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Brenner M, Zakhary B, Coimbra R, Scalea T, Moore L, Moore E, Cannon J, Spalding C, Ibrahim J, Dennis B. Balloon Rises Above: REBOA at Zone 1 May Be Superior to Resuscitative Thoracotomy. J Am Coll Surg 2024; 238:261-271. [PMID: 38078640 DOI: 10.1097/xcs.0000000000000925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
BACKGROUND The use of Zone 1 REBOA for life-threatening trauma has increased dramatically. STUDY DESIGN The Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database was queried for blunt and penetrating trauma between 2013 and 2021. Outcomes were examined both for mechanisms of injury combined and separately and for combinations of abdominal injury with and without traumatic brain injury and chest injuries (Abbreviated Injury Scale [AIS] score >2). RESULTS A total of 531 patients underwent REBOA (408 with blunt injury and 123 with penetrating injury) and 1,603 (595 with blunt injury and 1,008 with penetrating injury) underwent resuscitative thoracotomy (RT). Mean age was 38.5 ± 16 years and mean injury severity score was 34.5 ± 21; 57.7% had chest AIS score of more than 2, 21.8% had head AIS score of more than 2, and 37.3% had abdominal AIS score of more than 2. Admission Glasgow Coma Scale was 4.9 + 4, and systolic blood pressure at aortic occlusion (AO) was 22 + 40 mmHg. No differences in outcomes in REBOA or RT patients were identified between institutions (p > 0.5). After inverse probability weighting, Glasgow Coma Scale, age, injury severity score, systolic blood pressure at AO, CPR at AO, and blood product transfusion, REBOA was superior to RT in both blunt (odds ratio [OR] 4.7, 95% CI 1.9 to 11.7) and penetrating (OR 4.9, 95% CI 1.7 to 14) injuries, across all spectrums of injury (p < 0.01). Overall mortality was significantly higher for AO more than 90 minutes compared with less than 30 minutes in blunt (OR 4.6, 95% CI 1.5 to 15) and penetrating (OR 5.4, 95% CI 1.1 to 25) injuries. Duration of AO more than 60 minutes was significantly associated with mortality after penetrating abdominal injury (OR 5.1, 95% CI 1.1 to 22) and abdomen and head (OR 5.3, 95% CI 1.6 to 18). CONCLUSIONS In-hospital survival is higher for patients undergoing REBOA than RT for all injury patterns. Complete AO by REBOA or RT should be limited to less than 30 minutes. Neither hospital and procedure volume nor trauma verification level impacts outcomes for REBOA or RT.
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Affiliation(s)
- Megan Brenner
- From the Department of Surgery, UCLA Medical Center, Los Angeles, CA (Brenner)
| | - Bishoy Zakhary
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System Medical Center, Moreno Valley, CA (Zakhary, Coimbra)
| | - Raul Coimbra
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System Medical Center, Moreno Valley, CA (Zakhary, Coimbra)
| | - Thomas Scalea
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD (Scalea)
| | - Laura Moore
- Department of Surgery, University of Texas, McGovern Medical School, Houston, TX (L Moore)
| | - Ernest Moore
- Department of Surgery, Ernest E Moore Shock Trauma Center, Denver, CO (E Moore)
| | - Jeremy Cannon
- Department of Surgery, Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (Cannon)
| | - Chance Spalding
- Department of Surgery, Ohio Health Grant Medical Center, Columbus, OH (Spalding)
| | - Joseph Ibrahim
- Department of Surgery, Orlando Health Medical Group Surgery, Orlando, FL (Ibrahim)
| | - Bradley Dennis
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN (Dennis)
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Shan Y, Zhao Y, Li C, Gao J, Song G, Li T. Efficacy of partial and complete resuscitative endovascular balloon occlusion of the aorta in the hemorrhagic shock model of liver injury. World J Emerg Med 2024; 15:10-15. [PMID: 38188550 PMCID: PMC10765071 DOI: 10.5847/wjem.j.1920-8642.2024.