Haryana, India

Correspondence Address:
Dr. Shubhabrata Banerjee
Department of Peripheral Vascular and Endovascular Sciences, Medanta, The Medicity, Gurgaon, Haryana


Trauma is one of the leading causes of mortality and morbidity especially in the young or middle age group. The lethal triad of trauma (hypothermia, coagulopathy, and acidosis) is almost always triggered by initial uncontrolled or concealed hemorrhage. Time is of utmost importance in terminating the vicious cycle. Endovascular interventions along with open surgical management in a hybrid suite not only decrease surgical time, avoid exposure to anesthesia, hasten recovery, but most importantly breakdown the catastrophic sequelae of ongoing bleed by rapid hemorrhage control. They allow vascular control at difficult surgical terrains such as subclavian or iliac vessels with much compared ease and rapidity. We present four interesting cases of peripheral and thoracic outlet vascular trauma and its sequelae managed with endovascular adjuncts at different points in the resuscitative and rehabilitation stations. In our first case of a stab injury over the right femoral artery with acute hemorrhage, a covered stent across the transected artery was curative as well as hastened recovery. In the second case in the hybrid suite, a long segment of balloon occlusion of the iliac artery allowed rapid physiology control and easier surgical repair of the transected common femoral vessels. The third case required a covered stent across the leak from a previously repaired subclavian vessel to prevent life-threatening hemothorax. In another interesting case of a badly mutilated posttraumatic shoulder with an axillary pseudo-aneurysm, a covered stent across the axillary vessel facilitated further reconstructive shoulder surgery.

How to cite this article:
Banerjee S, Patel HM, Verma H, Sheorain V K, Grover T, Parakh R. Hybrid Operating Theater Could Increase Role of Endovascular Adjuncts in Peripheral and Thoracic Outlet Vascular Trauma.Indian J Vasc Endovasc Surg 2015;2:75-79

How to cite this URL:
Banerjee S, Patel HM, Verma H, Sheorain V K, Grover T, Parakh R. Hybrid Operating Theater Could Increase Role of Endovascular Adjuncts in Peripheral and Thoracic Outlet Vascular Trauma. Indian J Vasc Endovasc Surg [serial online] 2015 [cited 2022 Sep 28 ];2:75-79
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Full Text


Trauma is one of the leading causes of mortality and morbidity especially in the young or middle age group. The lethal triad of trauma (hypothermia, coagulopathy, and acidosis) is almost always triggered by initial uncontrolled or concealed hemorrhage. Time is of utmost importance in terminating the vicious cycle.

Endovascular interventions (EVIs) are an important and evolving adjunct to open surgical management of peripheral vascular injuries. Used judiciously by trained personnel, they not only decrease surgical time, avoid exposure to anesthesia, hasten recovery but most importantly breakdown the catastrophic sequelae of ongoing bleed by rapid hemorrhage control. Role of EVIs in aortic trauma has been well-established. In aortic trauma, endovascular approach provides rapid hemostasis, whereas open surgery is very morbid and patient could have substantial blood loss before bleeding is controlled. However, in peripheral trauma results of open as well as EVIs are equivocal. One of the major limitations of EVIs in extremity trauma is hemodynamic instability. Traditionally, EVIs is performed in cath labs and open surgery in different operation theaters. Apart from being located in different locations in the hospital, separately trained staff for each modality is also required. In case of failed endovascular approach, shifting of patient to open surgery theaters could be time-consuming. However, with more and more increasing numbers of hybrid operation theaters, role of endovascular adjuvants in the management of peripheral trauma could be increased as well. Being in hybrid theater, the interventionist has advantage of attempting endovascular control of bleeding by different techniques, that is, proximal balloon occlusion, covered stent graft, etc. After bleeding is controlled, either definitive endovascular or open surgery could be performed the same time. Furthermore, in case failure of endovascular approach, open conversion could be done the same time without delay. We present four interesting cases of traumatic vascular injury which were managed in hybrid Artis Zeego™ (SIEMENS).

