Endovascular Suites and the Emergency Vascular Service

Introduction

Hemorrhage control is a critical component of any facility that manages trauma patients. This core capability exists in many forms, from mechanical devices, such as tourniquets for extremity hemorrhage to invasive surgical procedures. Within the domain of hospital care, operative exploration is the gold standard for hemodynamically unstable patients, whereas catheter-based endovascular techniques are reserved for stable patients who can tolerate transfer to a remote interventional radiology (IR) suite.

This paradigm has largely been a product of geography and specialty boundaries. IR suites tend to be remote to resuscitation personnel and equipment, such as anesthesiology support and blood banking. The option of converting from an endovascular to an open surgical approach is often limited by the logistical difficulty of transferring patients back and forth to the operating room (OR) from the IR suite.

Furthermore, in a conventional model of separated IR and OR suites, there is often little cross-discipline appreciation of the burden of disease. The personnel performing the endovascular procedure may not promptly discern the physiology of a declining trauma patient and recognize when a truncated procedure or conversion to an open approach is desirable. Equally, the requestors of the endovascular approach may not appreciate the limitations of endovascular technology and interventions.

To address this gap, a new concept is starting to emerge, where operative hemorrhage control can be augmented with endovascular adjuncts by a single, multidisciplinary team in one location. This is especially useful in certain anatomically challenging locations, such as noncompressible torso hemorrhage, or to preserve tissue plains to prevent cross contamination between fields, such as protecting retroperitoneal vascular structures from an intraperitoneal hollow viscous injury. Similarly, some injuries may be optimally managed by endovascular means with an operative approach held in reserve, such as blunt thoracic aorta injuries (BTAI).

The limitations of a conventional model of nonintegrated IR and OR management can be addressed by a combination of technological and system solutions. The issue of geography can be addressed by the development of a hybrid trauma operating room (HTOR) which colocates operative and endovascular capability. Although a specialist room such as an HTOR is necessary for integrated care, it is not sufficient to provide said care without the addition of a seamlessly integrated service. Personnel who are trained in both disciplines and the physical workings of the rooms are required to make the integrated concept work.

This chapter aims to discuss all of these issues and the evidence surrounding HTOR and the clinical teams required to deliver an integrated trauma vascular service. Much of this data is borne out of the experience of establishing such a service at the R Adams Cowley Shock Trauma Center at the University of Maryland, Baltimore.

Endovascular Suites