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 10/20/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) can temporarily control traumatic bleeding. However, its prolonged use potentially leads to ischemia-reperfusion injury (IRI). Partial REBOA (pREBOA) can alleviate ischemic burden; however, its security and effectiveness prior to operative hemorrhage control remains unknown. Hence, we aimed to estimate the efficacy of pREBOA in a swine model of liver injury using an experimental sliding-chamber ballistic gun. METHODS Twenty Landrace pigs were randomized into control (no aortic occlusion) (n=5), intervention with complete REBOA (cREBOA) (n=5), continuous pREBOA (C-pREBOA) (n=5), and sequential pREBOA (S-pREBOA) (n=5) groups. In the cREBOA and C-pREBOA groups, the balloon was inflated for 60 min. The hemodynamic and laboratory values were compared at various observation time points. Tissue samples immediately after animal euthanasia from the myocardium, liver, kidneys, and duodenum were collected for histological assessment using hematoxylin and eosin staining. RESULTS Compared with the control group, the survival rate of the REBOA groups was prominently improved (all P<0.05). The total volume of blood loss was markedly lower in the cREBOA group (493.14±127.31 mL) compared with other groups (P<0.01). The pH was significantly lower at 180 min in the cREBOA and S-pREBOA groups (P<0.05). At 120 min, the S-pREBOA group showed higher alanine aminotransferase (P<0.05) but lower blood urea nitrogen compared with the cREBOA group (P<0.05). CONCLUSION In this trauma model with liver injury, a 60-minute pREBOA resulted in improved survival rate and was effective in maintaining reliable aortic pressure, despite persistent hemorrhage. Extended tolerance time for aortic occlusion in Zone I for non-compressible torso hemorrhage was feasible with both continuous partial and sequential partial measures, and the significant improvement in the severity of acidosis and distal organ injury was observed in the sequential pREBOA.
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Affiliation(s)
- Yi Shan
- Department of Emergency Medicine, Chinese PLA Medical School, Beijing 100853, China
- Department of Emergency Medicine, the Sixth Medical Center of PLA General Hospital, Beijing 100048, China
| | - Yang Zhao
- Department of Emergency Medicine, the Sixth Medical Center of PLA General Hospital, Beijing 100048, China
- Department of Emergency Medicine, School of Medicine, South China University of Technology, Guangzhou 510006, China
| | - Chengcheng Li
- Department of Emergency Medicine, the Sixth Medical Center of PLA General Hospital, Beijing 100048, China
- Department of Emergency Medicine, School of Medicine, South China University of Technology, Guangzhou 510006, China
| | - Jianxin Gao
- Department of Emergency Medicine, the First Medical Center of PLA General Hospital, Beijing 100853, China
| | - Guogeng Song
- Department of Emergency Medicine, the Sixth Medical Center of PLA General Hospital, Beijing 100048, China
| | - Tanshi Li
- Department of Emergency Medicine, the First Medical Center of PLA General Hospital, Beijing 100853, China
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Aoki M, Matsumura Y, Izawa Y, Hayashi Y. Ultrasound assessment is useful for evaluating balloon volume of resuscitative endovascular balloon occlusion of the aorta. Eur J Trauma Emerg Surg 2023; 49:2479-2484. [PMID: 37430175 DOI: 10.1007/s00068-023-02309-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 06/20/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Endovascular balloon occlusion of the aorta (EBOA) increases proximal arterial pressure but may also induce life-threatening ischemic complications. Although partial REBOA (P-REBOA) mitigates distal ischemia, it requires invasive monitoring of femoral artery pressure for titration. In this study, we aimed to titrate P-REBOA to prevent high-degree P-REBOA using ultrasound assessment of femoral arterial flow. METHODS Proximal (carotid) and distal (femoral) arterial pressures were recorded, and perfusion velocity of distal arterial pressures was measured by pulse wave Doppler. Systolic and diastolic peak velocities were measured among all ten pigs. Total REBOA was defined as a cessation of distal pulse pressure, and maximum balloon volume was documented. The balloon volume (BV) was titrated at 20% increments of maximum capacity to adjust the degree of P-REBOA. The distal/proximal arterial pressure gradient and the perfusion velocity of distal arterial pressures were recorded. RESULTS Proximal blood pressure increased with increasing BV. Distal pressure decreased with increasing BV, and distal pressure sharply decreased by > 80% of BV. Both systolic and diastolic velocities of the distal arterial pressure decreased with increasing BV. Diastolic velocity could not be recorded when the BV of REBOA was > 80%. CONCLUSION The diastolic peak velocity in the femoral artery disappeared when %BV was > 80%. Evaluation of the femoral artery pressure by pulse wave Doppler may predict the degree of P-REBOA without invasive arterial monitoring.