 Case Reports

Case 1

A 22-year-old boy with a history of road traffic accident presented in the emergency with an isolated right upper thigh stab injury, 5 h back. On primary survey, he was a transient responder with expanding hematoma of right thigh upto groin crease, with impalpable distal pulses [Figure 1]a. After initial rapid fluid resuscitation, patient was rushed to the hybrid operation suite, where under local anesthesia peripheral angiogram from a contralateral common femoral artery (CFA) puncture showed active contrast extravasation from proximal right superficial femoral artery (SFA) [Figure 1]b. Under roadmap tool, transaction site was crossed with 0.035 hydrophilic Terumo™ wire and a covered self-expandable stent (Fluency™ BARD) was deployed across extravasation site. Completion angiography showed no active bleed. Patient was discharged in 48 h with distal pulses palpable and ankle-brachial index of 1.03. He was kept on deep vein thrombosis prophylaxis by compression stockings. Limb swelling gradually subsided over 6 months.{Figure 1}

Case 2

A 35-year business man with an alleged history of a close range firearm injury over the right thigh 3 h before presented in the emergency in shock with an expanding hematoma right thigh up to groin crease. An immediate hybrid approach was considered. Under local anesthesia, angiogram was performed from left CFA approach. It showed active contrast extravasation from a right distal external iliac artery (EIA) and CFA. After passing 0.035 hydrophilic Terumo™ into wire into right CFA, a 7 mm × 100 mm long percutaneous transluminal angioplasty balloon was inflated in a common iliac artery (CIA) and EIA [Figure 2]a. General anesthesia was induced and simultaneous exploration of the groin was done. Complete laceration of the CFA was repaired with interposition venous graft [Figure 2]b. Palpable balloon and glide wire in proximally controlled artery facilitated repair of the vessel. After proximal control of proximal EIA, balloon was deflated and removed.{Figure 2}

The rapid control of hemodynamic status prevented the lethal triad of hypercoagulability, acidosis and bleeding to initiate and thus paved the way to rapid recovery and lesser postoperative morbidity. Patient was discharged on day 6 after groin drain removal.

Case 3

A 31-year shopkeeper with an alleged history of road traffic accident presented in a community hospital with a penetrating wound over the right infraclavicular region which was attempted for vascular repaired but was packed and rushed for further care. On presentation, patient was having severe shortness of breath and heaviness of chest since. He was tachycardic, pale, and tachypneic in the emergency with diminished air entry of the injured site which prompted an emergency chest drain which let out 500 ml of fresh blood immediately. Contrast computerized tomography (CT) scan of the chest revealed gross hemothorax of the right side with collapsed lungs and partial disruption of the subclavian artery and active contrast extravascation. Since there was partial disruption, endovascular first approach was planned and under local anesthesia in hybrid suite right groin and right brachial access taken. Angiogram showed partial filling defect in second part of the subclavian artery with slow extravasation of contrast [Figure 3]a. Antegrade wire could not be passed from subclavian artery into brachial artery and kept on going into extravascular space. Retrograde attempt of passing wire from brachial end into subclavian artery was successful and wire was snared in abdominal aorta to femoral end [Figure 3]b. Covered stent Fluency™ (BARD) was placed across the lesion. Completion run showed no breach in continuity [Figure 3]c. Entire operating time was 45 min under local anesthesia. The patient was discharged on day 3 with a postoperative video-assisted thoracic surgery for residual thoracic collection.{Figure 3}

Case 4

A 22-year male was evaluated in the OPD with a huge posttraumatic pseudo-aneurysm from right axillary artery around the right shoulder [Figure 4]a and b. The badly mutilated shoulder was a difficult surgical terrain and no orthopedic reconstructive surgical procedure could be undertaken without excluding the pseudo-aneurysm. A covered stent graft via a groin access successfully excluded the pseudo-aneurysm and later hematoma evacuation and the shoulder reconstruction was done by the orthopedics team under same anesthesia [Figure 4]c and d.{Figure 4}


Peripheral vascular injuries

Arterial vascular injuries could be classified as central which includes injury to aorta and its first level branches (subclavian, carotid, coeliac, superior mesenteric artery, renal, and CIAs). Endovascular treatment of aortic injuries has been well-described with excellent outcomes, and should be done whenever feasible. Peripheral vascular injuries, defined as injuries of, or distal to, the axillo-brachial and femoro-popliteal vessels, while uncommon overall, account for the majority of civilian vascular trauma. [1] Lower extremity injuries are more common than upper, and the majority of injuries are due to penetrating trauma, which accounts for 75-80% of cases. [2] In United States between 1997 and 2003, 7286 patients underwent open repair of their arterial injury, and 281 endovascular procedures (3.7%) were performed. Between 2000 and 2003, the proportion of EVIs versus open for arterial trauma increased from 2.4% to 8.1%. Stent use substantially increased from 12 in 2000 to 30 in 2003; endograft use increased from one in 2000 to 37 in 200. [3] Slightly more patients undergoing an endovascular procedure survived to hospital discharge (89.7%) compared with patients undergoing an open procedure (87.3%), although this difference including mortality was not statistically significant. Iliac artery injury has a reported 40% mortality. Penetrating and blunt injuries to the popliteal artery have mortalities of 10.5 and 27.5%, respectively, and injuries to the tibial arteries have an amputation rate of 38%. [4],[5]

The popliteal and iliac arteries are most suitable for EVI based on their challenging surgical accessibility.

