Adili: A warm welcome to a new episode of Vessels in Focus, the podcast of the German Society for Vascular Surgery and Vascular Medicine. My name is Farzin Adili; I am a vascular surgeon and the current President of the German Society for Vascular Surgery. My guest today is Professor Tomislav Stojanovic, Head of the Department of Vascular Surgery at Wolfsburg Hospital. Tom, it’s great to have you here.
Stojanovic: Thank you very much, Farzin; I’m delighted to be here.
Adili: Yes, I’d like to start with an experience I had last week. I was invited to give a talk on the history of reconstructive vascular surgery at the annual conference of the German Society for Angiology. And whilst preparing for this talk, I realised something I’d actually never really thought about before. Throughout the millennia-long history of surgery – and therefore also of vascular surgery – the focus for the vast majority of that time was really solely on the question of how to stop a haemorrhage. Injured vessels were compressed, cauterised or ligated, but there was one thing that could not be done: reconstructing a bleeding vessel whilst simultaneously stopping the bleeding. This is something that has only been practised in the last 100 years, and it began with the groundbreaking work of Alexis Carrel in Lyon, who developed vascular suturing into a reproducible technique and was awarded the Nobel Prize in Medicine in 1912 for his work. It was, in fact, a revolution, one must say, for surgery evolved from a practice of occlusion and ligation to one of reconstruction.
Today, we vascular surgeons implant fenestrated, branched aortic prostheses. We reconstruct vessels in almost every part of the body, using open, endovascular and hybrid techniques. Nevertheless, the very oldest task of our speciality – controlling life-threatening haemorrhage – is, of all things, still occasionally our greatest challenge. There is a very personal reason
why I am telling you this today. Last week, a 25-year-old man was admitted to our hospital as an emergency case; he had become trapped in a crane during a serious accident at work and, after being freed, suffered haemorrhagic shock before being brought to hospital. We initiated the appropriate diagnostic procedures in the trauma theatre, and the injury pattern was catastrophic. On the right-hand side, the external iliac artery and vein had been torn away. In addition, there was a laceration of the bladder, a tear in the urethra, and on the opposite side we found a dissection of the external iliac artery as well as a traumatic transection of the femoral bifurcation. There was also an unstable open-book fracture of the pelvic ring with profuse bleeding from the sacral plexus. It was therefore not merely a pelvic fracture with accompanying vascular injury, but also massive soft-tissue trauma – an internal amputation. The senior consultant in vascular surgery on duty reconstructed the pelvic and inguinal vessels and succeeded in restoring arterial blood flow to the legs. We fought for this young man’s life for two days, but were ultimately never able to fully control the bleeding – the diffuse haemorrhages. This patient subsequently died, partly due to the severe soft-tissue injuries. This case really affects me deeply.
I’d like to ask you, Tom, as head of our Commission for Disaster Medicine and Vascular Traumatology, how do you view this case? In your opinion, where do the limits of definitive reconstruction lie, and when must damage control be consistently applied?
Stojanovic: Yes, Farzin, this really is a case that is, of course, personally deeply distressing. Essentially, not much has changed. Stop the bleeding is still one of the guiding principles that remains a top priority today in disaster medicine and vascular traumatology, along with treat first what kills first – and that is, as a rule, the bleeding. So, in such a complex case, one really has to say that we then have to switch to what we’re actually trained to do – namely, reconstruction, controlling bleeding – to a sort of 360-degree approach to surgery, in other words, damage control – taking the patient’s physiology into account and working as a team with the surgeon, but also, of course, and above all, with the anaesthetist, to ensure that the most essential procedures are carried out first, so that the patient’s physiology has a chance to catch up. And that can sometimes be extremely difficult, as in the case – which I can very vividly imagine – where you try to do the bare essentials first, just to get the patient off the operating table at all, only for their physiological condition to then get the better of you.
