Resuscitative endovascular balloon occlusion of the aorta (REBOA) in a pediatric swine liver injury model: A pilot study

The Effects of Increasing Aortic Occlusion Times at the Level of the Highest Renal Artery (Zone II) in the Normovolemic Rabbit Model

PURPOSE

The purpose of this study was to evaluate the effects of increasing zone II resuscitative endovascular balloon occlusion of the aorta (REBOA) occlusion times on physiological, end-organ and inflammatory responses in rabbits to assess the safe aortic occlusion time in a normovolemic rabbit model.

METHODS

The zone ll aorta was occluded with a balloon in 32 rabbits (8 animals each for 15, 30, 60, and 90 min). 8 rabbits served as a control. ELISAs were used to examine the serum levels of ALT, AST, Cr, BUN, MDA, SOD, IL-8, IL-6, and TNF-α; HE staining was used to identify the morphological changes in the kidney; RT-PCR was used to detect the mRNA levels of IL-6, IL-8, TNF-α and NF-κB in the kidney and uterus; and Western blotting was used to measure the protein expression levels of IL-6, IL-8, TNF-α and NF-κB in the kidney and uterus.

RESULTS

Plasma concentrations of liver markers, kidney markers, inflammatory factors and oxidative stress indicators were significantly increased at the end of reperfusion in the 30 min, 60 min and 90 min groups. Damage to the kidney occurred in the 30 min, 60 min and 90 min groups. The mRNA and protein expression levels of IL-6, IL-8, TNF-α and NF-κB in the kidney and uterus were significantly increased at the end of reperfusion in the 30 min group, and as the time of occlusion extended, these levels continued to increase.

CONCLUSION

Activation of systemic inflammation and ischaemia-reperfusion injury of end-organs occurred when the occlusion time reached 30 min. Therefore, 15 min should be regarded as a safe period of REBOA in zone II.

Quantifying the need for pediatric REBOA: A gap analysis

BACKGROUND

Trauma is the leading cause of death in children. Resuscitative endovascular balloon occlusion of the aorta (REBOA) provides temporary hemorrhage control, but its potential benefit has not been assessed in children. We hypothesized that there are pediatric patients who may benefit from REBOA.

METHODS

Trauma patients <18 years old at a level 1 pediatric trauma center between 2009 and 2019 were queried for deaths, pre-hospital cardiac arrest, massive transfusion protocol activation, transfusion requirement, or hemorrhage control surgery. These patients defined the cohort of severely injured patients. From this cohort, patients with intraabdominal injuries for which REBOA may provide temporary hemorrhage control were identified, including solid organ injury necessitating intervention, vascular injury, or pelvic hemorrhage.

RESULTS

There were 239 severely injured patients out of 6538 pediatric traumas. Of these, 38 had REBOA-amenable injuries (15.9%) with 34.2% mortality, accounting for 10.2% of all pediatric trauma deaths at one center. Eleven patients with REBOA-amenable injuries had TBI (28.9%). Patients with REBOA-amenable injuries represented 0.6% of all pediatric traumas.

CONCLUSION

Nearly 20% of severely injured pediatric patients could potentially benefit from REBOA. The overall proportion of pediatric patients with REBOA-amenable injuries is similar to adult studies.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

Level III.

REBOA as a New Damage Control Component in Hemodynamically Unstable Noncompressible Torso Hemorrhage Patients

Noncompressible torso hemorrhage is one of the leading causes of preventable death worldwide. An efficient and appropriate evaluation of the trauma patient with ongoing hemorrhage is essential to avoid the development of the lethal diamond (hypothermia, coagulopathy, hypocalcemia, and acidosis). Currently, the initial management strategies include permissive hypotension, hemostatic resuscitation, and damage control surgery. However, recent advances in technology have opened the doors to a wide variety of endovascular techniques that achieve these goals with minimal morbidity and limited access. An example of such advances has been the introduction of the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), which has received great interest among trauma surgeons around the world due to its potential and versatility in areas such as trauma, gynecology & obstetrics and gastroenterology. This article aims to describe the experience earned in the use of REBOA in noncompressible torso hemorrhage patients. Our results show that REBOA can be used as a new component in the damage control resuscitation of the severely injured trauma patient. To this end, we propose two new deployment algorithms for hemodynamically unstable noncompressible torso hemorrhage patients: one for blunt and another for penetrating trauma. We acknowledge that REBOA has its limitations, which include a steep learning curve, its inherent cost and availability. Although to reach the best outcomes with this new technology, it must be used in the right way, by the right surgeon with the right training and to the right patient.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) for temporization of hemorrhage in adolescent trauma patients

BACKGROUND/PURPOSE

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as an alternative technique for traumatic hemorrhage control in the adult population. The purpose of this study is to describe the details of REBOA placement in adolescent trauma patients.

METHODS

Patients 18 years of age or less who received REBOA for aortic occlusion (AO) from August 2013 to February 2017 at 2 urban tertiary care centers were included.

RESULTS

7 adolescent trauma patients received REBOA by trauma surgeons for both blunt (n = 4) and penetrating mechanisms (n = 3); mean age was 17 + 1.5 years, mean admission lactate 13.0 + 4.85 mmol/L, and mean Hgb 10.7 + 2.7 g/dL. 3 patients received REBOA through a 12Fr sheath and 4 through a 7Fr sheath. AO occurred mostly at the distal thoracic aorta (Zone I) (85.7%) and also in the distal abdominal aorta (Zone III) (14.3%). 57% of patients were in arrest with ongoing CPR at the time of REBOA. In-hospital mortality was 57%; all of these patients were in arrest at the time of REBOA, had return of spontaneous circulation (ROSC), and survived to the operating room. No complications from REBOA were identified.

CONCLUSION

REBOA appears to be feasible for use in adolescents despite their smaller caliber vessels, even with use of a 12Fr sheath. REBOA results in improved physiology and can bridge adolescent trauma patients presenting in extremis to the operating room.

TYPE OF STUDY

Treatment/therapeutic study LEVEL OF EVIDENCE: Level IV.

Nationwide use of REBOA in adolescent trauma patients: An analysis of the AAST AORTA registry

BACKGROUND

Trauma is the leading cause of death for children and adolescents. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive method of hemorrhage control used primarily in adults. We aimed to characterize REBOA use in pediatric patients.

METHODS

The American Association for the Surgery of Trauma (AAST) Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry was queried for patients <18 years old undergoing REBOA placement (2013-2020). The primary outcome was mortality. Secondary outcomes included injury severity score (ISS), additional interventions, and complications.

RESULTS

Eleven patients with a median age of 17 years old had REBOA placed, with a survival rate of 30%. Inflation of the REBOA balloon resulted in a significant increase in systolic blood pressure (SBP) (median SBP pre-REBOA 53 mmHg vs. post-REBOA 110 mmHg, p=0.0007). Patients were severely injured with a median ISS of 29 (interquartile range 16-42). There were no access-site complications. All three surviving patients had a discharge Glasgow Coma Scale of 15.

CONCLUSION

REBOA is used in patients <18 years old, but all reported patients in this registry were adolescents. No REBOA-related complications were reported. Identifying pediatric patients who may benefit from REBOA and modifying currently existing technology for this group of patients is an area of ongoing research.