1
|
Li RF, Gong XF, Xu HB, Lin JT, Zhang HG, Suo ZJ, Wu JL. Age affects vascular morphology and predictiveness of anatomical landmarks for aortic zones in trauma patients: implications for resuscitative endovascular balloon occlusion of the aorta. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02512-z. [PMID: 38656432 DOI: 10.1007/s00068-024-02512-z] [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: 02/22/2024] [Accepted: 03/30/2024] [Indexed: 04/26/2024]
Abstract
PURPOSE Understanding the vascular morphology is fundamental for resuscitative endovascular balloon occlusion of the aorta. This study aimed to evaluate the effect of aging on length and diameter of aorta and iliac arteries in trauma patients, and to investigate the predictiveness of anatomical landmarks for aortic zones. METHODS A total of 235 patients in a regional trauma center registry from September 1, 2018, to January 3, 2024, participated in the study. Reconstruction of computed tomography was applied to the torso area. The marginal diameter and length of aorta and iliac arteries were measured. Anatomical landmark distances and aortic marginal lengths were compared. RESULTS The length and diameter of aorta and iliac arteries increased with age, and a tortuous and enlarged morphology was observed in older patients. There was a good regression between age and diameter of the aorta. Neither the jugular notch, the xiphisternal joint, nor the umbilicus could reliably represent specific margins of aortic zones. The distance between the mid-sternum and femoral artery (427 ± 25 to 442 ± 25 mm for right, and 425 ± 28 to 440 ± 26 mm for left) was predictive for zone 1 in all groups. The distance between the lower one-third junction of the xiphisternum to the umbilicus and femoral artery (232 ± 19 to 240 ± 17 mm for right, and 229 ± 20 to 237 ± 19 mm for left) was predictive for zone 3 aorta. CONCLUSION Aging increases the length and diameter of aorta and iliac arteries, with a tortuous and enlarged morphology in geriatric populations. The mid-sternum and the lower one-third junction of the xiphisternum to the umbilicus were predictive landmarks for zone 1 and zone 3, respectively.
Collapse
Affiliation(s)
- Rui-Fa Li
- Department of Critical Care Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, No. 89 Taoyuan Road, Nanshan District, Shenzhen, 510182, Guangdong, China
| | - Xue-Fang Gong
- Department of Pulmonary and Critical Care Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, No. 89 Taoyuan Road, Nanshan District, Shenzhen, 510182, Guangdong, China
| | - Hong-Bo Xu
- Department of Critical Care Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, No. 89 Taoyuan Road, Nanshan District, Shenzhen, 510182, Guangdong, China
| | - Jin-Tuan Lin
- Department of Critical Care Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, No. 89 Taoyuan Road, Nanshan District, Shenzhen, 510182, Guangdong, China
| | - Hai-Gang Zhang
- Department of Critical Care Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, No. 89 Taoyuan Road, Nanshan District, Shenzhen, 510182, Guangdong, China
| | - Zhi-Jun Suo
- Department of Critical Care Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, No. 89 Taoyuan Road, Nanshan District, Shenzhen, 510182, Guangdong, China
| | - Jing-Lan Wu
- Department of Critical Care Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, No. 89 Taoyuan Road, Nanshan District, Shenzhen, 510182, Guangdong, China.
