The IVC is the most commonly injured abdominal vessel and accounts for about 25% of abdominal vascular injuries (1). Penetrating injuries are by far the most common and account for 90% of the IVC injuries. Treatment of IVC injuries includes direct repair, patch repair, interposition of vein grafts, atrio caval shunting, and packing. Anterior perforations are repaired best using a continuous suture (venorrhaphy). In some patients with concomitant anterior and posterior perforation of the IVC, the posterior wound can be exposed and repaired from inside the vessel by extending the anterior wound (16). This approach is carried out when the patient is stable. When the patient is hemodynamically unstable with active bleeding or severe infrarenal injuries, or when repair produces stenosis, ligation is a first-option treatment and well tolerated (17). However, caution is required due to the likelihood of appearance of compartment syndrome in the lower limbs. Measurement of the pressures in the anterior compartment of the legs, bilateral fasciotomies if needed, maintaining the circulating volume stable in the postoperative period, and use of elastic compression wraps are some of the main strategies to assist this group of patients (17). Recently, in a review with 100 IVC injuries, ligation was performed in 25 cases with good results and without trace of lower extremity edema (17). However, there have been occasional reports of severe edema in postoperative period that has required later interposition grafting (18). On the other hand, ligation of the suprarenal IVC is not an acceptable option, because it results in renal failure. In these situations, common approaches are the application of a large venous patch taken from either the superior mesenteric or the ovarian vein and the application of a PTFE patch. However, this approach is rarely successful because of the patient’s poor hemodynamic status (18).

In the last few years, several reports (Table 1) on endovascular techniques based on the management of these complex injuries have been reported. Castelli et al. (19) reported their experience in a patient with blunt trauma. The injury of the IVC revealed by CT angiography was treated using a stent graft. Unfortunately, the patient died due to traumatic brain injury on post trauma day 2. Three other cases with a same similar management approach have recently been published (20–22). The mortality rate of patients, who arrive at the hospital with IVC injuries, ranges between 20 and 57% (23–30). About half of the patients with IVC injuries die before reaching the hospital and before any medical intervention.

The abdominal aorta represents the second most common site of injuries (21%) reported after the IVC (25%) (1). For better estimation and approach, aorta injuries were classified based on CT findings and the presence of free rupture during laparotomy. Azizzadeh et al. (31) initially and Starnes et al. later (32) proposed a classification based on the alteration of the symmetric aortic shape observed in CT as follows:

Intimal tear/minimal aortic injury: absence of aortic external contour abnormality and intimal defect and/or thrombus of <10 mm in length or width.

In a review of abdominal gunshot injuries, 2.7% were localized in the abdominal aorta (33). The infrarenal part was found injured in 50% of the patients, the supraceliac in 25%, and the remained space between celiac trunk and RAs was injured in 25% of patients (33, 34). Blunt abdominal aortic injury is rare and is related to biomechanical direct and indirect forces that take effect on the abdominal aorta, situated between the spinal column and the peritoneum and abdominal viscera. Intimal dissection is the result of these forces that can also lead to aortic transection. Moreover, thrombosis in the abdominal aorta due to the same mechanism or as a complication of aortic dissection has also been reported (34, 35).

The management of aortic injuries is complex and depends on various factors, such as the type, size, and location of the injury. Penetrating aortic injuries obviously require open repair due to the rapid extravasation of blood in the peritoneal and/or retroperitoneal cavity, which leads to life-threatening conditions. In case of blunt trauma, management may be less urgent. Blunt aortic injuries with small intimal tears could be managed conservatively, with closely follow-up (36–43). In cases of large intimal flaps or free rupture, open (1, 2, 10, 34, 36, 41, 43–63) or endovascular repair are required (5, 6, 10, 36, 38, 41, 60, 64–78) (Table 2).