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Affiliation(s)
- Makoto Aoki
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Yosuke Matsumura
- Department of Intensive Care, Chiba Emergency Medical Center, Chiba, Japan.
| | - Yoshimitsu Izawa
- Department of Emergency and Critical Care Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Yosuke Hayashi
- Department of Emergency and Critical Care Medicine, Japan Red Cross Narita Hospital, Narita, Japan
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Stene Hurtsén A, McGreevy DT, Karlsson C, Frostell CG, Hörer TM, Nilsson KF. A randomized porcine study of hemorrhagic shock comparing end-tidal carbon dioxide targeted and proximal systolic blood pressure targeted partial resuscitative endovascular balloon occlusion of the aorta in the mitigation of metabolic injury. Intensive Care Med Exp 2023; 11:18. [PMID: 37032421 PMCID: PMC10083152 DOI: 10.1186/s40635-023-00502-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/16/2023] [Indexed: 04/11/2023] Open
Abstract
BACKGROUND The definition of partial resuscitative endovascular balloon occlusion of the aorta (pREBOA) is not yet determined and clinical markers of the degree of occlusion, metabolic effects and end-organ injury that are clinically monitored in real time are lacking. The aim of the study was to test the hypothesis that end-tidal carbon dioxide (ETCO2) targeted pREBOA causes less metabolic disturbance compared to proximal systolic blood pressure (SBP) targeted pREBOA in a porcine model of hemorrhagic shock. MATERIALS AND METHODS Twenty anesthetized pigs (26-35 kg) were randomized to 45 min of either ETCO2 targeted pREBOA (pREBOAETCO2, ETCO2 90-110% of values before start of occlusion, n = 10) or proximal SBP targeted pREBOA (pREBOASBP, SBP 80-100 mmHg, n = 10), during controlled grade IV hemorrhagic shock. Autotransfusion and reperfusion over 3 h followed. Hemodynamic and respiratory parameters, blood samples and jejunal specimens were analyzed. RESULTS ETCO2 was significantly higher in the pREBOAETCO2 group during the occlusion compared to the pREBOASBP group, whereas SBP, femoral arterial mean pressure and abdominal aortic blood flow were similar. During reperfusion, arterial and mesenteric lactate, plasma creatinine and plasma troponin concentrations were higher in the pREBOASBP group. CONCLUSIONS In a porcine model of hemorrhagic shock, ETCO2 targeted pREBOA caused less metabolic disturbance and end-organ damage compared to proximal SBP targeted pREBOA, with no disadvantageous hemodynamic impact. End-tidal CO2 should be investigated in clinical studies as a complementary clinical tool for mitigating ischemic-reperfusion injury when using pREBOA.
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Affiliation(s)
- Anna Stene Hurtsén
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
- Centre for Clinical Research and Education, County Council of Värmland, Karlstad, Sweden.
- School of Medical Sciences, Örebro University, Örebro, Sweden.
| | - David T McGreevy
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | | | - Claes G Frostell
- Anesthesiology and Intensive Care, Department of Clinical Sciences, Karolinska Institute at Danderyd Hospital, Stockholm, Sweden
| | - Tal M Hörer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Kristofer F Nilsson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- School of Medical Sciences, Örebro University, Örebro, Sweden
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Pollock GA, Lo J, Chou H, Kissen MS, Kim M, Zhang V, Betz A, Perlman R. Advanced diagnostic and therapeutic techniques for anaesthetists in thoracic trauma: an evidence-based review. Br J Anaesth 2023; 130:e80-e91. [PMID: 36096943 DOI: 10.1016/j.bja.2022.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/27/2022] [Accepted: 07/02/2022] [Indexed: 01/06/2023] Open
Abstract
Anaesthetists play an important role in the evaluation and treatment of patients with signs of thoracic trauma. Anaesthesia involvement can provide valuable input using both advanced diagnostic and therapeutic interventions. Commonly performed interventions may be complicated in this setting including airway management, damage control resuscitation, and acute pain management. Anaesthetists must consider additional factors including airway injuries, vascular injuries, and coagulopathy when treating this population. This evidence-based review discusses traumatic thoracic injuries with a focus on new interventions and modern anaesthesia techniques. This review further serves to support the early involvement of anaesthetists in the emergency department and other areas where they can provide value to the trauma care pathway.