| |
Collapse
|
2
|
Kaminski C, Beardslee LA, Rajani R. Sensorized Endovascular Technologies: Additional Data to Enhance Decision-Making. Ann Vasc Surg 2024; 99:105-116. [PMID: 37922964 DOI: 10.1016/j.avsg.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/29/2023] [Accepted: 10/07/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Current endovascular procedures rely mostly on anatomic information, guided by fluoroscopy, to perform interventions (i.e. angioplasty, stent placement, coils). However, the structural parameters provided by these imaging technologies do not provide any physiological data on either the disease state or efficacy of intervention. Additional endovascular tools are needed to collect physiologic and other both anatomic and nonanatomic data to further individualize endovascular interventions with the ultimate goal of improving patient outcomes. This review details the current state of the art for these sensorized endovascular technologies and details systems under development with the aim of identifying gaps and new directions. The objective of this review was to survey the Vascular Surgery literature, engineering literature, and commercially available products to determine what exists in terms of sensor-enabled endovascular devices and where gaps and opportunities exist for further sensor integration. METHODS Search terms were entered into search engines such as Google and Google Scholar to identify endovascular devices containing sensors. A variety of terms were used including directly search for items such as "sensor-enabled endovascular devices" and then also completing more refined searches bases on areas of interest (i.e. fractional flow reserve, navigation, retrograde endovascular balloon occlusion of the aorta, etc.). For the most part, systems were included where the sensor was mounted directly onto the catheter and implantable sensors such as those that have been investigated for use with stents have been excluded. RESULTS The authors were able to identify a body of literature in the area of endovascular devices that contain sensors to measure physiologic information. However, areas where additional sensing capabilities may be useful were identified. CONCLUSIONS Several different types of sensors and sensing systems were identified that have been integrated with endovascular catheters. Although a great deal of work has been done in this field, there are additional useful data that could be obtained from additional novel sensing technologies. Furthermore, significant effort needs to be allocated to carefully studying how these new technologies can be employed to actually improve patient outcomes.
Collapse
Affiliation(s)
- Candice Kaminski
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Luke A Beardslee
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Ravi Rajani
- Department of Surgery, Emory University School of Medicine, Atlanta, GA.
| |
Collapse
|
3
|
Kenawy DM, Zhang Y, Elsisy M, Abdel-Rasoul M, Chun Y, Clark WC, Tillman BW. A self calibrating, magnetic sensor approach accurately positions an aortic damage control stent in a porcine model. Trauma Surg Acute Care Open 2023; 8:e001220. [PMID: 38089400 PMCID: PMC10711854 DOI: 10.1136/tsaco-2023-001220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 10/09/2023] [Indexed: 02/01/2024] Open
Abstract
Objectives Non-compressible torso hemorrhage remains a high mortality injury, with difficulty mobilizing resources before exsanguination. Previous studies reported on a retrievable stent graft for damage control and morphometric algorithms for rapid placement, yet fluoroscopy is impractical for the austere environment. We hypothesized that magnetic sensors could be used to position stents relative to an external magnet placed on an anatomic landmark, whereas an electromagnet would allow self-calibration to account for environmental noise. Methods A magnetic sensor alone (MSA) and with integrated stent (MSIS) were examined in a porcine model under anesthesia. A target electromagnet was placed on the xiphoid process (position 0 cm). Sensors were placed in the aorta and measurements obtained at positions 0 cm, +4 cm, and +12 cm from the magnet and compared with fluoroscopy. Sensors were examined under conditions of tachycardia/hypertension, hypotension, vibration, and metal shrapnel to simulate environmental factors that might impact accuracy. General linear models compared mean differences between fluoroscopy and sensor readings. Results Both sensors were compatible with a 10 French catheter system and provided real-time assessment of the distance between the sensor and magnetic target in centimeters. Mean differences between fluoroscopy and both magnetic sensor readings demonstrated accuracy within ±0.5 cm for all but one condition at 0 cm and +4 cm, whereas accuracy decreased at +12 cm from the target. Using the control as a reference, there was no significant difference in mean differences between fluoroscopy and both MSA or MSIS readings at 0 cm and +4 cm for all conditions. The system retained effectiveness if the target was overshot. Conclusion Magnetic sensors achieved the highest accuracy as sensors approached the target. Oscillation of the electromagnet on and off effectively accounts for environmental noise.This approach is promising for rapid and accurate placement of damage control retrievable stent grafts when fluoroscopy is impractical. Level of evidence Not applicable.
