The evolving field of acute care surgery includes trauma surgery, emergency general surgery, and surgical critical care. Transcatheter arterial embolization has been established as a less invasive treatment for traumatic bleeding. The combination of interventional radiology and acute care surgery has improved the outcomes of trauma patients. This review article focuses on the role of interventional radiology in the trauma field of acute care surgery.

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Since the Hybrid Emergency Room System (HERS) developed in 2017, many facilities have adopted it when setting up new computed tomography or emergency rooms. Regardless of whether they have HERS, the term has become more common, and it likely interests several medical teams.
HERS allows for medical treatment while ensuring both safety and rapidity, making it a highly valuable emergency room, especially for trauma and emergency cases. However since HERS is based on IVR-CT, it also requires the involvement of radiologists and IR specialists, suggesting that it can be effectively used within the field of radiology as well. It is desirable for radiologists and IR specialists to share their knowledge of HERS and promote its use widely. This discussion will cover the operation of HERS, present cases, and examine the roles of radiologists and IR specialists in this system.

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Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a resuscitative procedure that uses a balloon catheter for treating patients with non-compressible torso hemorrhage patients. REBOA can temporarily control hemorrhage distal to the occlusion while maintaining proximal pressure. This conceptually attractive and reasonable procedure has not necessarily contributed to good outcomes. REBOA should be used for suitably selected patients under appropriate management. The degree of proximal pressure elevation due to REBOA depends on the stressed blood volume, occlusion site and rate, and cardiac contractile function. Excessive elevation of proximal pressure may increase hemorrhage for patients with head or chest trauma. Therefore, the principle of REBOA management should be partial REBOA with permissive hypotension until tertiary hemostasis. We should also strive to shorten the occlusion time as much as possible after REBOA and be careful to avoid REBOA-related complications, such as ischemia-reperfusion injury.

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The Indigo system (Penumbra Inc., Alameda, CA, USA), a new thrombus aspiration device for acute lower limb ischemia and acute superior mesenteric artery occlusion, was first covered by health insurance in Japan on September 1st, 2023. Until now, thrombolytic therapy has been widely performed for these acute arterial occlusive diseases, but, it has become difficult due to the suspension of the supply of urokinase preparations. The Indigo system promotes active thrombectomy using a vacuum pump that generates substantial suction and is expected to be a promising alternative treatment in the current circumstances. This article introduces the basics of the Indigo system and how to use it by presenting clinical cases.

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The Japanese Society of Interventional Radiology (JSIR) has been approved as a subspecialty society by the Japanese Medical Specialty Board. Consequently, the title of those certified in this field will change from ‘IR Specialist’ to ‘Specialist in Radiologic Intervention’, and preparations are underway to hold the first examination for this certification after 2026. Due to this change in the system, individuals who have trained in non-radiology specialties under the Board’s basic medical specialty system since 2018 will no longer be able to pursue the ‘Specialist in Radiologic Intervention’ designation.
In response, the JSIR believes it is necessary to establish a ‘Certified Emergency IR Physician’ system to ensure the quality and dissemination of IR, particularly for those who have specialized in departments other than radiology, especially emergency medicine.
After extensive deliberations, it was decided that the requirements for becoming a ‘Certified Emergency IR Physician’ include having a specialty in a primary medical field such as emergency medicine, having completed at least three years of training with experience in more than 100 cases (including at least 60 emergency IR cases), and passing an examination that includes imaging diagnostics related to IR.

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Endovascular treatment (EVT) for vein graft failure is associated with various complications. A case of multiple pseudoaneurysm formation following balloon angioplasty for an occluded saphenous vein graft is reported.
An octogenarian man with a history of distal bypass surgery using the great saphenous vein for a left foot ulcer presented with ulcer recurrence due to graft occlusion. During EVT for the occluded graft, vessel rupture occurred and was managed with stent graft placement. In addition, wall irregularities suggestive of dissection were observed but were managed conservatively. One month post-procedure, multiple pseudoaneurysms developed along the vein graft at sites corresponding to previous wall irregularities. They were successfully treated with additional stent graft placement.
This case highlights the importance of careful balloon sizing and the potential progression of seemingly minor vein graft injuries to significant complications following EVT.

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