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Affiliation(s)
- Gabriel A Pollock
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Thoracic Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Regional Anaesthesia & Acute Pain Service Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Jessie Lo
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Regional Anaesthesia & Acute Pain Service Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Henry Chou
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Thoracic Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael S Kissen
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Thoracic Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Regional Anaesthesia & Acute Pain Service Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michelle Kim
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Vida Zhang
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Thoracic Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Trauma Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alexander Betz
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ryan Perlman
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Trauma Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Organ perfusion during partial REBOA in haemorrhagic shock: dynamic 4D-CT analyses in swine. Sci Rep 2022; 12:18745. [PMID: 36335161 PMCID: PMC9637200 DOI: 10.1038/s41598-022-23524-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022] Open
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) increases proximal blood pressure while inducing distal ischemia of visceral organs. The evaluation of distal ischemia severity during REBOA is a prerequisite for safe resuscitation of haemorrhagic shock patients with REBOA. We evaluated changes in blood flow and organ perfusion due to the degree of occlusion using dynamic 4D-computed tomography (CT). We compared the results with those of a previous study on euvolemic status. Delayed enhancement of the inferior vena cava (IVC) without retrograde flow was observed in the 4D-volume rendering images in the high-degree occlusion. The time-density curve (TDC) of the liver parenchyma (liver perfusion) and superior mesenteric vein (SMV) demonstrated a decreased peak density and a delayed peak in high-degree occlusion. The change rate of the area under the TDC of the liver and SMV decreased linearly as the degree of occlusion increased (PV, Y = -1.071*X + 106.8, r2 = 0.972, P = 0.0003; liver, Y = -1.050*X + 101.8, r2 = 0.933, P = 0.0017; SMV, Y = -0.985*X + 100.3, r2 = 0.952, P = 0.0009). Dynamic 4D-CT revealed less severe IVC congestion during P-REBOA in haemorrhagic shock than in euvolemia. Analyses of TDC of the liver and SMV revealed a linear change in organ perfusion, regardless of intravascular volume.
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Power A, Parekh A, Parry N, Moore LJ. Cushioned on the way up, controlled on the way down during resuscitative endovascular balloon occlusion of the aorta (REBOA): investigating a novel compliant balloon design for optimizing safe overinflation combined with partial REBOA ability. Trauma Surg Acute Care Open 2022; 7:e000948. [PMID: 35949246 PMCID: PMC9295662 DOI: 10.1136/tsaco-2022-000948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 07/04/2022] [Indexed: 11/11/2022] Open
Abstract
Background There are a variety of devices capable of performing resuscitative endovascular balloon occlusion of the aorta (REBOA), with most containing compliant balloon material. While compliant material is ideal for balloon inflation due to its “cushioning” effect, it can be problematic to “control” during deflation. The COBRA-OS (Control Of Bleeding, Resuscitation, Arterial Occlusion System) was designed to optimize inflation and deflation of its compliant balloon and was tested in vitro and in vivo with respect to its overinflation and partial REBOA abilities. Methods For overinflation, the COBRA-OS was inflated in three differently sized inner diameter (ID) vinyl tubes until balloon rupture. It was then overinflated in six harvested swine aortas and in all three REBOA zones of three anesthetized swine. For partial REBOA, the COBRA-OS underwent incremental deflation in a pulsatile benchtop aortic model and in zone 1 of three anesthetized swine. Results For overinflation, compared with the known aortic rupture threshold of 4 atm, the COBRA-OS exceeded this value in only the smallest of the vinyl tubes: 8 mm ID tube, 6.5 atm; 9.5 mm ID tube, 3.5 atm; 13 mm ID tube, 1.5 atm. It also demonstrated greater than 500% overinflation ability without aortic damage in vitro and caused no aortic damage when inflated to maximum inflation volume in vivo. For partial REBOA, the COBRA-OS was able to provide a titration window of between 3 mL and 4 mL in both the pulsatile vascular model (3.4±0.12 mL) and anesthetized swine (3.8±0.35 mL). Discussion The COBRA-OS demonstrated the ability to have a cushioning effect during inflation combined with titration control on deflation in vitro and in vivo. This study suggests that despite its balloon compliance, both safe overinflation and partial REBOA can be successfully achieved with the COBRA-OS. Level of evidence Basic science.