So damage control is a top priority here; essentially, we have to get used to switching our mindset in such situations from an emergency operation to, in effect, a disaster scenario, where we can ask ourselves, What can we achieve with as few resources as possible to stop the bleeding, so that the patient has a chance to stabilise? And sometimes that’s just not possible, because the patient’s condition or the injury is simply what it is.
Adili: Sure, let me put it this way: after a case like that, we naturally carry out a detailed debriefing, and a whole series of questions have simply come to mind. Should we have set different priorities earlier on? Should we have opted for a temporary solution rather than definitive reconstruction? Would other haemorrhage control measures have made a difference? I’m thinking, for example, of REBOA; I’m thinking of the use of temporary intravascular shunts, but also the interplay between surgical haemostasis, pelvic stabilisation, packing, interventional radiology and haemostatic resuscitation. And, of course, the question arises as to whether we are adequately prepared for such situations at all. How would you review the course of events and draw concrete conclusions for the entire treatment pathway?
Stojanovic: Well, I would try to bring the whole team together – that is, the surgeons directly involved, but essentially also the on-site emergency doctor and the anaesthesia team who admitted the patient to the hospital and then continued to look after them in the operating theatre – and then perhaps go through the individual phases again step by step, to see where decisions were made, where the course of action diverged, and whether – looking back now, as hindsight is always 20/20, of course – we would actually make the same decisions again in situation Y at time X, or whether we might have stopped at a certain point. But to see whether, in hindsight, in situation Y at time X, we’d make the same decisions again, or whether at some point we’d stop in the sense that, We’re not going to provide definitive treatment just yet, but instead insert a shunt, stabilise the pelvis, do everything we can, resuscitate the patient with blood products and coagulants, and above all manage their temperature, then transfer them to the intensive care unit and reassess the situation at times X and Y. I think a sensible debrief like that, where you can go through it calmly, is something I’d definitely do. But I’m sure you’ve done it that way too.
Adili: Yes, and we’re now going to go through this in great detail again in a larger panel with everyone involved – including the anaesthetists, radiologists and urologists – once we’ve first discussed a few technical aspects.
Most haemorrhages can, of course, be controlled using standard surgical techniques. However, complex injuries to large vessels naturally require specialised surgical expertise. But there is a point where a surgical haemorrhage – which practically every surgeon should or must be able to manage – becomes a highly complex vascular surgical problem. In trauma care, we have well-established structures, A&E teams and guidelines. Vascular surgery is not always involved from the outset. Tom, in your view, when is it absolutely essential to call in a vascular surgeon? So what criteria are decisive here? For example, a central vascular injury, an expanding haematoma, or limb ischaemia caused by uncontrollable bleeding? Or does it depend primarily on whether the primary treatment team can still safely manage the situation?
Stojanovic: Well, I believe that, relatively speaking, the vascular surgeon is involved far too rarely. I believe that, at the very latest – for example, in the case of major haemorrhage or trauma where a vascular injury is to be expected, such as deceleration trauma, a fall from a great height or a completely wrecked vehicle, and where the trauma CT scan then suggests a vascular injury, the vascular surgeon must or should be involved right from the start. But limb ischaemia is also a situation where the vascular surgeon should be involved. So I believe that if they’re ultimately not involved enough – although, of course, acute haemorrhage should normally be managed by a trauma surgeon or general surgeon, depending on who’s on duty in the trauma theatre. However, I believe that, given how specialised we’ve become by now – and as you mentioned at the start – open procedures, endovascular procedures, hybrid procedures, as well as things like shunt placement, packing and so on – all of that is part of our repertoire, and I’d rather, well, personally I think, it’s better to call us in ‘once too often’ when we’re not actually needed, rather than once too few and then, in effect, find ourselves playing catch-up with ischaemia, bleeding or the overall situation. So I think we should be involved more often.
Adili: I’d like to pick up on that for a moment. What would you say, for example, to a trauma surgeon who thinks she can manage an injured artery just as well herself? I’m asking this quite deliberately to provoke a reaction, because we don’t want to argue about professional responsibilities whilst the patient is bleeding to death; rather, the point is to determine when the specific expertise of a vascular surgeon actually makes a difference.
