Vascular Management & Damage Control
Control hemorrhage while preserving salvageable organ and limb perfusion. During reconstructive surgery, obtain temporary control, improve exposure and call the appropriate vascular, trauma or pelvic surgical team early. Definitive repair is appropriate when it can be completed promptly in a stable patient; abbreviated damage-control surgery is reserved for physiology or injury complexity that makes continued reconstruction unsafe.[1][2]
Most comparative evidence on this page comes from major trauma, not iatrogenic injury during elective GU reconstruction. ESVS 2025 explicitly excludes iatrogenic injuries from its formal scope; applying its exposure and perfusion principles to an intraoperative GU injury is an extrapolation. Its abdominal recommendations are often based on low-certainty evidence and expert consensus.[2]
Immediate priorities
- Communicate and obtain temporary control. Stop the injuring maneuver, apply directed pressure or packing, activate the major-hemorrhage response when indicated, and summon experienced help. Avoid blind clamps or sutures in a blood-filled field.
- Expose the injury and secure vascular control. Enlarge or convert the operative approach when necessary. Identify the vessel, adjacent ureter/bowel/nerves, and appropriate inflow and outflow control before releasing tamponade or opening a contained hematoma.
- Resuscitate while controlling the source. Anesthesia and the blood bank manage blood products, temperature, ionized calcium and coagulation alongside the operation. Laboratory correction cannot substitute for source control.
- Choose repair, endovascular treatment, shunting or ligation according to anatomy and physiology. The fastest technically possible maneuver may sacrifice an organ or limb; make that tradeoff explicit. Do not postpone an achievable definitive repair simply because the injury is called “damage control.”[1][2][3]
A negative FAST examination does not exclude abdominal or retroperitoneal bleeding. Use CT angiography when the patient can safely undergo it; unstable ongoing hemorrhage requires a control strategy that does not wait for imaging. Fracture pattern alone cannot identify the bleeding vessel or determine the need for embolization.[1][2][4]
When to stage the operation
Damage-control surgery interrupts worsening shock, hypothermia, acidosis and coagulopathy when definitive reconstruction would impose an intolerable additional burden. Its phases are:[1][2]
- Abbreviated source control: secure bleeding and contamination, preserve perfusion with a temporary shunt when necessary, and use temporary closure if definitive closure is unsafe.
- Physiologic recovery: restore perfusion, temperature and hemostasis; reassess for ongoing bleeding, ischemia and abdominal compartment syndrome.
- Planned completion: remove or revise packing, replace temporary shunts, assess bowel/organ viability and complete repair and closure as soon as the patient's condition permits.
There is no universal “under 90 minutes, then wait 24–36 hours” prescription. Persistent hemorrhage, threatened perfusion or compartment syndrome requires earlier intervention. Conversely, opening a recently controlled field according to a fixed clock may be inappropriate. Document the reason for staging and the findings that will trigger return to the operating room.[1][2]
Resuscitation: keep the indication explicit
| Measure | Practical interpretation |
|---|---|
| Blood pressure | European trauma guidance permits SBP 80–90 mmHg only during early uncontrolled traumatic bleeding without brain or spinal injury. Severe traumatic brain injury requires a higher perfusion target; the guideline recommends MAP at least 80 mmHg. These are not routine intraoperative GU or postpartum targets. |
| Blood products | Activate the local major-hemorrhage protocol. Trauma guidance supports initial plasma/red-cell or factor-based strategies with platelet support, followed by laboratory or viscoelastic guidance. It does not require a fixed 1:1:1 regimen throughout every hemorrhage. |
| TXA | For a bleeding or high-risk adult trauma patient, give it as early as possible and within three hours of injury: 1 g IV over ten minutes, then 1 g over eight hours. Do not wait for viscoelastic testing. Postpartum timing/dosing and elective surgical indications have their own protocols. |
| Fibrinogen and coagulation factors | Identify and treat the relevant deficit. Trauma guidance supports fibrinogen replacement for functional deficiency or a Clauss level at or below 1.5 g/L. Empiric PCC or high-dose cryoprecipitate for every injured patient is not supported by the trials below. Anticoagulant reversal is a separate indication. |