Collapse
Affiliation(s)
- Dahlia M Kenawy
- Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Yifan Zhang
- Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Moataz Elsisy
- Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Mechanical Design and Production Department, Cairo University Faculty of Engineering, Cairo, Egypt
| | - Mahmoud Abdel-Rasoul
- Biomedical Informatics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Youngjae Chun
- Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - William C Clark
- Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Bryan W Tillman
- Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| |
Collapse
|
4
|
Validation of a miniaturized handheld arterial pressure monitor for guiding full and partial REBOA use during resuscitation. Eur J Trauma Emerg Surg 2022; 49:795-801. [PMID: 36273349 DOI: 10.1007/s00068-022-02121-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 09/27/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a well-validated method for the control of noncompressible truncal hemorrhage. In lower resource or battlefield settings, the need for arterial line setup and monitoring is problematic and potentially prohibitive. We sought to evaluate the accuracy and precision of a miniaturized portable device (Centurion COMPASS®) versus standard arterial pressure monitoring using standard ER-REBOA and partial REBOA (pREBOA) as a high-fidelity and space-/time-conserving alternative. METHODS A total of 40 swine underwent a four-phase validation/precision study (each phase using five ER-REBOAs and five pREBOAs). Phases I/II evaluated accuracy with full and pREBOA in uninjured animals. Phases III/IV duplicated the previous phases but in a severe hemorrhagic shock model. Carotid and femoral pressures were monitored with both intra-arterial pressure systems and the COMPASS® device. The vascular flow was measured by aortic flow probes. Correlation and Bland-Altman analysis were performed. RESULTS There was a strong correlation in accuracy testing of proximal and distal COMPASS® devices compared to standard intra-arterial pressure monitoring (r = 0.94, 0.8; p < 0.005) as well as during precision testing (r = 0.98, 0.89 p < 0.005) in the uninjured phases. Similar accuracy and reliability were demonstrated in hemorrhagic shock, with a strong correlation for the proximal and distal COMPASS® devices (r = 0.98, 0.97; p < 0.005), as well as during precision testing (r = 0.99, 0.95; p < 0.005) in both full and pREBOA scenarios. Bland-Altman analysis showed extremely low bias between the COMPASS® and arterial line for both proximal (bias = 1.9) and distal (bias = 0.8) pressure measurements. CONCLUSION The COMPASS® provides accurate and precise pressure measurements during standard and partial REBOA in both uninjured and shock conditions. This device may help extend and enhance capability in any low-resource/battlefield settings, or even eliminate the need for standard intra-arterial invasive pressure monitoring and external setup.
Collapse
|
5
|
van der Burg BLSB, Vrancken S, van Dongen TTCF, Wamsteker T, Rasmussen T, Hoencamp R. Comparison of aortic zones for endovascular bleeding control: age and sex differences. Eur J Trauma Emerg Surg 2022; 48:4963-4969. [PMID: 35794255 DOI: 10.1007/s00068-022-02033-7] [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: 05/04/2022] [Accepted: 06/05/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE To gain insight into anatomical variations between sexes and different age groups in intraluminal distances and anatomical landmarks for correct insertion of resuscitative endovascular balloon occlusion of the aorta (REBOA) without fluoroscopic confirmation. MATERIALS All non-trauma patients receiving a computed tomography angiography (CT-A) scan of the aorta, iliac bifurcation and common femoral arteries from 2017 to 2019 were eligible for inclusion. METHODS Central luminal line distances from the common femoral artery (CFA) to the aortic occlusion zones were measured and diameters of mid zone I, II and III were registered. Anatomical landmarks and correlations were assessed. A simulated REBOA placement was performed using the Joint Trauma System Clinical Practice Guideline (JTSCPG). RESULTS In total, 250 patients were included. Central luminal line (CLL) measurements from mid CFA to aortic bifurcation (p = 0.000), CLL measurements from CFA to mid zone I, II and III (p = 0.000) and zone I length (p = 0.000) showed longer lengths in men. The length of zone I and III (p = 0.000), CLL distance measurements from the right CFA to mid zone I (p = 0.000) and II (p = 0.013) and aortic diameters measured at mid zone I, II and III increased in higher age groups (p = 0.000). Using the JTSCPG guideline, successful deployment occurred in 95/250 (38.0%) in zone III and 199/250 (79.6%) in zone I. Correlation between mid-sternum and zone I is 100%. Small volume aortic occlusion balloons (AOB) have poor occlusion rates in zone I (0-2.8%) and III (4.4-34.4%). CONCLUSIONS Men and older age groups have longer CLL distances to zone I and III and introduction depths of AOB must be adjusted. The risk of not landing in zone III with standard introduction depths is high and balloon position for zone III REBOA is preferably confirmed using fluoroscopy. Mid-sternum can be used as a landmark in all patient groups for zone I. In older patients, balloon catheters with larger inflation volumes must be considered for aortic occlusion.