Well, I think that depends on their training. If the trauma surgeon has attended trauma courses, attended vascular suturing courses, has actually seen and practised this before, and knows what’s involved, then that’s certainly fine for many cases. If it’s simply a matter of suturing a blood vessel somewhere using unsuitable suture material, when one has little experience and has never seen this before, then I believe the harm may well outweigh the benefit. Of course, one could argue that placing an initial suture to control bleeding and then calling in a vascular surgeon would also be a good alternative. That is certainly a valid approach if a vascular surgeon is readily available. As I said, if the trauma surgeon has the necessary experience and has completed the relevant training courses, then this may well be possible in individual cases. However, I believe that, given our specialisation across all types of surgery – and trauma surgery is a very, very broad field – I don’t think everyone possesses that wealth of experience, and I suspect it’s less common amongst our younger colleagues. So, if in doubt, it’s better to call in the vascular surgeon. Also – and I’ve experienced this a few times – with lacerations to the wrist, they’ve said, Well, I can feel the pulse, but we just wanted to call you in so you could confirm it too. In the end, it turned out that the young man had walked through a pane of glass whilst drunk; the radial artery had been completely severed and the pulse he’d felt was actually just an arterial stump, and we’d actually been about to send him home with a skin graft. So you can’t generalise. I simply believe that, given the high degree of specialisation across all areas of surgery, the vascular surgeon really ought to be involved more often.
Adili: Yes, mutual familiarity, getting to know one another, trust, and perhaps training together on the odd occasion certainly play a major role, because I don’t always know off the top of my head which of my colleagues have already undergone further training in traumatology – specifically vascular traumatology – and which haven’t. But it would, of course, be very helpful if we knew one another, if we could practise these procedures together when there is no acute emergency.
Tom, I’d like to explore the topic of damage control with you in a bit more depth. As vascular surgeons, our day-to-day work has conditioned us to reconstruct vessels as anatomically correctly and durably as possible. In other words, a good anastomosis, a functioning bypass, a technically perfect reconstruction. That is, in a sense, our professional ambition. But a seriously injured, haemodynamically unstable patient sometimes requires something completely different. They do not necessarily always require an elegant reconstruction; rather, their immediate priority is that their life be saved. And sometimes this comes at the expense of quality of life, durability or even functionality. In your view, which techniques from the field of vascular surgical damage control must one truly master in such an extreme situation?
Stojanovic: Well, for a start – and this is an extreme situation – shunt placement is certainly essential in any case. That is, shunt placement, the presence of a shunt and rapid shunt placement, so that we can first get the patient out of ischaemia. Then, of course, packing, but also knowing which vessels you can simply ligate in an emergency in this situation, which ones can be ligated without major problems, and which vessels you’d be better off not ligating. And then, of course, restoring blood flow as quickly as possible. So, if we’re dealing with lower-leg trauma, a good venous bypass would certainly be an excellent option. But if the patient is in a situation where they won’t make it, then a bypass is the best available option for the quickest possible recanalisation and restoration of blood flow, and to bring them out of ischaemia. So in that case, it’s actually not about whether it’s the most elegant or ideal solution, but rather the technically best one. And if you can’t perform a reconstruction and have to resort to a temporary fix, that makes sense even in such extreme situations. And ultimately, it must also be said that, depending on the patient’s physiological condition, primary amputation may be the appropriate course of action in such a case; if the patient would not survive a prolonged procedure involving extensive vascular reconstruction due to the severity of their injuries, then that is certainly a valid option. So damage control should be the top priority in such a setting. We need to shift our mindset a little here. We actually need to switch from our elective practice and the expectation that we’ll do the very best possible, to prioritising survival first and then dealing with the rest.
Adili: So, for which injuries would you insert a temporary shunt at an early stage? And when, in your view, would it be wrong to invest too much in reconstruction? Or are there guidelines on this? What do the guidelines say?