The most commonly injured peripheral artery, the SFA, is easily accessible via surgical exposure, which negates the major benefits of EVIs outlined above. Exceptions to open surgical management occur in situations with concomitant orthopedic injuries where orthopedics hardware compromises surgical exposure or when an angiogram reveals a lesion that can be treated easily with quicker endovascular techniques and facilitate an efficient transition to orthopedic fixation. [6]

Therefore in peripheral arterial injuries, though surgical repair is the gold standard, endovascular approach gives advantage of lesser time, and decreases or obviates trauma of surgical dissection. Hemodynamically unstable patient and a "no" zones for endovascular stents, e.g., CFA, popliteal arteries are main limitations of applicability of endovascular in peripheral trauma. Operating such cases in the hybrid lab allows possible EVIs-either therapeutic (e.g., covered stents) of adjuvant (e.g., balloon occlusion for proximal control) to be done more often. In case of failure of endovascular approach, shifting time between angiography suite and operation room is avoided. Injuries to blood vessels in the thoracic outlet account for 5-10% of civilian and military vascular injuries. Morbidity is significant with a brachial plexus injury rate of 20-43%. Sixteen mortality of arterial and venous injuries is estimated to be 40% and 50%, respectively. [7],[8] Forty to 50% of penetrating axillo-subclavian trauma is amenable to endovascular management. [7]

Emergent surgical exposure of axillo-subclavian injuries is challenging and fraught with potential iatrogenic injury to neurovascular structures, blood loss, and prolonged operative times. Paraclavicular vascular exposures, including clavicle resection, imperil the vagus, phrenic, and recurrent laryngeal nerves; the brachial plexus; the thoracic duct and the underlying pleura, especially in the presence of a large hematoma or hemorrhage. Proximal surgical control may also necessitate a median sternotomy. Remote access to these injuries with endovascular techniques may decrease morbidity associated with surgical exposure. In addition to femoral access, axillo-subclavian injuries are accessible through retrograde brachial access, which allows for a direct approach to the injury while other injuries are being treated by the trauma team. Endovascular management, where feasible, has shown a significant reduction in operating room time and estimated blood loss when compare with similar surgical cohorts. [9]

Xenos et al. identified 27 such injuries between 1996 and 2002, of which 12 (42%) were deemed suitable for endovascular treatment. Seven injuries were managed with a variety of endovascular techniques, and these cases showed a significant reduction in odds ratio (OR) time (13,215 min vs. 19,315 min, P value 0.04) and estimated blood loss (7012.2 ml vs. 22,056.1 ml, P < 0.01) when compared with patients who underwent surgical repair. One-year patency rates were similar: 5 of 5 (100%) open repairs remained patent, 1 of 7 (14.3%) of the covered stents occluded with resultant arm claudication, and 2 of 7 (28.6%) (iatrogenic injuries) died secondary to complications of primary disease within 8 months. [9] In a retrospective examination of axillo-subclavian injuries, Danetz et al. found that a similar proportion of injuries are appropriate for endovascular techniques. Excluding emergency room deaths, 17 of 40 (43%) penetrating injuries were potentially treatable. Approximately, one-third of remaining injuries were deemed unsuitable for endovascular management due to hemodynamic instability because EVIs were performed in interventional suites remote from the OR. [7]

Carrick et al. identified 15 patients with penetrating subclavian artery injuries between 2004 and 2005, of which 4 of 10 (40%) survivors were managed successfully with endovascular techniques (covered stents) in an interventional suite separate from the OR. Eight of 10 (80%) patients underwent angiography, and 2 of 10 (20%) patients were taken directly to the OR secondary to hemodynamic instability. One failed endovascular attempt occurred during treatment of a pseudo-aneurysm near the origin of the dominant vertebral artery (VA) where stent-graft fixation was compromised to preserve VA flow. [10]

