Patients with severe high-energy and complex pelvic trauma, haemodynamic instability and massive blood loss belong to the most severe and highly lethal group of trauma patients, and their management is time-sensitive and challenging . Global mortality in polytraumatised patients presenting with pelvic ring fractures remains high (33%) despite improvements in management and treatment algorithms . The pelvis can create a multifocal haemorrhage, including significant retroperitoneal haematoma, which may not be easily compressible or possible to manage using traditional surgical methods . Treatment of pelvic ring fractures requires re-approximation of bony structures to address mechanical instability, damage-control resuscitation (DCR) to restore haemostasis, assessment for associated injuries and triage of investigations. In addition, multimodal haemorrhage control [external fixation and compression (damage-control orthopaedics), retroperitoneal packing (damage-control surgery), urgent radiologic angioembolisation or resuscitative endovascular balloon occlusion of the aorta (REBOA)] by multidisciplinary trauma specialists (general surgeons, orthopaedic surgeons, endovascular surgeons/interventional radiologists) is required [69, 72,73,74,75].
Follow-up sonography as part of secondary or tertiary surveys in patients without abdominal parenchymal organ lesions or free intra-abdominal fluid on initial WBCT is not routinely required, but should be performed if indicated on a clinical or laboratory basis due to its rapid and non-invasive character . New ultrasound techniques using second-generation contrast agents [contrast-enhanced ultrasound (CEUS)] have been developed, allowing all of the vascular phase to be performed in real time, increasing ultrasound capability to detect parenchymal injuries, enhancing some qualitative findings, such as lesion extension, margins and its relationship with capsule and vessels . These techniques are currently under investigation.
Fibrin and synthetic glues or adhesives have both haemostatic and sealant properties, and their significant effect on haemostasis has been shown in several randomised controlled human studies involving vascular, bone, skin and visceral surgery [472, 474, 478].
Traditionally, AMI has been treated with open surgery. Over the past two decades, the rapid development of endovascular techniques has made this approach an important alternative for patients with occlusion of the superior mesenteric artery (SMA). Some studies have shown that endovascular therapy is associated with lower rates of mortality and bowel resection than the traditional, open approach [11,12,13].
A careful medical history is important because distinct clinical scenarios are associated with the pathophysiological form of AMI . Patients with mesenteric arterial thrombosis often have a history of chronic postprandial abdominal pain, progressive weight loss, and previous revascularization procedures for mesenteric arterial occlusion. Patients with NOMI have pain that is generally more diffuse and episodic associated with poor cardiac performance. These patients are more likely to have suffered from cardiac failure, and recent surgery. Several other smaller cohorts also reported hemodialysis as a risk factor of NOMI [44, 45]. Furthermore, NOMI represents a cause of secondary worsening in septic shock, particularly in septic patients treated with high-dose vasoactive drugs.
Endovascular techniques have become popular in revascularization of the SMA. No randomized control trial has been performed to assess and compare open surgery to an endovascular approach, as patients with AMI are very heterogenic and physiologically different . Much controversy surrounds the use of endovascular techniques as primary management of AMI . Some studies report lesser need for laparotomy, less bowel resection, and significantly lower mortality rate with endovascular techniques compared to surgery .
Publications related to endovascular treatment of AMI have been evolving since 2010 [11, 12]. Several observational studies and meta-analyses comparing the outcomes of endovascular interventions and surgery have been published [13, 107,108,109,110].
The Guidelines of the European Society of Vascular Surgery showed a pooled overall 30-day mortality rate after endovascular therapy of 17.2% (367/2131), compared to 38.5% after open surgery (1582/4111) .
It is important to note that all studies that were focused on endovascular revascularization have high levels of heterogeneity. It is possible that patients undergoing open repair have more advanced disease resulting in long-segment bowel resection rates and poorer outcome. The 5-year survival following endovascular treatment and open vascular surgery was 40% and 30%, respectively .
The pooled estimate of technical success of endovascular intervention was 94%, based on a recent meta-analysis . On the other hand, the pooled estimate of the unplanned surgery rate of endovascular therapy was 40%.
