A meta-analysis of resuscitative endovascular balloon occlusion of the aorta (REBOA) or open aortic cross-clamping by resuscitative thoracotomy in non-compressible torso hemorrhage patients

Background

The objective of this systematic review and meta-analysis was to determine the effect of REBOA, compared to resuscitative thoracotomy, on mortality and among non-compressible torso hemorrhage trauma patients.

Methods

Relevant articles were identified by a literature search in MEDLINE and EMBASE. We included studies involving trauma patients suffering non-compressible torso hemorrhage. Studies were eligible if they evaluated REBOA and compared it to resuscitative thoracotomy. Two investigators independently assessed articles for inclusion and exclusion criteria and selected studies for final analysis. We conducted meta-analysis using random effect models.

Results

We included three studies in our systematic review. These studies included a total of 1276 patients. An initial analysis found that although lower in REBOA-treated patients, the odds of mortality did not differ between the compared groups (OR 0.42; 95% CI 0.17–1.03). Sensitivity analysis showed that the risk of mortality was significantly lower among patients who underwent REBOA, compared to those who underwent resuscitative thoracotomy (RT) (RR 0.81; 95% CI 0.68–0.97).

Conclusion

Our meta-analysis, mainly from observational data, suggests a positive effect of REBOA on mortality among non-compressible torso hemorrhage patients. However, these results deserve further investigation.

Electronic supplementary material

The online version of this article (doi:10.1186/s13017-017-0142-5) contains supplementary material, which is available to authorized users.

The effectiveness of hybrid treatment for sever multiple trauma: a case of multiple trauma for damage control laparotomy and thoracic endovascular repair

Background

Time is a crucial factor for the successful early management of the multi-trauma patient. Hybrid operating theaters, which support the integration of surgical treatment and interventional radiology, provide opportunities to reduce the time-to-surgery for life threatening conditions.

Case presentation

We describe the early successful treatment of a 54-year-old male who sustained multiple injuries when he was hit by a 1000 kg bale of wheat that fell from a height. He was admitted with hemorrhagic shock due to intra-abdominal bleeding, an unstable fracture of the pelvis, and blunt aortic injury, which was considered to be at high risk of rupture. External fixation was applied to the pelvis in the resuscitation bay, and the patient was transferred to a hybrid operating theater for treatment of both the intra-abdominal hemorrhage and blunt aortic injury. Damage control laparotomy and thoracic endovascular aortic repair were performed uneventfully.

Conclusions

Hybrid treatment, which combines emergency surgery and intraoperative interventional radiology, provides a prompt and appropriate management approach for the treatment of patients with severe multiple trauma and may improve patient outcomes.

How to manage tension gastrothorax: a case report of tension gastrothorax with multiple trauma due to traumatic diaphragmatic rupture

BACKGROUND

Tension gastrothorax is a kind of obstructive shock with prolapse and distention of the stomach into the thoracic cavity. Progressive gastric distension leads to mediastinal shift, reduced venous return, decreased cardiac output, and ultimately cardiac arrest. Therefore, it is crucial to decompress the stomach distension for the initial resuscitation of tension gastrothorax.

CASE PRESENTATION

A 75-year-old female was transported to our resuscitation bay due to motor vehicle crash. At the time of arrival to our hospital, the patient developed cardiac arrest. While undergoing cardiopulmonary resuscitation, an unstable pelvic ring was recognized, so we performed a resuscitative thoracotomy to control hemorrhage and to perform direct cardiac massage. Once we performed the thoracotomy, the stomach and omentum prolapsed out of the thoracotomy site and through the diaphragm rupture site and spontaneous circulation was recovered. Neither the descending aorta nor the heart was collapsed. Although we had continued the treatment for severe pelvic fracture (including blood transufusions), the patient died. Given that (1) the stomach prolapsed out of the body at the time of the thoracotomy; (2) at the same timing, spontaneous circulation returned; and (3) the descending aorta and heart did not collapse, we hypothesized that the main cause of the initial cardiac arrest was tension gastrothorax.

CONCLUSIONS

Recognition of tension gastrothorax pathophysiology, which is a form of obstructive shock, makes it possible to manage this injury correctly.

Pelvic trauma: WSES classification and guidelines

Complex pelvic injuries are among the most dangerous and deadly trauma related lesions. Different classification systems exist, some are based on the mechanism of injury, some on anatomic patterns and some are focusing on the resulting instability requiring operative fixation. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic impairment of pelvic ring function and the associated injuries. The management of pelvic trauma patients aims definitively to restore the homeostasis and the normal physiopathology associated to the mechanical stability of the pelvic ring. Thus the management of pelvic trauma must be multidisciplinary and should be ultimately based on the physiology of the patient and the anatomy of the injury. This paper presents the World Society of Emergency Surgery (WSES) classification of pelvic trauma and the management Guidelines.

