The RAPTOR: Resuscitation with angiography, percutaneous techniques and operative repair. Transforming the discipline of trauma surgery.

Exsanguination and death are rapid consequences of untreated hemorrhage. At its simplest, successful treatment requires expedient localization and arrest of bleeding concurrent to adequate resuscitation. Fortunately, the continued improvement of percutaneous therapies now allows them to become more relevant to these treatment goals. The most recent definition of “trauma interventional radiology” is therefore “minimally invasive endovascular techniques used to arrest hemorrhage.”1 This concept reflects an evolution from primarily diagnostic/noninvasive aortic arch angiograms and extremity peripheral vascular angiography, to therapeutic procedures for hemorrhage control.2 In essence, this approach involves, first, blocking bleeding blood vessels/organs via arterial embolization and/or balloon catheters, and, second, realigning blood vessels via stent grafts. Hemodynamic instability has now become only a relative contraindication with published targets such as the spleen, liver, kidney, pelvis, lungs and all major abdominal vessels (aorta, iliac, renal, lumbar, inferior vena cava).3 Balloon occlusion of the distal aorta for bleeding pelvic fractures and proximal aorta for cross-clamping is also well established.4 It is our opinion that percutaneous trauma procedures can therefore be divided into 2 distinct subgroups: emergent interventions aimed at arresting hemorrhage (e.g., intravascular balloon occlusion with or without arterial embolization), and urgent interventions used to repair damaged vessels (i.e., stent grafting). Whereas urgent stent grafting should be performed by clinicians with extensive training and experience in both diagnostic and therapeutic angiographic techniques, the emergent arrest of hemorrhage is encompassed within the very definition of “trauma surgeon.” Considering that 70% of emergency angiographies occur in “off-hours,” with less than 15% performed within 90 minutes of arrival, surgeons trained in emergent percutaneous endovascular techniques who are immediately available at the bedside would be ideal.5,6 The order in which percutaneous and open procedures are performed can also be dynamic and best suited to a clinician trained to address each concurrently in real time. This demand for cognitive changes in the priorities and urgency of care cannot be understated. As a growing proportion of trauma patients with hemodynamically important vascular injuries are being treated emergently with angiographic techniques, the acquisition of endovascular skills by readily available trauma surgeons seems logical and appropriate. Given the evolving concept that traumatologists should play a role in the emergent arrest of hemorrhaging trauma patients via balloon occlusion, angiography and potentially angioembolization, visionary surgeons have already begun to embrace these approaches.2–4,7,8 Although the best route of skill acquisition for the trauma surgeon of the future is still undefined (additional endovascular training within trauma fellowships v. formal vascular training v. supplementary interventional radiology training), some programs (US-based acute care surgery fellowships) have already started to incorporate this paradigm into their training algorithms (1– 3 months of angiography training). It is clear, however, that in countries like Canada where percutaneous techniques typically reside within the domain of vascular surgeons and interventional radiologists, we will need to work very closely with our colleagues to define the differences between percutaneous damage control techniques used to arrest ongoing hemorrhage on an emergent basis, versus advanced repairs and stent grafting that should be performed by true content experts on a more delayed and time-friendly basis. In an ideal scenario, these emergent percutaneous therapies would be performed in the same physical location as open interventions, resuscitation and critical care. This would prevent the dreaded transfer of patients from one venue to another (trauma bay v. operating theatre v. angiography suite v. intensive care unit). To this end, the RAPTOR suite (resuscitation with angiography, percutaneous techniques and operative repair) is becoming available in a small number of centres (Calgary, Canada, and Sydney, Australia). These single suites offer the ability to treat all aspects of a patient’s critical injury (i.e., fixed angiography system, operating room, interventional radiology suite and intensive care unit). Furthermore, stakeholders from all aspects of this care (trauma surgeons, interventional radiologists, anesthesiologists and nurses) are involved and will respond on an emergent basis as needed. Given these rapidly evolving operative platforms, as well as the new multifaceted training approaches, the future of trauma surgery appears interesting and bright.

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