In case of penetrating trauma, there are only a handful scenarios where percutaneous interventions may provide life-saving bleeding control especially in areas that are difficult to access surgically. These interventions may prevent the need for reoperation in the presence of rebleeding or assist in nonoperative management. This includes head and neck injuries, extremities and pelvic trauma, and great vessel and thoracic and solid abdominal organ injuries.

For all these scenarios, the common femoral artery is the recommended access site. All vascular regions of the body can be reached easily using specific catheters and guidewires. The retrograde puncture site should be located on the lower third of the femoral head seen on fluoroscopy. Avoid an arterial puncture above the inguinal ligament due to an increased chance of retroperitoneal bleeding that of course is not compressible or a puncture site too low because of the same reason. Especially, in case of extensive vascular trauma and the need for aortic stentgrafts, a surgical cutdown of the groin should be performed. Percutaneous access for stentgraft placement is also possible, but specific closure devices and techniques are necessary. In shock situations where blood pressure could be extremely low, ultrasound-guided puncture is recommended due to possible collapsed and nonpulsatile arteries. You should use preferential 4 F catheters with a 0.038 in. inner lumen, as you can use these devices as guiding catheters for ongoing superselective catheterization by microcatheters. Time-consuming exchange of standard 0.035 in. catheters should be avoided. Never lose your guidewire. Use one (or better two) French vascular sheaths greater than the catheters you use because the side port of the sheath can then be used for intra-arterial blood pressure measurements during the intervention by your anesthesiologists. They will appreciate you.

There are some basic imaging principles which should be kept in mind especially when searching bleeding sites. Four different imaging patterns of injured vessels could be identified during angiography (Fig. 19.2):

Considering the following top ten points, you can save much time, and therefore, these tips are recommended for a successful intervention:

In an optimal situation, the previous performed CT images guide you to the suspected bleeding area. That means that on one hand, if you do not have suspected signs of arterial bleeding, there is no indication for further time-consuming angiographic evaluation. On the other hand, if bleeding site was identified and the following angio is negative, prophylactic embolization due to possible end-organ failure and concomitant complications should be avoided. The primary goals of interventional procedures are stabilization of the patient and preservation of function of bleeding organs. However, in some cases, a less selective embolization (“shower embolization”) and a surviving patient are better than an interventional “tour de force” and a dead patient.

Common causes for negative angios are local vasospasm, local thrombosis, a venous bleeding, or a wrong catheter position. Therefore, angiographic images must be reviewed extensively in every case.