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Affiliation(s)
- Adam Power
- Surgery, Western University, London, Ontario, Canada
| | - Asha Parekh
- Engineering, Western University, London, Ontario, Canada
| | - Neil Parry
- Surgery, Western University, London, Ontario, Canada
| | - Laura J Moore
- Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
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THE PHYSIOLOGY OF AORTIC FLOW AND PRESSURES DURING PARTIAL RESUSCITATIVE ENDOVASCULAR BALLOON OCCLUSION OF THE AORTA (pREBOA) IN A SWINE MODEL OF HEMORRHAGIC SHOCK. J Trauma Acute Care Surg 2022; 93:S94-S101. [PMID: 35545802 DOI: 10.1097/ta.0000000000003667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Partial resuscitative endovascular balloon occlusion of the aorta (REBOA) has shown promise as a method to extend REBOA, but there lacks a standard definition of the technique. The purpose of this study was to investigate the relationships between distal and proximal mean arterial blood pressure (MAP) and distal aortic flow past a REBOA catheter. We hypothesize that a relationship between distal aortic flow and distal MAP in Zone 1 partial REBOA (pREBOA) is conserved and that there is no apparent relationship between aortic flow and proximal MAP. METHODS A retrospective data analysis of swine, cohort one underwent 20% controlled hemorrhage and then randomized to aortic flow of 400 ml/min or complete occlusion for 20 minutes (n = 11). Cohort two underwent 30% controlled hemorrhage followed by complete aortic occlusion for 30 minutes (n = 29). Then they all underwent REBOA wean in a similar stepwise fashion. Blood pressure was collected from above (proximal) and below (distal) the REBOA balloon. Aortic flow was measured using a surgically implanted supraceliac aortic perivascular flow probe. The time period of balloon wean was taken as the time point of interest. RESULTS A linear relationship between distal MAP and aortic flow was observed (R 2 value: 0.80), while no apparent relationship appeared between proximal MAP and aortic flow (R 2 value: 0.29). The repeated measures correlation coefficient for distal MAP (0.94, 95% Confidence Interval: 0.94 - 0.94) was greater than proximal MAP (-0.73, 95% Confidence Interval: -0.74 - -0.72). CONCLUSION The relationship between MAP and flow will be a component of next generation pREBOA control inputs. This study provides evidence that pREBOA techniques should rely on distal rather than proximal MAP for control of distal aortic flow. These data could inform future inquiry into optimal flow rates and parameters based on distal MAP in both translational and clinical contexts. LEVEL OF EVIDENCE Level V.
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Perlman R, Breen L, Pollock GA. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): Looking Back, Moving Forward. J Cardiothorac Vasc Anesth 2022; 36:3439-3443. [PMID: 35659831 DOI: 10.1053/j.jvca.2022.04.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 04/27/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Ryan Perlman
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Leah Breen
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Gabriel A Pollock
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA
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10
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Targeted Regional Optimization in Action: Dose-Dependent end Organ Ischemic Injury with Partial Aortic Occlusion in The Setting of Ongoing Liver Hemorrhage. Shock 2022; 57:732-739. [PMID: 35234207 DOI: 10.1097/shk.0000000000001922] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Targeted regional optimization (TRO) describes partial resuscitative endovascular balloon occlusion of the aorta (REBOA) strategy that allows for controlled distal perfusion to balance hemostasis and tissue perfusion. This study characterized hemodynamics at specific targeted distal flow rates in a swine model of uncontrolled hemorrhage to determine if precise TRO by volume was possible. METHODS Anesthetized swine were subjected to liver laceration and randomized into TRO at distal flows of 300 (n = 8), 500 (n = 8) or 700 ml/min (n = 8). After 90 minutes, the animals received damage control packing and were monitored for 6 hours. Hemodynamic parameters were measured continuously, and hematology and serologic labs obtained at predetermined intervals. RESULTS During TRO, the average percent deviation from the targeted flow was lower than 15.9% for all cohorts. Average renal flow rates were significantly different across all cohorts during TRO phase (p<0.0001; TRO300 = 63.1 ± 1.2; TRO500=133.70 ± 1.93; TRO700=109.3 ± 2.0), with the TRO700 cohort having less renal flow than TRO500. The TRO500 and TRO700 average renal flow rates inverted during the ICU phase (p < 0.0001; TRO300=86.20 ± 0.40; TRO500=148.50 ± 1.45; TRO700= 181.1 ± 0.70). There was higher BUN, creatinine, and potassium in the TRO300 cohort at the end of the experiment, but no difference in lactate or pH between cohorts. CONCLUSION This study demonstrated technical feasibility of TRO as a strategy to improve outcomes after prolonged periods of aortic occlusion and resuscitation in the setting of ongoing solid organ hemorrhage. A dose-dependent ischemic end-organ injury occurs beginning with partial aortic occlusion that progresses through the critical care phase, with exaggerated effect on renal function.