Stojanovic: There aren’t any guidelines like that. I mean, of course there are guidelines. The use of a shunt is highlighted in the guidelines as a primary measure, although it must be said that shunts should be inserted and checked regularly. So simply inserting the shunt is fine, but when repositioning the patient, if the shunt kinks or slips out, or the vessel kinks and the shunt stops working, that doesn’t relieve you of the need to monitor it. This is particularly true when you need to transport patients from A to B, or perhaps stabilise bones, or whatever the situation may be. So shunting is certainly one of the primary interventions; I would definitely opt for it. And if, now, the patient’s physiological condition permits – that is, if they are seriously ill, require intensive care, have multiple injuries, perhaps also with head and brain injuries that need to be treated first, then shunting is certainly the measure of choice as a temporary solution; I would prioritise that before we use a bypass, so that treatment of the other injuries doesn’t have to be put on hold. So in that situation, I’d opt for a shunt first.
If we have time to use a plastic bypass as the quickest possible measure – one we can simply take from the cupboard without much preparation – before anything else, then I’d go for that first. So, in principle, it now depends on the team’s decision: how unwell is the patient, and which injury is the most urgent.
Adili: Okay, I’d like to come back briefly to pelvic injuries. In cases of massive pelvic haemorrhage, the situation is particularly difficult, because we’re not only dealing with clearly defined arterial injuries, but also frequently with lacerations in the area of the presacral plexus and from the fracture sites. Compression using a pelvic clamp or a pelvic fixator also plays a key role here. How do you view the role of REBOA? I mean, we’re clearly talking about the possibility of interventional embolisation following pelvic stabilisation and packing, but also balloon occlusion of the aorta. With REBOA, we now have to distinguish very carefully between potential indications and the evidence. The randomised UK-REBOA trial showed no survival benefit for the use of REBOA in the emergency department, as investigated in that study. So, in your view, what is the most crucial first step for a haemodynamically unstable patient with a severe pelvic ring injury? How would you prioritise vascular control, packing, stabilisation and interventional procedures in this context?
Stojanovic: Well, REBOA isn’t generally recommended in the latest European guidelines either, because, as you said, it achieves short-term haemostasis, which is a good thing. You can certainly make use of that, but the longer it goes on, the more you’re naturally causing ischaemia alongside the haemostasis, which is obviously not good. So, in terms of prioritisation, if we have the option of, say, a ? and the presacral venous plexuses are a disaster if you open them up. That really is a Pandora’s box. If we can avoid that, then retroperitoneal or preperitoneal packing is certainly the treatment of choice in combination with, for example, endovascular procedures – not open surgery. In this context, of course, REBOA or, ultimately, any occlusion balloon – any occlusion balloon that we have at our disposal, even just for our ? aortas – can help to simply buy time. Buying time until, say, a vessel is occluded or a stent graft is placed via another vessel. So in that respect, I would already consider this part of the repertoire, but not as a stand-alone measure, merely as a temporary measure to buy time, in order to reach a stage where the patient can be stabilised.
Adili: And in your view, who makes the decision in such a situation that, for example, reconstruction isn’t carried out any further, but instead damage control is prioritised first?
Stojanovic: In principle, this has to be decided in consultation with a trauma surgeon and a vascular surgeon, ???, depending on what other injuries are present. So I see this as a team decision, involving the anaesthetist, of course – that’s absolutely clear. So it’s a team decision where you say, We could do this, that or the other. How is the patient doing? What injuries do they have? How can we stabilise them sufficiently so that they can be transferred to the intensive care unit first, where we can then replenish their fluids and warm them up again? And that has to be decided as a team. And the vascular surgeon definitely needs to be part of that. So no, no knee-jerk reactions, but a sensible, rational team decision between the trauma surgeon, the vascular surgeon and the anaesthetist.