| Temperature, calcium and fluids | Prevent hypothermia, measure and correct low ionized calcium, and avoid excessive crystalloid dilution. These measures accompany prompt hemostasis; calcium correction alone has not been shown to confer a mortality benefit. |
Major trials that change how to interpret resuscitation claims
| Trial and population | Main finding | Implication |
|---|---|---|
| PATCH-Trauma, 2023: prehospital TXA in advanced trauma systems; 1,310 randomized, 1,131 with the primary outcome determined | Favorable six-month functional survival 53.7% vs 53.5%, RR 1.00 (95% CI 0.90–1.12). Lower 28-day mortality was a secondary finding. | Retain early trauma TXA guidance, while acknowledging the null functional primary outcome; the secondary mortality result was not adjusted for multiple comparisons. |
| PROCOAG, 2023: empiric 4F-PCC added to ratio-based trauma transfusion; 324 analyzed | No reduction in 24-hour blood-product use. At least one thromboembolic event: 56/161 vs 37/157 (35% vs 24%), RR 1.48 (1.04–2.10). | Do not routinely add PCC to trauma transfusion without a specific indication. Patients taking anticoagulants were excluded; this does not invalidate indicated anticoagulant reversal. |
| CRYOSTAT-2, 2023: early empiric high-dose cryoprecipitate added to a major-hemorrhage protocol; 1,604 randomized | 28-day mortality 25.3% vs 26.1% in 1,531 with outcome data, adjusted OR 0.96 (0.75–1.23). | This does not support universal empiric high-dose cryoprecipitate, and does not test withholding treatment from a patient with documented fibrinogen deficiency. |
| FiiRST-2, 2025: fibrinogen concentrate plus PCC replacing plasma in the first two trauma packs; 217 randomized, 137 in the modified intention-to-treat analysis | Mean 24-hour blood-product use 20.8 vs 23.8 units, ratio 0.87 (one-sided 97.5% CI 0–1.19); superiority was not demonstrated, and recruitment stopped for futility. | This was a different strategy from PROCOAG. Neither equivalence nor a survival or safety advantage was established. |
| TOWAR, 2026: cluster-randomized prehospital whole blood vs components; 993 in primary analysis | 30-day mortality 25.9% vs 20.5%, adjusted OR 1.24 (0.87–1.76). | No demonstrated superiority of the initial whole-blood strategy. |
| SWiFT, 2026: prehospital whole blood vs components; 942 randomized, 616 with the primary composite determined | Death or massive transfusion by 24 hours 48.7% vs 47.7%, RR 1.02 (0.80–1.31). | Also no demonstrated superiority. Its composite endpoint and analysis population differ from TOWAR. Neither trial establishes equivalence or the optimal subsequent hospital regimen. |
These are treatment-strategy comparisons. Trial-specific blood-product “unit” definitions, exclusions and follow-up differ; raw unit counts and event rates should not be compared across rows as if the populations were interchangeable.
Vaginal and perineal hemorrhage
Identify the source: a visible laceration, expanding hematoma, operative pedicle, diffuse coagulopathic bleeding and bleeding tumor require different definitive treatment. Adequate light, exposure and analgesia/anesthesia are essential. Apply directed pressure while arranging repair or embolization; repeated blind deep sutures can injure the bladder, ureter, rectum or pelvic vessels.[2][12][13]
Vaginal packing can provide temporary tamponade when direct control is incomplete or while definitive treatment is being arranged. Place it under visualization, record the material and amount, monitor ongoing loss and physiology, and establish an explicit reassessment/removal plan. Consider urinary drainage when compression prevents voiding or accurate output monitoring is needed. Antibiotics depend on the procedure, infection, contamination and local protocol; a pack alone does not establish a universal broad-spectrum course.[12][13]
An expanding or symptomatic deep hematoma may require operative control, angiography/embolization or a combined approach. Do not drain a contained collection without a plan to control the resulting hemorrhage. In pelvic-fracture wounds, coordinate with trauma and orthopedic teams because vaginal/perineal bleeding may be only one component of a larger pelvic injury.[2][4]
For malignant vaginal bleeding, coordinate with gynecologic oncology, radiation oncology and interventional radiology, taking prior radiation, anatomy and the patient's goals into account. The Cochrane review found no eligible controlled comparisons establishing packing, TXA or embolization as equivalent to radiotherapy. Its descriptions of formalin and other caustic agents are not a validated routine recipe for reconstructive practice.[13]
Pelvic-fracture hemorrhage
Venous plexuses, cancellous bone and arterial branches may bleed together. Stabilization, packing and embolization address different parts of that problem; no single fixed sequence fits every patient or trauma system.[1][4]