Traditionally, aortic injuries are approached with the division of the midline of the retroperitoneum by the transverse mesocolon into the supramesocolic and inframesocolic regions. In the supramesocolic area, when hematoma is present, the surgeon has the time to mobilize all left-sided intra-abdominal viscera, including the colon, kidney, spleen, tail of the pancreas, and fundus of the stomach to the midline (left-sided medial visceral rotation) (79). This technique permits extensive exposure and visualization of the entire abdominal aorta from the aortic hiatus of the diaphragm to the aortic bifurcation. Drawbacks of this technique include the risk to damage the spleen and/or left kidney, accessories vessels originate from kidney, and the time to complete the maneuver (80). The bilateral subcostal abdominal approach with left medial rotation (“roof-top” approach) has been described as an alternative technique for treating various complex abdominal aortic pathologies. The main advantage is the avoidance of entering into the left thoracic cavity and that it may potentially be an attractive technique in cases of injuries in supramesocolic region (81). In the presence of active bleeding, immediate priority for the surgeon is the control of the bleeding by direct compression. Once this critical step is achieved, the next thought is to identify the bleeding vessel and to obtain proximal and distal control. However, due to the dense concentration of the major vessels (abdominal aorta, CA, SMA) in this area and the dense nature of the celiac plexus that surrounds the supraceliac aorta, in some cases, left thoracotomy traditionally seems the only safe way to obtain proximal aortic control (82). Injuries restricted within the inframesocolic area could be approached by retracting the transverse colon cephalad and mobilizing the small bowel to the right (79).

Supramesocolic injuries have a significantly worse outcome than inframesocolic injuries due to the viscera’s location, which makes aortic exposure challenging (34). The prognosis is better in case of blunt abdominal aortic trauma compared to penetrating trauma (37). Overall mortality after blunt and penetrating aortic injuries is estimated at 30 and 85%, respectively (37, 83, 84).

Endovascular management is used in selected cases, mainly in blunt aortic trauma. Any significant injury may be managed, if amenable, with stenting (64–78) or embolization (65). Unfortunately, existing data are limited to case reports (CRs) (Table 2) that describe injuries like limited infrarenal dissection and large intimal flaps (64–68, 70–78). Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) offers a new tool for control of non-compressible abdominal vascular injuries. Recent advances in device technology have permitted for rapid deployment through smaller delivery (7 Fr) systems without dependence on fluoroscopy (85). Current guidelines through the American College of Surgeons find REBOA to represent a less invasive means of providing thoracic aortic occlusion compared to left thoracotomy with cross clamp to decrease blood loss from abdominal hemorrhage. Pelvic hemorrhage may also be selectively controlled through inflation of the device in the infrarenal aorta (86). While these two deployment strategies are promising, no data are currently available to demonstrate a mortality benefit compared to traditional techniques of initial vascular control. With this new technology comes consideration of new potential complications including femoral arterial injuries as well as extremity ischemia. Despite these points, REBOA offers a novel, non-invasive means of obtaining rapid vascular control in the exsanguinating abdominal trauma patient (85).

Injury of the CA is rare and may occur at the main trunk or any of its branches (1). Since Patman et al. (87) reported the first case, few studies (88–95) are available in the literature (Table 2). Asensio et al. (1) presented the largest series in the literature, in which 12 patients suffered from CA injuries after penetrating trauma. Eleven were treated with ligation and one with primary repair. The authors concluded that patients are not amenable to simple arteriorrhaphy should undergo ligation, which should not cause any short morbidity other than the risk of gallbladder necrosis (1). However, few data exist in the literature describing the consequences of this procedure, and surgeons should not worry about ligating the hepatic artery proper proximal to the origin of gastroduodenal artery, since the collateral flow through this vessel will maintain the viability of the liver. The reported mortality rate ranges from 38 to 75% (87, 88, 90–92). Therefore, the hemodynamic status of the patient, the complexity of the indicated operation (direct repair or conduit/graft needed for repair) and the associated injuries taking priority on operation plan should contribute to the final decision-making of repairing the celiac artery.

Injury to the PV trunk is relatively rare. Penetrating injuries are responsible for about 90% of the cases, as they are confirmed after laparotomy (96). The major percentage of patients, victims of PV penetrating injuries, present signs of hemorrhagic shock and require emergency laparotomy (97). On the other hand, blunt trauma often provokes thrombosis of the vessel and occasionally avulsion and bleeding (97).