Adili: Yes, that makes perfect sense. I remember, Tom, a piece of advice an experienced senior registrar gave me many years ago. At this point: warm regards to Ralf Ritter. The right surgical strategy serves to turn an exceptional situation into a standard one. And I believe this applies particularly well to vascular traumatology. If I can quickly assess a large vessel both proximally and distally, then I’ve already solved a significant part of the problem. But that’s precisely what you need to be able to do. The retroperitoneal approaches, exposure of the iliac vessels, control of bleeding in the pelvis or the rapid management of an injury to the femoral bifurcation – just to stick with the lower abdomen and groin for now, not to mention the intra-abdominal organs. Fortunately, however, we very rarely encounter many of these situations in our day-to-day clinical practice. Hence my next question, which I almost always ask in my podcasts. Where does a young vascular surgeon actually learn such techniques? Is standard specialist training sufficient, or do we need specialised trauma courses, simulations, anatomical dissection courses, structured training programmes – perhaps even in collaboration with the German Armed Forces? What’s your view on this?
Stojanovic: Yes, that’s exactly my point. You’re absolutely right. Ralf Ritter is an outstanding, extremely experienced surgeon. But back then, surgery was still carried out much more openly. That was, in principle, before the rise of the endovascular era. In short, it’s relatively difficult to provide further training in this area nowadays, just as open aortic surgery is also a challenge to teach in any meaningful way. That means we need different approaches. And I personally believe that we can help develop such approaches, building on a certain foundation of basic surgical experience gained during the later stages of residency or specialist training, but also during senior registrar training. This can only be corrected or made up for through dissection courses – using anatomical specimens. There are, of course, courses, sometimes involving live simulations. Technical simulation using manikins isn’t quite there yet, but it may well become just as common in the future. 3D virtual scenarios are certainly conceivable, so that we can at least develop the right mindset – and that’s the important thing: the mindset of knowing where you need to go and what you want to achieve. And then there’s the second part: the actual procedure. And I believe the gold standard really is anatomical dissection courses, so that we can practise these things at our own pace – things we otherwise cannot practise in the operating theatre. Perhaps supplemented by live training.
And in the context of the German Armed Forces, this is certainly a very strong argument, because, of course, the German Armed Forces train differently, as they place different demands on surgeons. In that respect, these Bundeswehr courses are certainly also applicable – certainly not for everyone, but certainly to a limited extent – in a civilian setting as well. And that’s what we should be practising. The formats already exist – there’s no need to reinvent the wheel – the question is how to adapt them to a limited space.
Adili: One question that is very much on the agenda at the moment is that of operational capability when not just one seriously injured person, but a large number of patients need to be treated simultaneously. We have just spoken at length about how difficult it can be to provide optimal care for even a single seriously injured patient. And at the same time, we are witnessing a fundamental change in our security situation. In the event of high-intensity combat operations, the Bundeswehr assumes that on any given day up to 1,000 wounded and sick individuals could reach Germany for further treatment. This is a planning assumption, not a prediction. As a rule, these patients will already have received initial treatment. Nevertheless, such a high number would present us with considerable challenges. Among these patients, as we know from current experience in Ukraine, there would be numerous people with penetrating injuries, blast and crush injuries, complex vascular injuries and massive blood loss. And, of course, Bundeswehr surgeons cannot manage this task on their own. To do so, they rely on all of us working in the civilian sector. The civilian healthcare system would therefore have to take on a significant proportion of this care. At the same time, of course, care for our other patients must not be allowed to break down. So, Tom, what capabilities would civilian surgery actually need to have in place for this? In other words, where would you start when it comes to building up such capabilities?