| Intervention | Role and limitations |
|---|---|
| Pelvic binder and mechanical stabilization | Apply the binder at the greater trochanters, not the iliac crests, for suspected unstable pelvic-ring injury. Monitor skin/pressure effects and replace temporary compression with an appropriate stabilization plan. A binder does not control every arterial or abdominal source. |
| Preperitoneal pelvic packing (PPP) | Rapid tamponade of predominantly venous/osseous bleeding, particularly when immediate angiography is unavailable or the patient needs operative control. Stabilization improves the counterpressure needed for packing. |
| Angiography and embolization | Targets arterial bleeding, including CT extravasation or persistent bleeding despite stabilization/packing. Absence of a CT blush does not exclude an arterial injury. Selectivity and embolic agent depend on anatomy, physiology and the interventional team's judgment. |
| Combined or hybrid care | Packing and embolization are complementary. Their order depends on the dominant threat, immediate resources and response to treatment. A patient needing laparotomy for an abdominal injury must not be denied it to preserve pelvic tamponade. |
PPP exposure: enter the preperitoneal space through a short lower abdominal incision and pack toward the posterior pelvis on both sides of the bladder, maintaining separation from an abdominal operative field when feasible. If abdominal exploration is needed, a separate laparotomy can preserve the packing compartment. Document pack location and number. WSES describes revision/removal at 48–72 hours, but ongoing bleeding, infection, compartment effects or other urgent findings require reassessment sooner; timing is individualized.[4]
Internal iliac artery ligation is a selective rescue option when repair or embolization is unsuitable or unavailable. It can fail because of collateral supply and does not reliably control venous/osseous bleeding. Identify the ureter, iliac vein and arterial branches before ligation. Bilateral arterial sacrifice is not free of gluteal, pelvic-organ or bowel ischemia; small survivor series reporting no local complication do not establish zero risk.[2]
REBOA: a restricted rescue strategy
Resuscitative endovascular balloon occlusion of the aorta temporarily reduces distal arterial flow. ESVS 2025 recommends against routine use in bleeding trauma patients. A rise in blood pressure after inflation is not proof of survival benefit.[2][5]
In UK-REBOA, 90 patients were randomized to a REBOA strategy plus standard care or standard care alone. Ninety-day mortality was 25/46 vs 18/43; Bayesian OR 1.58 (95% credible interval 0.72–3.52), with an 86.9% posterior probability of increased mortality. Only 19 of 46 assigned to the strategy actually had a balloon inflated, and two controls crossed over. The trial raises concern for harm from the strategy; it is not a randomized comparison of actual balloon recipients against nonrecipients.[5]
| Aortic zone | Anatomical extent and use |
|---|---|
| I | Left subclavian artery to celiac origin; selected subdiaphragmatic abdominal or combined abdominal/pelvic hemorrhage. Occlusion compromises visceral, renal and lower-body perfusion. |
| II | Celiac origin to the lowest renal artery; avoid deployment across these visceral/renal branches. |
| III | Lowest renal artery to aortic bifurcation; selected isolated pelvic/junctional hemorrhage. Proximal visceral branches remain perfused, but lower-body ischemia and reperfusion injury remain substantial risks. |
If selected by an experienced team, REBOA requires immediate access to definitive hemorrhage control, attention to bleeding above the balloon and monitoring for access injury, migration, ischemia and reperfusion effects. There is no universally safe occlusion duration. Partial or intermittent occlusion may change distal flow but does not guarantee safety or justify delaying hemostasis. A negative FAST scan alone cannot clear a patient for balloon inflation.[1][2][5]
Abdominal vascular control
Exposure before repair
Use Operative Exposure for the anatomical approach. Direct pressure or packing may permit controlled extension of the incision and vessel-specific proximal/distal control. Supraceliac aortic clamping is a rescue maneuver for selected catastrophic abdominal arterial hemorrhage; it is not the first step for every venous injury or contained retroperitoneal hematoma.[2][3]
- Supraceliac access: expose the aortic hiatus through the gastrohepatic window, identify and protect the esophagus, and develop a controlled clamp site. Avoid blind circumferential dissection that can avulse posterior aortic branches.