In such a scenario, depending on cardiac output and peripheral vascular resistance, a combination of noradrenaline and dobutamine rather than vasopressin should be considered to minimize the possible negative impact on the intestinal microcirculation . Renal replacement therapy, which is often required in case of acute kidney injury, may contribute to hemodynamic stabilization and facilitate optimization of fluid balance. Because of the potential bacterial translocation from the injured gut, broad-spectrum antibacterial treatment according to current guidelines should be continued after surgery based upon the degree of contamination and culture results . Systemic heparin is administered postoperatively (with activated partial thromboplastin time (aPTT) between 40 and 60) in all patients. Low-molecular weight heparin (LMWH) in therapeutic doses is a good alternative if no surgical interventions are planned. Enteral feeding is preferred, but some patients may need parenteral nutrition for a prolonged time due to short bowel and intestinal failure.
Classically open revascularization approaches have been used and described, in combination with damage control laparotomy. Recent developments, with improvement in early diagnosis, have allowed endovascular techniques to be implemented. Although evidence for the impact of endovascular interventions is limited at this time, they have apparent advantages over open surgery in some patients.
Vascular surgery is a surgical subspecialty in which diseases of the vascular system, or arteries, veins and lymphatic circulation, are managed by medical therapy, minimally-invasive catheter procedures and surgical reconstruction. The specialty evolved from general and cardiovascular surgery where it refined the management of ONLY the vessels, and no longer treating the heart or other organs (primarily the veins and arteries). Modern vascular surgery includes open surgery techniques, endovascular (minimally invasive) techniques and medical management of vascular diseases - unlike the parent specilaties. The vascular surgeon is trained in the diagnosis and management of diseases affecting all parts of the vascular system excluding the coronaries and intracranial vasculature. Vascular surgeons also are called to assist other physicians to do surgery near vessels, or to salvage vascular injuries that include hemorrhage control, dissection, occlusion or simply for safe exposure of vascular structures.
Early leaders of the field included Russian surgeon Nikolai Korotkov, noted for developing early surgical techniques, American interventional radiologist Charles Theodore Dotter who is credited with inventing minimally invasive angioplasty (1964), and Australian Robert Paton, who helped the field achieve recognition as a specialty. Edwin Wylie of San Francisco was one of the early American pioneers who developed and fostered advanced training in vascular surgery and pushed for its recognition as a specialty in the United States in the 1970s. The most notable historic figure in vascular surgery is the 1912 Nobel Prize winning surgeon, Alexis Carrel for his techniques used to suture vessels.
The surgeon Dr. Thomas J. Fogarty invented a balloon catheter which was designed to remove clots from occluded vessels was used as a the eventual model to do endovascular angioplasty. Further development of the field has occurred via joint efforts between interventional radiology, vascular surgery, and interventional cardiology. This area of vascular surgery is called Endovascular Surgery or Interventional Vascular Radiology, a term that some in the specialty append to their primary qualification as Vascular Surgeon. Endovascular and endovenous procedures (e.g., EVAR) can now form the bulk of a vascular surgeon's practice.
Dr. Edward "Ted" Dietrich, one of Dr. DeBakey's associates, went on to pioneer many of the minimally invasive techniques that later became hallmarks of endovascular surgery. Dietrich later founded the Arizona Heart Hospital in 1998 and served as its medical director from 1998 to 2010. In 2000, Diethrich performed the first endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm. Dietrich trained several future leaders in the field of endovascular surgery at the Arizona Heart Hospital including Venkatesh Ramaiah, MD who served as medical director of the institution following Dietrich's death in 2017.
The development of endovascular surgery has been accompanied by a gradual separation of vascular surgery from its origin in general surgery. Most vascular surgeons would now confine their practice to vascular surgery and, similarly, general surgeons would not be trained or practise the larger vascular surgery operations or most endovascular procedures. More recently, professional vascular surgery societies and their training program have formally separated vascular surgery into a separate specialty with its own training program, meetings and accreditation. Notable societies are Society for Vascular Surgery (SVS), USA; Australia and New Zealand Society of Vascular Surgeons (ANZSVS). Local societies also exist (e.g., New South Wales Vascular and Melbourne Vascular Surgical Association (MVSA)). Larger societies of surgery actively separate and encourage specialty surgical societies under their umbrella (e.g., Royal Australasian College of Surgeons (RACS)). 2b1af7f3a8