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Ronaldi AE, Madurska MJ, Bozzay JD, Polcz JE, Baer DG, Burmeister DM, White PW, Rasmussen TE, White JM. Targeted Regional Optimization: Increasing the Therapeutic Window for Endovascular Aortic Occlusion In Traumatic Hemorrhage. Shock 2021; 56:493-506. [PMID: 34014887 DOI: 10.1097/shk.0000000000001814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
ABSTRACT Resuscitative endovascular balloon occlusion of the aorta (REBOA) allows for effective temporization of exsanguination from non-compressible hemorrhage (NCTH) below the diaphragm. However, the therapeutic window for aortic occlusion is time-limited given the ischemia-reperfusion injury generated. Significant effort has been put into translational research to develop new strategies to alleviate the ischemia-reperfusion injury and extend the application of endoaortic occlusion. Targeted regional optimization (TRO) is a partial REBOA strategy to augment proximal aortic and cerebral blood flow while targeting minimal threshold of distal perfusion beyond the zone of partial aortic occlusion. The objective of TRO is to reduce the degree of ischemia caused by complete aortic occlusion while providing control of distal hemorrhage. This review provides a synopsis of the concept of TRO, pre-clinical, translational experiences with TRO and early clinical outcomes. Early results from TRO strategies are promising; however, further studies are needed prior to large-scale implementation into clinical practice.
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Affiliation(s)
- Alley E Ronaldi
- Walter Reed National Military Medical Center, The Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Marta J Madurska
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Maryland
| | - Joseph D Bozzay
- Walter Reed National Military Medical Center, The Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Jeanette E Polcz
- Walter Reed National Military Medical Center, The Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | | | - David M Burmeister
- Walter Reed National Military Medical Center, The Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Paul W White
- Walter Reed National Military Medical Center, The Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Todd E Rasmussen
- Walter Reed National Military Medical Center, The Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Joseph M White
- Walter Reed National Military Medical Center, The Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Kinslow K, Shepherd A, Sutherland M, McKenney M, Elkbuli A. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Use in Animal Trauma Models. J Surg Res 2021; 268:125-135. [PMID: 34304008 DOI: 10.1016/j.jss.2021.06.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 05/14/2021] [Accepted: 06/21/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) was developed to prevent traumatic exsanguination. We aim to identify the outcomes in animal models with 1) partial versus complete REBOA occlusion and 2) zone 1 versus 2 placements. METHODS The PRISMA guidelines were followed. We conducted a search of PubMed, EMBASE and Google Scholar for REBOA studies in animal trauma models using the following search terms: "REBOA trauma", "REBOA outcomes" "REBOA complications". SYRCLE's RoB Tool was utilized for the risk of bias and study quality assessment. RESULTS Our search yielded 14 RCTs for inclusion. Eleven studies directly investigated partial REBOA versus total aortic occlusion. Overall, partial REBOA techniques were associated with similar attainment of proximal MAP but with significantly less ischemic burden. Significant mortality benefit with partial occlusion was observed in three studies. Survival time post-occlusion also was improved with zone 3 placement versus zone 1 (100% versus 33%; P < 0.01). CONCLUSIONS There appears to be a fine balance between desired proximal arterial pressure and time of occlusion for overall survival and subsequent risk of distal ischemia. Many "partial occlusion" techniques may be superior in attaining such balance over prolonged REBOA inflation where no distal flow is allowed. Tailored zone 3 placement may offer significant mortality and morbidity advantages compared to sustained total occlusion and indiscriminate zone 1 placement strategies. As clear conclusions regarding REBOA are unlikely to be established in animal models, larger randomized investigations utilizing human subjects are needed to describe optimal REBOA technique and applicability in greater detail.