Due to the location (retro/suprapancreatic) of the PV, the friability of its wall and the greater volume of blood through it, the management of this vessel injury is challenging. Exposure of retro-pancreatic PV and its major branches can be achieved by mobilization and medial rotation of the right colon and hepatic flexure of the colon, in association with extensive Kocher mobilization of the duodenum (26, 91). More often, stapled division of the neck of the pancreas is necessary for successful exposure (98–100). The same technique for dissection of the suprapancreatic PV has also been described (98, 99). There are several PV repair techniques, but lateral venorrhaphy is preferred (98, 99). Complex reconstruction using resection with end-to-end anastomosis, interposition grafting, transposition of splenic vein down to the SMV to replace the proximal PV, an end-to-side portocaval shunt, and a veno-venous shunt from the SMV to the distal PV or IVC have also been described (26, 91, 98–100). In addition, ligation of the vein is another surgical option compatible with survival, but in such cases bowel edema and wall necrosis are often complications. The experience after portal ligation is restrictive in the literature; however, there is no evidence of development portal hypertension in such cases (91, 98, 99). The mortality rate in PV injuries is high and ranges between 50 and 72% (101–103).

Several studies on SMA injuries have been conducted at experienced trauma centers (1, 84, 87, 91–93, 104–115) (Table 2). Since Fullen et al. (115) proposed an anatomic classification of injuries to the SMA, their management depends on the level of injury. Injuries in zone 1 (trunk proximal to the inferior pancreaticoduodenal artery) and zone 2 (between the inferior pancreaticoduodenal artery and the middle colic artery) can be achieved by left-sided medial visceral rotation and dissection anteriorly to the left kidney. Then the anterior aspect of the aorta including the SMA will be visible (79). However, these zones are characterized by high level of surgical difficulties, and under active bleeding in an unstable patient, the use of intraluminal shunt into the debrided ends of SMA should be considered. If the patient is stable and the proximal part of the SMA should be replaced, saphenous vein or prosthetic grafts have been described (84). On the other hand, injuries in zones III (distal to middle colic artery) and IV (the segmental intestinal branches) should be approached directly without any additional surgical manipulation.

Injuries of the inferior mesenteric artery (IMA) are rare. All the published studies (1, 87, 88, 93) reported results of IMA associated with other visceral vessels (Table 3). The main described mechanism was penetrating injury and accounted for 1% of all abdominal injuries (1). In critical situations, experts proposed ligation of the IMA with remarkable results for the bowel due to the rich collateral blood supply (1, 93).

The management of renovascular injuries depends on the mechanism of injury, the time of diagnosis, the ischemia time, the general condition of the patient, and the presence of a contralateral normal kidney. Injuries to the renal vasculature (zone 2) are difficult to manage due to the small size of the vessel and its location deep in the retroperitoneum. Occasionally, small injuries after penetrating trauma can be repaired by lateral arteriorrhaphy or resection and end-to-end anastomosis (11, 93). Interposition grafting with saphenous vein, PTFE graft, and rarely harvesting of the splenic and hepatic arteries in order to replace the left/right RAs, respectively, has also been presented (116). However, the latter approach is not advisable under hemodynamic instability but when the patient is stable. In cases with penetrating wounds associated with hemodynamic instability and with significant renovascular injuries or long period of ischemia, nephrectomy may be the better choice, as long as a normal contralateral kidney was confirmed (11). The survival rate after penetrating injuries ranges between 65 and 87% (117) with renal salvage in only 30–40% of the cases (118, 119).

The management of blunt injuries to the RAs is complicated by the often-delayed diagnosis and prolonged ischemia of the kidney. The patients often complain about abdominal and flank pain, whereas associated signs like gross or microscopic hematuria are also reported. The management of isolated main RA occlusion remains controversial. Treatment options include immediate nephrectomy, non-operative management, or revascularization by surgical or endovascular techniques (11). In stable patients with short warm ischemia time (<5 h), revascularization should be performed (11, 16, 93). In cases of delayed diagnosis (>5 h), most surgeons avoid revascularization, unless the injury involves both kidneys or solitary kidney, due to the disappointing results after revascularization (120, 121). Other patients, assuming they have a normally functioning contralateral kidney, should be either monitored or considered for endovascular procedures. At least, patients with bilateral RA injuries or those with solitary kidney should be strongly considered for revascularization (11).