Stojanovic: Yes, that’s a highly complex issue. Naturally, the Bundeswehr – when you speak to colleagues in the Bundeswehr, they say, Well, we – that is, our Bundeswehr colleagues – are on the front line and, of course, we try to provide immediate assistance there. And for everything that survives the front line – namely those thousand casualties who are now arriving – we are ultimately responsible. We’re actually not in a bad position at all, because we already have a system in place via the national trauma centres, where patients are admitted into the system and can also be distributed. And we have a number of trauma centres, so that in the end, if you distribute those thousand a day, it could well be manageable. Beyond that, if we now also consider – and these are all, shall we say, matters and considerations from the Bundeswehr – the fact that these thousand people arriving from the front with injuries are essentially suffering from limb injuries, because major abdominal, thoracic injuries sustained at the front are rarely survived, as the journey to Germany alone can sometimes take several days. This means we will be faced with limb injuries, with reconstructive surgery – which, in principle, we are already carrying out – and, of course, with infected wounds that become infected over the course of several days. However, it becomes more problematic when one considers scenarios in which, even here at home, such situations – for example, acts of sabotage, explosions or whatever else might occur – mean that we have to build up the expertise here that our colleagues in the Bundeswehr possess on the ground. It would certainly make sense to distribute these skills amongst a few people, at least within the supra-regional trauma centres – but in every supra-regional trauma centre – so that, should such injuries actually occur here, we would be prepared for them.
Adili: You head our Commission on Disaster Medicine and Vascular Traumatology, and amongst other things, you deal with training programmes, shunt techniques, REBOA and collaboration with other specialist disciplines. Where does the DGG stand today, and what specific projects is your commission currently pursuing?
Stojanovic: Well, to put it another way, if you talk to our colleagues in the German Armed Forces – who are, in principle, our partners and points of contact – they tend to they even believe that, from their perspective, the vascular surgeon is predestined to work as an emergency surgeon there, because they understand haemorrhages, because they generally don’t panic when faced with them, and because they possess the techniques, tactile sensitivity and the right mindset for the job. So, essentially, our colleagues in the Bundeswehr do indeed see vascular surgeons as the ideal candidates for trauma and emergency surgery. What we see as our weaknesses – and this is now the commission’s task – is precisely what we discussed earlier: that we don’t need to be taught skills or access techniques when suturing a blood vessel, but we have forgotten how to create large access routes or no longer practise them sufficiently. And this is where I see the commission’s role: to establish affordable courses – dissection courses and access route courses – alongside the standard vascular suturing techniques, which we naturally teach to our younger colleagues. So that will be the biggest challenge: establishing these access courses – which do exist, but are very expensive – with a specific focus on vascular surgery.
Adili: Yes, you’ve hit the nail on the head there. The courses do cost a fair bit, and that will, of course, still pose a major challenge for all of us.
Yes, Tom, as we come to the end of our conversation, I’d like to briefly return to where we started. For more than 2,000 years, surgeons have been faced with injured blood vessels and their main task has essentially been to stop the bleeding. Today we have technical capabilities that our predecessors could not even have dreamt of. But when a patient bleeds to death before our very eyes, what ultimately counts is exactly what mattered back then. Namely, can we control the bleeding in time? And perhaps that is precisely the most important insight from our conversation. So, one final question for you: if, from tomorrow, you could implement a single change at every vascular surgery clinic in Germany to improve the management of the most severe vascular injuries, what would it be?
Stojanovic: That’s a very good question. I’d just like to add that, as a first step for our commission, we want to establish an evaluation system for vascular trauma in Germany in the form of a vascular database for vascular injuries. So, in that respect, you first need to know what we’re talking about. But if a change were to take place in any case, then I would offer more courses and send people on them. I try to implement this in my clinic as far as I can, by sending people on precisely these kinds of specialised trauma courses. And this has actually already borne fruit, because we’ve been able to save the lives of a number of young people who were admitted with stab wounds, particularly to the chest. So that’s something close to my heart. If I could do that and the resources were available, that’s what I’d put into practice.
Adili: Yes, the abdominal stab wound – a injury to a branch of the portal vein – was also what prompted Alexis Carrel, as a young medical student at the time, to explore the issue of vascular sutures. I think that’s a fitting conclusion and a valuable thought for us to take away.
Dear Tom, thank you very much for what I believe has been an open and important conversation. And to you, dear listeners, I’d like to thank you for tuning in to Vessels in Focus. Please feel free to leave your comments and feedback on Spotify or at podcasts@medizinkommunikation.org. I hope you’ve gained some interesting insights into our work in the field of vascular traumatology, and until next time on Vessels in Focus. Stay well, and do stay in touch.
