Endovascular trauma management: New symposium will explore opportunities, techniques, controversies

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Trauma teams are showing increasing interest in resuscitative endovascular balloon occlusion of the aorta (REBOA) and other techniques of minimally invasive resuscitation. In response to the growing enthusiasm, the Endovascular Resuscitation & Trauma Management (EVTM) Symposium is delivering cutting-edge educational programs to an international audience of trauma professionals and related specialists.

The first EVTM Symposium was held last year in Örebro, Sweden. Topics included multidisciplinary approaches to endovascular bleeding control, prehospital REBOA, military applications, vascular access, the latest REBOA techniques, imaging systems and other new technologies.

The inaugural conference was such a success that organizers are planning two follow-up events for 2018. The second European EVTM Symposium will take place in Örebro in June 2018. And the recently announced Pan-American EVTM Symposium will be held in Houston, Texas, in February 2018.

Trauma System News recently interviewed Tal Hörer, MD, PhD, associate professor of surgery at Örebro University Hospital & University. Dr. Hörer is the founder of the EVTM Symposium. He talked about the latest trends in endovascular trauma management and what trauma leaders can expect from this year’s conferences.

Q. What are the most important new trends in endovascular trauma management?

Hörer: We are moving away from seeing REBOA as only a bleeding stopper and toward viewing it as a tool for stabilizing the patient. REBOA doesn’t just stop the bleeding; you can also use it to gain time to think about other options and to try other interventions.

Tal Hörer, MD, PhD, associate professor of surgery at Örebro University Hospital & University

Tal Hörer, MD, PhD, associate professor of surgery at Örebro University Hospital

Along these lines, the most exciting development in endovascular trauma management is “partial REBOA” — which means you don’t occlude the aorta totally, you try to occlude it partially to maintain perfusion to the patient’s organs.

This has many potential uses. We know of trauma cases where the right specialists were not available in the hospital, so REBOA was used to hold pressure and keep the patient alive until the specialists arrived to provide definitive care. We also know of three cases of “transfer REBOA,” where a patient is stabilized with REBOA or partial REBOA and then transferred to another center with higher treatment capabilities. Two of these cases took place in the U.S.

And I should note that endovascular resuscitation tools are moving beyond trauma to problems like cardiogenic shock, iatrogenic bleeding, spontaneous bleeding and postpartum hemorrhage. In fact, we are starting a new registry for postpartum bleeding and REBOA. The registry will be managed by a U.S. center, so this is an exciting cooperation on a totally new subject. People are even starting to think about using REBOA as a bridge to ECMO. So the concept of endovascular resuscitation is expanding.

Q. What are the biggest misconceptions about endovascular trauma management?

Hörer: There are two misconceptions. One is that endovascular resuscitation always goes very fast. It doesn’t. It can take some time to perform these procedures. People say, “Just embolize it” — but that may take half an hour. So endovascular trauma management is not a magic solution.

The other misconception is the exact opposite — that only good old open surgery can solve any given problem. This is a misconception because at times minimally invasive techniques can help you solve problems better than surgery can — for example, traumatic pelvic bleeding.

As part of this, it’s important to realize that hybrid procedures are also a possibility. For example, you can use REBOA to stabilize a patient before you move to a laparotomy. In this case, the endovascular technique is used to win time and prevent problems. Or you might do an endovascular procedure with embolization, but you also pack the pelvis. Or say you have a patient bleeding in the lung who has no blood pressure. You can use a balloon to get some pressure and then do a thoracotomy as a parallel procedure to close the bleeding. This approach is controversial, but it has been done.

So there are no magic tools. But in the right patient at the right place with the right team, you can use endovascular techniques to do amazing things.

Q. Why did you and your colleagues start the EVTM Symposium?

Hörer: Many trauma congresses have a small amount of information about using endovascular tools to treat bleeding patients. But most of the time this information is quite old and not up to date with new technologies. The EVTM Symposium is the only conference dedicated to endovascular resuscitation and new technologies and data in this area.

We held our first EVTM Symposium in 2017 in Sweden. This first event was such a great success that we immediately began planning the second European EVTM Symposium, which will take place in June 2018.

But meanwhile I suggested to some contacts in the United States that they consider hosting a similar event sometime in the future. As it turned out, there was a strong demand from our American colleagues to do a U.S. event right away. So we are launching the Pan-American EVTM Symposium in 2018. And that will take place February 8 and 9 in Houston. Both events will be available via live feed on the internet, which is unique.

As I said, this symposium is the only congress dedicated to endovascular resuscitation. It’s also the only event where you can find people speaking about solving bleeding problems in a multidisciplinary way.

Q. What specialties should come together to provide multidisciplinary bleeding control?

Hörer: Endovascular trauma management naturally leads to a multidisciplinary way of thinking. In my institution, it includes trauma surgeons, vascular surgeons, general surgeons, anesthesiologists, and interventional radiologists. And of course the problems don’t stop after surgery, so the multidisciplinary team also includes ICU and rehabilitation staff. It also includes prehospital providers, helicopter EMS and military medics who bring the patients in.

But it also depends where you work. In Europe, for example, the trauma surgeon operates but maybe does not take care of the patient on day two and day three (it’s the ICU people). In other countries, there are some very advanced team approaches. I know of a team in Israel where a trauma surgeon leads the process but there is a dedicated radiologist on call to put the REBOA in. So far they have done 12 cases working in this model.

The great thing about multidisciplinary care is that it lets us discover a lot of tools. One very hot issue now is the use of ECMO to address sepsis in trauma patients, maybe not in the first hours but later on. Here we can learn a lot from colleagues like cardiologists and thoracic surgeons. What catheter do you use? What balloon do you use? What ECMO machine are you using?

Q. Speaking of equipment, what are the latest tools of endovascular resuscitation?

Hörer: There are a lot of amazing new tools for diagnosing and treating bleeding, and they are becoming more widespread. There are two major companies in the market now with 7 French REBOA balloons; and one or two more are coming soon, so there is great interest in this. And then of course there are a lot of different catheters, sheaths, embolization agents, stent grafts, endografts and other devices.

But we have also seen huge development in imaging — from ultrasound to C-arms to CT to hybrid suites. Many of these pieces of equipment are very expensive but very useful. For example, you have “CT on rails” which lets you move the CT to the patient instead of moving the patient to the CT. I know of three hospitals in Europe where this is installed and eight in Japan. We are building one of these now in my institution, and they will only become more widespread.

Q. Who should attend the EVTM Symposium?

Hörer: Anybody who is interested in the treatment of hemostatically unstable patients. Trauma/general surgeons, vascular surgeons and nurses should be there, of course, but also anesthetists, interventional radiologists, prehospital providers, military providers, etc. We also hope to see gynecologists who deal with postpartum bleeding.

We are very interested in a multidisciplinary approach to these issues. This conference is a great opportunity for people to collaborate, and I hope everybody who has an interest in these exciting techniques can come and be a part of what we are doing.

Find out more and register to attend

To find out more about the EVTM Symposium and register to attend, click the links below:

Become a sponsor of this landmark conference

The EVTM Symposium will be attended by hundreds of physicians who will help shape the future of trauma care. Your company can reach attendees directly by sponsoring content in the EVTM Conference Newsletter. For more information, send an email to Robert Fojut.

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