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Abdominal vascular injury

What's new

The European Society for Vascular Surgery (ESVS) has released new guidelines for the management of vascular trauma, including abdmonial vascular injury. For blunt minor injuries to the abdominal aorta, iliac, renal, or superior mesenteric arteries (ESVS grade 1) without ongoing bleeding, nonoperative management with surveillance and antithrombotic therapy is recommended. For patients in shock with ongoing bleeding, immediate surgical exploration and hemorrhage control should be performed. Endovascular stent graft repair is suggested for hemodynamically stable patients with external contour abnormalities, such as pseudoaneurysms (ESVS grade 2). Open surgical repair is the first-line treatment for blunt or penetrating abdominal aortic injury with free hemorrhage and hemodynamic instability (ESVS grade 3). Synthetic graft material is recommended for aortic reconstruction in emergency situations, even in the presence of concomitant bowel injury. .

Background

Overview

Definition
Abdominal vascular injury refers to any trauma to the major blood vessels in the abdomen, which can lead to potential life-threatening hemorrhage.
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Pathophysiology
Abdominal vascular injury typically results from trauma or iatrogenic causes, such as surgical procedures. The injury can lead to disruption of the vessel wall, resulting in bleeding and potential organ ischemia due to loss of blood supply.
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Epidemiology
The prevalence of abdominal vascular injury is particularly high in trauma patients, especially in instances of motor vehicle accidents, falls from height, or interpersonal violence.
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Disease course
The clinical manifestations of abdominal vascular injury can be acute or delayed. Acute symptoms include hypotension and abdominal pain, which can be indicative of ongoing bleeding. Delayed symptoms may include anemia due to chronic blood loss or an abdominal bruit, which can suggest the presence of a vascular injury.
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Prognosis and risk of recurrence
The mortality and morbidity rates associated with this injury are high due to the potential for life-threatening hemorrhage.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of abdominal vascular injury are prepared by our editorial team based on guidelines from the European Society for Vascular Surgery (ESVS 2025), the Eastern Association for the Surgery of Trauma (EAST/WTA/PTS 2023), the Pan-European Multidisciplinary Task Force for Advanced Bleeding Care in Trauma (ABC-T 2023,2019), the American Heart Association (AHA/ACC 2022), ...
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Diagnostic investigations

FAST ultrasound
As per EAST 2011 guidelines:
Avoid relying on FAST results to exclude intraperitoneal bleeding in the presence of a pelvic fracture.
D
Rely on FAST results in patients with unstable vital signs and pelvic fracture to decide on laparotomy to control bleeding.
A
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  • Angiography

Medical management

Nonoperative management: as per ESVS 2025 guidelines, offer nonoperative management with surveillance and antithrombotic therapy in patients without ongoing bleeding and with blunt minor injuries to the abdominal aorta, iliac, renal, or superior mesenteric arteries (ESVS grade 1) on CTA.
A
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  • Tranexamic acid

  • Antibiotic prophylaxis

Therapeutic procedures

Pelvic packing: as per ABC-T 2023 guidelines, perform temporary extraperitoneal packing when bleeding is ongoing and/or when angioembolization cannot be achieved promptly. Consider combining extraperitoneal packing with open abdominal surgery when necessary.
B
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  • Angioembolization

  • REBOA

Surgical interventions

Emergency surgery: as per ESVS 2025 guidelines, perform immediate surgical exploration and hemorrhage control in patients in shock with ongoing bleeding and suspicion of major abdominal vascular injury.
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  • Damage-control surgery

  • Exploration of hematoma

  • Definitive repair

Specific circumstances

Pediatric patients
As per EAST/PTS/WTA 2023 guidelines:
Consider performing emergency department thoracotomy in pediatric patients presenting pulseless to the emergency department following a penetrating abdominopelvic injury with signs of life.
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Avoid performing emergency department thoracotomy in pediatric patients presenting pulseless to the emergency department following a penetrating abdominopelvic injury without signs of life.
D
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  • Patients with mesenteric artery injury

  • Patients with renal artery injury

  • Patients with abdominal venous injury

Follow-up and surveillance

Imaging follow-up
As per ACC/AHA 2022 guidelines:
Consider obtaining surveillance imaging at intervals appropriate for the repair approach and location in patients with blunt traumatic aortic injury undergone aortic repair.
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Consider obtaining surveillance CT at 1 month, 6 months, and 12 months after the diagnosis and, if stable, at appropriate intervals thereafter (depending on the type and extent of the injury) in patients with blunt traumatic aortic injury not undergone repair.
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