- Infrarenal access: mobilize bowel and expose the retroperitoneum; the left renal vein is an important landmark, but identify the actual renal arterial origins and any variants before choosing the clamp site.
- Right medial visceral rotation provides broad caval/right renal/iliac exposure; left medial visceral rotation provides aortic and visceral-branch exposure. A local Kocher maneuver is not the same as a complete right-sided rotation.[2][3]
Vessel-specific decisions
| Injury | Reconstruction and damage-control considerations |
|---|---|
| Aorta | Obtain controlled inflow/outflow access; choose primary repair, patch, interposition or selected endovascular repair according to the defect. Emergency synthetic reconstruction may be necessary even with bowel injury, but contamination, coverage and subsequent surveillance still matter. |
| Common/external iliac artery | Preserve limb perfusion by repair or a temporary shunt when definitive reconstruction cannot be completed promptly. Ligation can cause limb-threatening ischemia. |
| Infrarenal IVC or major iliac vein | Repair when readily achievable. Ligation may be necessary in extremis, with important consequences for venous outflow, thrombosis, limb swelling and compartment pressure. It is not a benign equivalent to repair. |
| Suprarenal/retrohepatic IVC | Requires specialist planning and control appropriate to the injured segment. Packing may provide temporary control. Formal total hepatic vascular exclusion requires suprahepatic and infrahepatic caval control plus hepatic inflow control (Pringle); Pringle plus an infrarenal clamp alone is incomplete. ESVS recommends against atriocaval shunting for IVC trauma. |
| SMA/celiac or portal-system vessels | Assess the injured segment, collateral supply and bowel/hepatic viability. Repair, selected endovascular restoration or shunting may preserve perfusion. Neither celiac sacrifice nor loss of a mesenteric branch is automatically harmless. Plan reassessment when bowel viability is uncertain. |
| Renal vessels | Consider active bleeding, a solitary or bilateral threatened kidney, ischemia duration and reconstructibility. A devascularized unilateral kidney discovered after trauma is a different problem from a freshly recognized, potentially salvageable intraoperative renal artery injury. No single 60-minute rule decides salvage or nephrectomy. |
Observational comparisons of ligation and repair are heavily confounded by injury severity and physiology. Mortality associated with a suprarenal IVC injury must not be presented as mortality caused by suprarenal ligation. Small hybrid balloon series establish feasibility, not superiority over conventional control.[2]
Temporary intravascular shunts
A shunt can restore flow while resuscitation, skeletal stabilization or complex reconstruction proceeds. Select the device and diameter for the vessel; ensure secure fixation without obstruction, confirm flow and reassess for thrombosis, dislodgement and distal ischemia. These are specialist bridging procedures, not definitive repairs.[2]
Convert to definitive reconstruction as soon as feasible, ideally during the initial operation. Reports of shunts remaining patent for many hours do not establish a safe waiting period. Similarly, the traditional six-hour limb-ischemia concept is not permission to delay revascularization. Systemic anticoagulation, fasciotomy and subsequent antithrombotic therapy depend on bleeding risk, the repair and the limb's condition; none is automatic for every vascular injury.[2]
Obstetric hemorrhage: follow a cause-directed protocol
Postpartum hemorrhage requires immediate obstetric and anesthesia leadership, resuscitation and assessment for uterine atony, retained tissue, genital-tract trauma and coagulopathy. The WHO/FIGO/ICM consolidated guideline is the reference for its treatment bundle and escalation; a trauma blood-pressure target or a universal sequence of ligations should not be transplanted into this setting.[12]
Uterotonics treat uterine atony; they do not close a laceration or repair uterine rupture. When bleeding remains uncontrolled, tamponade, operative repair/compression sutures, devascularization, embolization or hysterectomy are selected according to the cause, clinical trajectory and available expertise. Do not delay definitive surgery, including hysterectomy when required, merely to work through every conservative option.[12]
- Start first-response care concurrently: uterine massage, an oxytocic, TXA, IV fluids, genital-tract examination and escalation. WHO recommends initiating available bundle components promptly, ideally within 15 minutes of diagnosis. For PPH, TXA is 1 g IV over ten minutes within three hours of birth, with a second 1 g if bleeding continues after 30 minutes or restarts within 24 hours after the first dose; this differs from the trauma infusion above.