The RAPTOR: "Resuscitation with angiography, percutaneous techniques and operative repair" - suite is hybrid unit designed for both interventional radiology and operative interventions-overcomes the drawbacks of many traditional angio suites that are not designed for anesthesia or interventions in unstable patients. Percutaneous trauma procedures are aimed at arresting hemorrhage (e.g., intravascular balloon dilation/occlusion with or without arterial embolization), and to repair damaged vessels (e.g., stent grafting). It is instrumental in expedient hemorrhage control by providing integrated operating, CT and angiographic facilities in a single location and reduces decision-making time with no destination choices to make and there is no time lost in transit between two venues should one technique fail. Most importantly it has the capacity to provide ongoing resuscitation while obtaining imaging. [11],[12]

However, there are several limitations of the hybrid approach. First and foremost is round the clock availability hybrid suite with trained nurse and technician staff as well as a good stock of endovascular devices. High running cost and availability of multi-disciplinary input to ensure appropriate resource use and interventions are other major limitations. However, understanding and addition of hybrid suites in dedicated trauma centers can set up a better role model and could be followed by others.


Though limited by logistics and dearth of trained personnel in trauma centers across the country, it happens to be the most promising and effective adjunct to surgery in rapid recovery of patients with peripheral vascular injury and with strong potential toward saving limbs as well as life in trauma setting. It facilitates surgical exposure in difficult surgical terrains such as the iliac vessels and subclavian vessels. It also stabilizes the physiology and prevents trauma complications and hastens recovery and decreases hospital stay and prevents morbidity and loss of work days-of immense importance considering trauma as the so called disease of the youth.

However long-term patency, surveillance protocol and anti-platelet and anticoagulation protocol postprosthetic stents in a trauma setting remains to be studied.


1Holcomb JB, Fox EE, Scalea TM, Napolitano LM, Albarado R, Gill B, et al. Current opinion on catheter-based hemorrhage control in trauma patients. J Trauma Acute Care Surg 2014;76:888-93.
2du Toit DF, Coolen D, Lambrechts A, de V Odendaal J, Warren BL. The endovascular management of penetrating carotid artery injuries: Long-term follow-up. Eur J Vasc Endovasc Surg 2009;38:267-72.
3Reuben BC, Whitten MG, Sarfati M, Kraiss LW. Increasing use of endovascular therapy in acute arterial injuries: Analysis of the National Trauma Data Bank. J Vasc Surg 2007;46:1222-6.
4Alvarez-Tostado J, Tulsyan N, Butler B, Rizzo A. Endovascular management of acute critical ischemia secondary to blunt tibial artery injury. J Vasc Surg 2006;44:1101-3.
5Hutto JD, Reed AB. Endovascular repair of an acute blunt popliteal artery injury. J Vasc Surg 2007;45:188-90.
6Johnson CA. Endovascular management of peripheral vascular trauma. Semin Intervent Radiol 2010;27:38-43.
7Danetz JS, Cassano AD, Stoner MC, Ivatury RR, Levy MM. Feasibility of endovascular repair in penetrating axillosubclavian injuries: A retrospective review. J Vasc Surg 2005;41:246-54.
8Tillman BW, Vaccaro PS, Starr JE, Das BM. Use of an endovascular occlusion balloon for control of unremitting venous hemorrhage. J Vasc Surg 2006;43:399-400.
9Xenos ES, Freeman M, Stevens S, Cassada D, Pacanowski J, Goldman M. Covered stents for injuries of subclavian and axillary arteries. J Vasc Surg 2003;38:451-4.
10Carrick MM, Morrison CA, Pham HQ, Norman MA, Marvin B, Lee J, et al. Modern management of traumatic subclavian artery injuries: A single institution's experience in the evolution of endovascular repair. Am J Surg 2010;199:28-34.
11Ball CG, Kirkpatrick AW, D'Amours SK. The RAPTOR: Resuscitation with angiography, percutaneous techniques and operative repair. Transforming the discipline of trauma surgery. Can J Surg 2011;54:E3-4.
12Kirkpatrick AW, Vis C, Dubé M, Biesbroek S, Ball CG, Laberge J, et al. The evolution of a purpose designed hybrid trauma operating room from the trauma service perspective: The RAPTOR (Resuscitation with Angiography Percutaneous Treatments and Operative Resuscitations). Injury 2014;45:1413-21.