Resuscitative endovascular balloon occlusion of the aorta with a low profile, wire free device: A game changer?

A 24 year old male arrived to our hospital after a motor cycle crash with evidence of a traumatic brain injury and in hemorrhagic shock not responsive to volume administration. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) was performed in a timely fashion using a new, low profile, wire free device. This lead to rapid reversal of hypotension while his bleeding source was sought and controlled.

Recently, REBOA has emerged as an adjunct in the hypotensive trauma patient with noncompressible torso hemorrhage. As first described, this procedure makes use of commonly available vascular surgery and endovascular products requiring large introducer sheaths (12–14 French) and long guidewires. Concerns regarding this technique center around the safety and feasibility of using such equipment in the emergency setting outside an angiography suite. This has likely limited widespread adoption of this technique. To address these concerns, newer products designed to be placed through a smaller sheath (7 French) and without the use of guidewires have been developed. Here we report on our first clinical use of such a device that we believe represents a significant advance in the care of the trauma patient.

Endovascular solutions for the management of penetrating trauma: an update on REBOA and axillo-subclavian injuries

PURPOSE

Endovascular procedures continue to gain acceptance as management options for penetrating traumatic injuries. Currently, several areas of potential endovascular application are being investigated. However, the bulk of the literature on this topic is still limited to case series or small retrospective studies. Therefore, we performed a review of the published experience involving the application of endovascular therapy to trauma patients who have sustained penetrating injuries with focus on outcomes of resuscitative endovascular balloon occlusion of the aorta (REBOA) and endovascular repair of axillo-subclavian injuries.

METHODS

Published case reports, retrospective and prospective studies of REBOA and axillo-subclavian injuries were systematically reviewed.

RESULTS

A total of 7 studies on REBOA and 10 studies on endovascular repair of axillo-subclavian injuries were included. Overall, REBOA was used as an adjunct for hemorrhage control and resuscitation in patients at risk of cardiopulmonary arrest, preventing further cardiovascular collapse successfully. For axillo-subclavian injuries, endovascular stent placement had efficacy comparable to the traditional open repair.

CONCLUSION

REBOA is a safe and effective alternative to open thoracotomy in critically ill trauma patients at risk of death due to torso hemorrhage. Endovascular repair outcomes are comparable to open repair after axillo-subclavian injuries. Long-term results of endovascular repair remain to be defined in this patient population.

Lower limb ischemia caused by resuscitative balloon occlusion of aorta

Background

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emergency procedure to manage severe hemorrhagic shock from torso injury but can cause severe ischemia of the lower extremities. However, lower extremity ischemia occurring as a complication of REBOA has been rarely reported. We describe the severe lower extremity ischemia caused by REBOA with a 12-Fr sheath in a small-built patient.

Case representation

The patient was a 16-year-old male who developed severe hemorrhagic shock due to abdominal blunt trauma. Following REBOA with a 12-Fr sheath on the right femoral artery, an emergency laparotomy and angiography to control the hemorrhage were performed. Twenty-eight hours after admission, suspecting lower extremity ischemia and compartment syndrome, we removed the sheath with a manual maneuver and performed fasciotomy. The limb ischemia was thus partially resolved. However, amputation was necessary because of ischemic necrosis on day 32. Our patient was physically small, and the diameter of his femoral artery on the contralateral site of sheath placement was also small. Therefore, disproportion of the sheath and femoral artery sizes may have caused the ischemic complication.

Conclusion

Our experience highlights the importance of appropriate size selection for the sheath in line with the target vessel. We also recommend postoperative monitoring of limb perfusion in such cases with the use of near-infrared spectroscopy to facilitate the early detection of ischemia.

Resuscitative endovascular balloon occlusion of the aorta: what is the optimum occlusion time in an ovine model of hemorrhagic shock?

PURPOSE

The aim of this study is to evaluate the early survival and organ damage following 30 and 60 min of thoracic resuscitative endovascular balloon occlusion of the aorta (REBOA) in an ovine model of severe hemorrhagic shock.