The advancement of endovascular techniques has opened new horizons in the management of renovascular injuries. However, experience with this technique is still limited (8, 122–127). First, Sclafani and Becker (122) reported eight patients with penetrating (n = 6) and blunt trauma (n = 2), who were treated with angiographic embolization. Seven of these eight patients underwent successful procedures with preservation of the renal function, and only one nephrectomy due to hematuria was performed. Later, another study (123) reported the same results after angiographic embolization, obviating the need for open surgery. All patients presented normal functioning status at discharge. In more recent years, few CRs (Table 3) document the successful use of various stents to obliterate intimal flaps after RA injuries without short-term complications (8, 124–131). Thus, endovascular treatment may play an important role in selected cases of blunt renovascular trauma, when patients are stable with injuries like intimal tears, acute occlusions, false aneurysms, and arteriovenous fistulae.

Injury of the renal vein is the result of penetrating and blunt trauma mechanisms. Although, blunt avulsion injuries result in exsanguination, under penetrating trauma, the patient may be stabilized with retroperitoneal tamponade (1). Lateral venorrhaphy remains the first treatment choice; however, it is not possible in case of extensive injuries. In these cases, ligation of the renal vein has been proposed unless the collateral vein circulation is inappropriate, to maintain stable and vital the kidneys. Ligation of the left renal vein is tolerated well due to satisfactory venous drainage through the left gonadal vein, left adrenal vein, and lumbar veins. This choice is not feasible in cases of the right renal vein, when the collateral vein flow is absent, and nephrectomy is the only choice (93). The survival rate ranged from 44 to 70% with a mean of 60% (1, 93).

Injuries of the iliac arteries due to penetrating or blunt trauma are described in the literature (Table 2). Penetrating trauma is by far the most common mechanism of injury, whereas blunt trauma remains uncommon; the only available data on blunt trauma come from CRs. Velmahos et al. (132) published their experience in 30 patients suffering from blunt injury to the iliac arteries. Seventeen patients (56.6%) underwent embolization of the bleeding internal iliac arteries as primary treatment while the rest of the patients had undergone to laparotomies before the embolization. The success rate was 97% (29–30) in controlling pelvic hemorrhage. Later, Cestero et al. (133) reported that iliac artery injury occurred after penetrating trauma in 10% of the cases, whereas 26% of the patients had combined arterial and venous injuries. The common involved site is the common iliac artery (CIA) and the branches of the internal iliac artery for penetrating and blunt trauma, respectively. Often the patient shows severe hypotension and abdominal distension in case of penetrating trauma and with signs of absent or diminished femoral pulses (1, 41, 44). Thrombosis is observed in later stages of blunt injuries through diagnostic imaging such as Duplex ultrasound and/or CT (41).

Surgical exploration should be carried out in cases of active bleeding after penetrating trauma and if blunt trauma persists with associated intraperitoneal leak, hematoma that creates absent or diminished femoral pulses or it has continuing expansion (11, 44). Arterial injuries could be repaired with vascular sutures (arteriorrhaphy) or interposition of venous/PTFE grafts. Special consideration should be taken to avoid graft infection, for which some authors proposed an extra-anatomic bypass as the method of treatment (134). On the other side, supporters of the endovascular technique proposed this approach in order to avoid complications due to the contamination of the graft.

Thus, endovascular treatment is a trustworthy alternative in cases of further graft infection and in cases with false aneurysm, arteriovenous fistulae, major intimal tears, and vessel’s thrombosis (135). Moreover, it was also proposed by some experts as the first-line therapeutic option due to the low complication rate in cases of chronic traumatic injuries of the CIA or external iliac artery (7, 136).

Iliac venous injuries are technically challenging due to the difficult exposure caused by anatomic placement behind the arteries. Injuries on the common and/or external iliac veins could be managed with lateral repair with polypropylene sutures (4-0, 5-0) or with ligation (1). In case of significant narrowing after lateral repair, treatment with anticoagulants is appropriate to reduce the risk of thrombosis and/or pulmonary embolism. Ligation is usually well tolerated although many patients develop transient leg edema. Complex reconstruction with spiral grafts or prosthetic materials is not recommended.

The traditional pre-peritoneal pelvic packing represents a trustworthy alternative to address venous hemorrhage in complex pelvic fractures (137). The “trigger” to perform this technique is the persistent hemodynamic instability of the patient despite two units of red blood cells transfusion during the initial resuscitation (137). Other proposed indications were unstable patients with pelvic hematoma diagnosed on focused assessment with sonography in trauma exam and in cases of unavailable angiographic embolization in some centers (138). The survival rate of patients with iliac venous injuries ranges between 65 and 95% (1, 25, 93, 107, 117, 134).