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Affiliation(s)
- Kyle Kinslow
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida
| | - Aaron Shepherd
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida; Department of Surgery, University of South Florida, Tampa, Florida
| | - Mason Sutherland
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida; Department of Surgery, University of South Florida, Tampa, Florida
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida; Department of Surgery, University of South Florida, Tampa, Florida
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida; Department of Surgery, University of South Florida, Tampa, Florida.
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Kinslow K, Shepherd A, McKenney M, Elkbuli A. Resuscitative Endovascular Balloon Occlusion of Aorta: A Systematic Review. Am Surg 2021; 88:289-296. [PMID: 33605780 DOI: 10.1177/0003134820972985] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The data on resuscitative endovascular balloon occlusion of the aorta (REBOA) use continue to grow with its increasing use in trauma centers. The data in her last 5 years have not been systematically reviewed. We aim to assess current literature related to REBOA use and outcomes among civilian trauma populations. METHODS A literature search using PubMed, EMBASE, and JAMA Network for studies regarding REBOA usage in civilian trauma from 2016 to 2020 is carried out. This review followed preferred reporting items for systematic reviews and meta-analysis guidelines. RESULTS Our search yielded 35 studies for inclusion in our systematic review, involving 4073 patients. The most common indication for REBOA was patient presentation in hemorrhagic shock secondary to traumatic injury. REBOA was associated with significant systolic blood pressure improvement. Of 4 studies comparing REBOA to non-REBOA controls, 2 found significant mortality benefit with REBOA. Significant mortality improvement with REBOA compared to open aortic occlusion was seen in 4 studies. In the few studies investigating zone placement, highest survival rate was seen in patients undergoing zone 3. Overall, reports of complications directly related to overall REBOA use were relatively low. CONCLUSION REBOA has been shown to be effective in promoting hemodynamic stability in civilian trauma. Mortality data on REBOA use are conflicting, but most studies investigating REBOA vs. open occlusion methods suggest a significant survival advantage. Recent data on the REBOA technique (zone placement and partial REBOA) are sparse and currently insufficient to determine advantage with any particular variation. Overall, larger prospective civilian trauma studies are needed to better understand the benefits of REBOA in high-mortality civilian trauma populations. STUDY TYPE Systematic Review. LEVEL OF EVIDENCE III- Therapeutic.
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Affiliation(s)
- Kyle Kinslow
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| | - Aaron Shepherd
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
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Russo RM, White JM, Baer DG. Partial Resuscitative Endovascular Balloon Occlusion of the Aorta: A Systematic Review of the Preclinical and Clinical Literature. J Surg Res 2021; 262:101-114. [PMID: 33561721 DOI: 10.1016/j.jss.2020.12.054] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 12/04/2020] [Accepted: 12/16/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) has become a standard adjunct for the management of life-threatening truncal hemorrhage, but the technique is limited by the sequalae of ischemia distal to occlusion. Partial REBOA addresses this limitation, and the recent Food and Drug Administration approval of a device designed to enable partial REBOA will broaden its application. We conducted a systematic review of the available animal and clinical literature on the methods, impacts, and outcomes associated with partial REBOA as a technique to enable targeted proximal perfusion and limit distal ischemic injury. We hypothesize that a systematic review of the published animal and human literature on partial REBOA will provide actionable insight for the use of partial REBOA in the context of future wider clinical implementation of this technique. METHODS Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Protocols guidelines, we conducted a search of the available literature which used partial inflation of a REBOA balloon catheter. Findings from 22 large animal studies and 14 clinical studies met inclusion criteria. RESULTS Animal and clinical results support the benefits of partial REBOA including extending the resuscitative window extended safe occlusion time, improved survival, reduced proximal hypertension, and reduced resuscitation requirements. Clinical studies provide practical physiologic targets for partial REBOA including a period of total occlusion followed by gradual balloon deflation to achieve a target proximal pressure and/or target distal pressure. CONCLUSIONS Partial REBOA has several benefits which have been observed in animal and clinical studies, most notably reduced ischemic insult to tissues distal to occlusion and improved outcomes compared with total occlusion. Practical clinical protocols are available for the implementation of partial REBOA in cases of life-threatening torso hemorrhage.