METHODS

Eighteen sheep were induced into shock by undergoing a 35 % controlled exsanguination over 30 min. Animals were randomized into three groups: 60-min REBOA 30 min after the bleeding (60-REBOA), 30-min REBOA 60 min after the bleeding (30-REBOA) and no-REBOA control (n-REBOA). Resuscitation with crystalloids and whole blood was initiated 20 and 80 min after the induction of shock. Animals were observed for 24 h with serial potassium and lactate measurements. Autopsy was performed to evaluate organ damage.

RESULTS

Two animals of the n-REBOA group died within 90 min of shock induction; no hemorrhagic deaths were observed in the REBOA groups. Twenty-four-hour survival for the 60-, 30-, and n-REBOA groups was 0/6, 5/6, and 4/6 (P = 0.002). In 60-REBOA, potassium and lactate were increased at 270-min time point: from 4.3 to 5.1 mEq/l and from 3.7 to 5.1 mmol/L, respectively. Both these values were significantly higher than in the n-REBOA group (P = 0.029 for potassium and P = 0.039 for lactate). Autopsy revealed acute tubular necrosis in all died REBOA group animals.

CONCLUSIONS

In this ovine model of severe hemorrhagic shock, REBOA can be used to prevent early death from hemorrhage; however, 60 min of occlusion results in significant metabolic derangement and organ damage that offsets this gain.

Resuscitative endovascular balloon occlusion of the aorta for control of noncompressible truncal hemorrhage in the abdomen and pelvis

BACKGROUND

Noncompressible truncal hemorrhage is a leading cause of potentially preventable death in trauma and acute care surgery patients. These patients are at high risk of exsanguination before potentially life-saving surgical intervention may be performed. Temporary aortic occlusion is an effective means of augmenting systolic blood pressure and perfusion of the heart and brain in these patients. Aortic occlusion temporarily controls distal bleeding until permanent hemostasis can be achieved. The traditional method for temporary aortic occlusion is via resuscitative thoracotomy with cross clamping of the descending aorta. While effective, resuscitative thoracotomy is highly invasive and may worsen blood loss, hypothermia, and coagulopathy by opening an otherwise uninjured body cavity. Resuscitative endovascular balloon occlusion of the aorta (REBOA) achieves temporary aortic occlusion using an occlusive balloon catheter that is introduced into the aorta via endovascular access of the common femoral artery. For this reason it is thought that REBOA could provide a less-invasive method for temporary aortic occlusion. Our purpose is to describe our experience with the implementation of REBOA at our Level 1 trauma center.

METHODS

A retrospective case series describing all cases of REBOA performed at a prominent level 1 trauma center between October 2011 and September 2015. The study inclusion criteria were any patient that received a REBOA procedure in the acute phases after injury. There were no exclusion criteria. Data were collected from electronic medical records and the hospital's trauma registry.

RESULTS

A total of 31 patients underwent REBOA during the study period. The median age of REBOA patients was 47 (interquartile range [IQR] = 27 to 63) and 77% were male. A majority (87%) of patients sustained blunt trauma. The median injury severity score was 34 (IQR = 22 to 42). The overall survival rate was 32% but varied greatly between subgroups. Balloon inflation resulted in a median increase in systolic blood pressure of 55-mm Hg (IQR 33 to 60), in cases where the data were available (n = 20). A return to spontaneous circulation was noted in 60% of patients who had arrested before REBOA (n = 10). Overall, early death by hemorrhage was 28% with only 2 deaths in the emergency department before reaching the operating room.

CONCLUSIONS

REBOA is an effective method for achieving temporary aortic occlusion in trauma patients with noncompressible truncal hemorrhage. Balloon inflation correlated with increased blood pressure and temporary hemorrhage control in a vast majority of patients.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) in the pre-hospital setting: An additional resuscitation option for uncontrolled catastrophic haemorrhage

This report describes the first use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the pre-hospital setting to control catastrophic haemorrhage. The patient, who had fallen 15 meters, suffered catastrophic internal haemorrhage associated with a pelvic fracture. He was treated by London's Air Ambulance's Physician-Paramedic team. This included insertion of a REBOA balloon catheter at the scene to control likely fatal exsanguination. The patient survived transfer to hospital, emergency angio-embolization and subsequent surgery. He was discharged neurologically normal after 52 days and went on to make a full recovery. The poor prognosis in catastrophic torso haemorrhage and novel endovascular methods of haemorrhage control are discussed. Also the challenges of Pre-Hospital REBOA are discussed together with the training and governance required for a safe system.