- Balloon tamponade has prerequisites: WHO supports it for refractory atony after vaginal birth when surgery and blood are immediately available, a first-line treatment protocol is implemented, retained tissue/trauma are reasonably excluded, trained personnel are present and monitoring is adequate. WHO advises against intrauterine gauze packing for PPH; this is distinct from vaginal or preperitoneal packing for another bleeding source.
- Prepare surgery while arranging embolization. Neither transfer to angiography nor repeated conservative attempts should delay necessary operative control. Use an obstetric major-hemorrhage protocol: WHO's fibrinogen goal is at least 2 g/L, rather than simply importing the trauma threshold, and it does not establish one optimal transfusion ratio.[12]
After control: document the unresolved risks
The handoff should identify the vessel and injury, repair/ligation/shunt performed, clamp and ischemia times, residual perfusion concerns, retained packs, anticipated return to surgery, and the vascular team's surveillance and antithrombotic plan. Continue assessment for recurrent bleeding, bowel or renal ischemia, limb compromise, compartment syndrome and thromboembolism. VTE prophylaxis begins when hemostasis and the wider injury pattern permit.[1][2]
Companion pages
- Operative Exposure — positioning, incisions and visceral mobilization.
- Pelvic Vascular Anatomy — vessels and anatomical variation.
- Anticoagulation Reversal — agent-specific reversal, distinct from empiric trauma factor replacement.
- VTE Prophylaxis — postoperative prevention and bleeding-risk assessment.
References
1. Rossaint R, Afshari A, Bouillon B, et al. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care. 2023;27:80. doi:10.1186/s13054-023-04327-7.
2. Wahlgren CM, Aylwin C, Davenport RA, et al. ESVS 2025 Clinical Practice Guidelines on the Management of Vascular Trauma. Eur J Vasc Endovasc Surg. 2025;69:179–237. doi:10.1016/j.ejvs.2024.12.018.
3. Kobayashi LM, Costantini TW, Hamel MG, Dierksheide JE, Coimbra R. Abdominal vascular trauma. Trauma Surg Acute Care Open. 2016;1:e000015. doi:10.1136/tsaco-2016-000015.
4. 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.
5. 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;330:1862–1871. doi:10.1001/jama.2023.20850.
6. Gruen RL, Mitra B, Bernard SA, et al. Prehospital tranexamic acid for severe trauma. N Engl J Med. 2023;389:127–136. doi:10.1056/NEJMoa2215457.
7. Bouzat P, Charbit J, Abback PS, et al. Efficacy and safety of early administration of 4-factor prothrombin complex concentrate in patients with trauma at risk of massive transfusion: the PROCOAG randomized clinical trial. JAMA. 2023;329:1367–1375. doi:10.1001/jama.2023.4080.
8. da Luz LT, Karkouti K, Carroll J, et al. Factors in the initial resuscitation of patients with severe trauma: the FiiRST-2 randomized clinical trial. JAMA Netw Open. 2025;8:e2532702. doi:10.1001/jamanetworkopen.2025.32702.
9. Davenport R, Curry N, Fox EE, et al. Early and empirical high-dose cryoprecipitate for hemorrhage after traumatic injury: the CRYOSTAT-2 randomized clinical trial. JAMA. 2023;330:1882–1891. doi:10.1001/jama.2023.21019.
10. Sperry JL, Guyette FX, Cotton BA, et al. Prehospital resuscitation with type O whole blood for trauma and hemorrhage. N Engl J Med. 2026;394:2317–2328. doi:10.1056/NEJMoa2602167.
11. Smith JE, Cardigan R, Sanderson E, et al. Prehospital whole blood in traumatic hemorrhage — a randomized controlled trial. N Engl J Med. 2026;394:2305–2316. doi:10.1056/NEJMoa2516043.
12. World Health Organization, FIGO, ICM. Consolidated guidelines for the prevention, diagnosis and treatment of postpartum haemorrhage. 2025. WHO publication.
13. 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.