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Affiliation(s)
- Rachel M Russo
- United States Air Force, 60(Th) Medical Group, Travis Air Force Base, California; University of California Davis Medical Center, Sacramento, California
| | - Joseph M White
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Heindl SE, Wiltshire DA, Vahora IS, Tsouklidis N, Khan S. Partial Versus Complete Resuscitative Endovascular Balloon Occlusion of the Aorta in Exsanguinating Trauma Patients With Non-Compressible Torso Hemorrhage. Cureus 2020; 12:e8999. [PMID: 32775079 PMCID: PMC7402546 DOI: 10.7759/cureus.8999] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Hemorrhage is a major cause of death globally, yet our options to control the condition have remained limited. The standard intervention for patients suffering from a non-compressible torso hemorrhage (NCTH) typically involves resuscitative thoracotomy (RT) with aortic cross-clamping. Apart from being extraordinarily invasive, the survival rates for this procedure remain low. Over the years, research has surfaced that offers much promise regarding the use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in exsanguinating patients. Although this type of procedure is not yet universally recognized as a gold standard, it holds some hope for the development of additional research regarding how we can make use of this advancement to improve survival in trauma patients. Complete REBOA (c-REBOA) has not gained wide acceptance due to the undeniable effects it has on normal physiology, metabolic effects, long-term complications, and mortality. Partial REBOA (p-REBOA) is not yet fully validated by research but could potentially be the answer to our problem. The critical question that we should address at this juncture is as follows: how can we improve the survival of patients with an NCTH in the least invasive way possible, while also reducing the feared complications associated with c-REBOA?
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Affiliation(s)
- Stacey E Heindl
- Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Dwayne A Wiltshire
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Ilmaben S Vahora
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Nicholas Tsouklidis
- Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA.,Health Care Administration, University of Cincinnati Health, Cincinnati, USA.,Medicine, Atlantic University School of Medicine, Gros Islet, LCA
| | - Safeera Khan
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for Use in Temporizing Intra-Abdominal and Pelvic Hemorrhage: Physiologic Sequelae and Considerations. Shock 2020; 54:615-622. [DOI: 10.1097/shk.0000000000001542] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Matsumura Y, Higashi A, Izawa Y, Hishikawa S, Kondo H, Reva V, Oda S, Matsumoto J. Organ ischemia during partial resuscitative endovascular balloon occlusion of the aorta: Dynamic 4D Computed tomography in swine. Sci Rep 2020; 10:5680. [PMID: 32231232 PMCID: PMC7105501 DOI: 10.1038/s41598-020-62582-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 03/16/2020] [Indexed: 12/02/2022] Open
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) increases proximal pressure, and simultaneously induces distal ischemia. We aimed to evaluate organ ischemia during partial REBOA (P-REBOA) with computed tomography (CT) perfusion in a swine model. The maximum balloon volume was recorded as total REBOA when the distal pulse pressure ceased. The animals (n = 4) were scanned at each 20% of the maximum balloon volume, and time-density curve (TDC) were analysed at the aorta, portal vein (PV), liver parenchyma, and superior mesenteric vein (SMV, indicating mesenteric perfusion). The area under the TDC (AUTDC), the time to peak (TTP), and four-dimensional volume-rendering images (4D-VR) were evaluated. The TDC of the both upper and lower aorta showed an increased peak and delayed TTP. The TDC of the PV, liver, and SMV showed a decreased peak and delayed TTP. The dynamic 4D-CT analysis suggested that organ perfusion changes according to balloon volume. The AUTDC at the PV, liver, and SMV decreased linearly with balloon inflation percentage to the maximum volume. 4D-VR demonstrated the delay of the washout in the aorta and retrograde flow at the inferior vena cava in the highly occluded status.
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Affiliation(s)
- Yosuke Matsumura
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Chiba, Japan.
| | - Akiko Higashi
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Chiba, Japan
| | - Yoshimitsu Izawa
- Department of Emergency and Critical Care Medicine, Saiseikai Utsunomiya Hospital, Utsunomiya, Tochigi, Japan.,Department of Emergency and Critical Care Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Shuji Hishikawa
- Center for Development of Advanced Medical Technology, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Hiroshi Kondo
- Department of Radiology, Teikyo University School of Medicine, Itabashi, Tokyo, Japan
| | - Viktor Reva
- Department of War Surgery, Kirov Military Medical Academy, Ulitsa Akademika Lebedeva, St Petersburg, Russia
| | - Shigeto Oda
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Chiba, Japan
| | - Junichi Matsumoto
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
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