Resuscitative endovascular balloon occlusion of the aorta

The management of non-compressible torso hemorrhage can be problematic. Current therapy requires either open or interventional radiologic control of bleeding vessels and/or organs. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a new tool to stabilize patients in shock by achieving temporary inflow occlusion of non-compressible torso hemorrhage. This proactive technique represents a paradigm shift in achieving hemodynamic stability in patients as a bridge to definitive hemostasis. REBOA is applicable by trauma professionals, including emergency physicians, at the bedside in the emergency department, but its use needs to be considered within the context of available evidence and a robust system encompassing training, accreditation, multidisciplinary involvement and quality assurance. We review the evolving role of REBOA and discuss unanswered questions and future applications.

The use of resuscitative endovascular balloon occlusion of the aorta to control hemorrhagic shock during video-assisted retroperitoneal debridement or infected necrotizing pancreatitis

INTRODUCTION

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a technique that has been shown to provide central vascular control to support proximal aortic pressure and minimize hemorrhage in a wide variety of clinic settings, however the role of REBOA for emergency general surgery is less defined.

CASE DESCRIPTION

This is a report of a 44 year old man who experienced hemorrhagic shock during video-assisted retroperitoneal debridement (VARD) for necrotizing pancreatitis where REBOA was used to prevent ongoing hemorrhage and death.

DISCUSSION

This is the first documented report REBOA being used during pancreatic debridement in the literature and one of the first times it has been used in emergency general surgery. The use of REBOA is an option for those in hemorrhagic shock whom conventional aortic cross-clamping or supra-celiac aortic exposure is either not possible or exceedingly dangerous.

CONCLUSION

REBOA allows for adequate resuscitation and can be used as a bridge to definitive therapy in a range of surgical subspecialties with minimal morbidity and complications. The risks associated with insertion of wires, sheaths, and catheters into the arterial system, as well as the risk of visceral and spinal cord ischemia due to aortic occlusion mandate that the use of this technique be utilized in only appropriate clinical scenarios.

Treatment of intra-abdominal haemorrhagic shock by Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

PURPOSE

Haemorrhagic shock is commonly encountered in the emergency room and is associated with high morbidity and mortality. For intra-thoracic and intra-abdominal bleeding, treatment usually requires either surgery or an interventional radiologic procedure. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has already been described for pelvic fractures and intra-abdominal haemorrhages. In this case report, we present the use of REBOA in a patient admitted for haemorrhagic shock due to a ruptured splenic artery aneurysm.

CASE REPORT

We describe the case of a 35-year-old male with suspected massive pulmonary embolism. Prior to diagnostic confirmation by CT-scan, the patient suffered several cardiac arrests. CT-scan revealed a massive haemoperitoneum secondary to a ruptured aneurysm of the splenic artery. Because of refractory hypotension despite maximal conventional therapy, we used REBOA before patient transfer to the operating room for splenectomy.

CONCLUSIONS

This case underlines the feasibility of REBOA and discusses its role in uncontrollable intra-abdominal haemorrhagic shock.

The inflammatory sequelae of aortic balloon occlusion in hemorrhagic shock

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a hemorrhage control and resuscitative adjunct that has been demonstrated to improve central perfusion during hemorrhagic shock. The aim of this study was to characterize the systemic inflammatory response associated and cardiopulmonary sequelae with 30, 60, and 90 min of balloon occlusion and shock on the release of interleukin 6 (IL-6) and tumor necrosis factor alpha.

MATERIALS AND METHODS

Anesthetized female Yorkshire swine (Sus scrofa, weight 70-90 kg) underwent a 35% blood volume-controlled hemorrhage followed by thoracic aortic balloon occlusion of 30 (30-REBOA, n = 6), 60 (60-REBOA, n = 8), and 90 min (90-REBOA, n = 6). This was followed by resuscitation with whole blood and crystalloid over 6 h. Animals then underwent 48 h of critical care with sedation, fluid, and vasopressor support.

RESULTS

All animals were successfully induced into hemorrhagic shock without mortality. All groups responded to aortic occlusion with a rise in blood pressure above baseline values. IL-6, as measured (picogram per milliliter) at 8 h, was significantly elevated from baseline values in the 60-REBOA and 90-REBOA groups: 289 ± 258 versus 10 ± 5; P = 0.018 and 630 ± 348; P = 0.007, respectively. There was a trend toward greater vasopressor use (P = 0.183) and increased incidence of acute respiratory distress syndrome (P = 0.052) across the groups.

CONCLUSIONS

REBOA is a useful adjunct in supporting central perfusion during hemorrhagic shock; however, increasing occlusion time and shock results in a greater IL-6 release. Clinicians must anticipate inflammation-mediated organ failure in post-REBOA use patients.