Collapse
Affiliation(s)
| | - Suzanne Vrancken
- Department of Surgery, Alrijne Hospital Leiderdorp, Simon Smitweg 1, 2353GA, Leiderdorp, The Netherlands
| | | | - Tom Wamsteker
- Department of Surgery, Alrijne Hospital Leiderdorp, Simon Smitweg 1, 2353GA, Leiderdorp, The Netherlands
| | | | - Rigo Hoencamp
- Department of Surgery, Alrijne Hospital Leiderdorp, Simon Smitweg 1, 2353GA, Leiderdorp, The Netherlands
- Defense Healthcare Organization, Ministry of Defense, Utrecht, The Netherlands
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
6
|
Heo Y, Chang SW, Kim DH. Transsplenic Ultrasound-Guided Balloon Positioning During a Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta: A Case Report. JOURNAL OF ACUTE CARE SURGERY 2022. [DOI: 10.17479/jacs.2022.12.1.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an effective resuscitative modality to temporize noncompressible truncal hemorrhage. Confirming the proper position of the balloon catheter in the target aortic zone is vital. Currently, there is a need for nonradiographical methods. This would overcome the drawbacks of conventional imaging modalities, such as fluoroscopy. Several studies have suggested ultrasound-guided visualization via subxiphoid, transperitoneal, or transesophageal views as an alternative to conventional imaging methods. However, such views are easily obscured in emergency settings. Herein, we report the case of a 70-year-old patient who was successfully resuscitated by REBOA under the guidance of transsplenic ultrasound. REBOA was safely performed using transsplenic visualization without fluoroscopy.
Collapse
|
7
|
Shi C, Li S, Wang Z, Shen H. Prehospital aortic blood flow control techniques for non-compressible traumatic hemorrhage. Injury 2021; 52:1657-1663. [PMID: 33750584 DOI: 10.1016/j.injury.2021.02.070] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/21/2021] [Accepted: 02/22/2021] [Indexed: 02/02/2023]
Abstract
Non-compressible hemorrhage in the junctional areas and torso could be life-threatening and its prehospital control remains extremely challenging. The aim of this review was to compare commonly used techniques for the control of non-compressible hemorrhage in prehospital settings, and thereby provide evidence for further improvements in emergency care of traumatic injuries. Three techniques were reviewed including external aortic compression (EAC), abdominal aortic junctional tourniquet (AAJT), and resuscitative endovascular balloon occlusion of the aorta (REBOA). In prehospital settings, all three techniques have demonstrated clinical effectiveness for the control of severe hemorrhage. EAC is a cost- and equipment-free, easy-to-teach, and immediately available technique. In contrast, AAJT and REBOA are expensive and require detailed instructions or systematic training. Compared with EAC, AAJT and REBOA have greater potentials in the management of traumatic hemorrhage. AAJT can be used not only in the junctional areas but also in pelvic and bilateral lower limb injuries. However, both AAJT and REBOA should be used for a limited time (less than 1 hour) due to possible consequences of ischemia and reperfusion. Compared with EAC and AAJT, REBOA is invasive, requiring femoral arterial access and intravascular guidance and inflation. Mortality from non-compressible hemorrhage could be reduced through the prehospital application of aortic blood flow control techniques. EAC should be considered as the first-line choice for many non-compressible injuries that cannot be managed with conventional junctional tourniquets. In comparison, AAJT or REBOA is recommended for better control of the aorta blood flow in prehospital settings. Although these three techniques each have advantages, their use in trauma is not widespread. Future studies are warranted to provide more data about their safety and efficacy.
Collapse
Affiliation(s)
- Changgui Shi
- Department of Surgery, Changzheng Hospital, Naval Medical University, Shanghai, China; Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Song Li
- Department of Surgery, Changzheng Hospital, Naval Medical University, Shanghai, China; Department of Orthopedics, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Zhinong Wang
- Department of Surgery, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Hongliang Shen
- Department of Surgery, Changzheng Hospital, Naval Medical University, Shanghai, China.
| |
Collapse
|
8
|
Weng D, Qian A, Zhou Q, Xu J, Xu S, Zhang M. A new method using surface landmarks to locate resuscitative endovascular balloon occlusion of the aorta based on a retrospective CTA study. Eur J Trauma Emerg Surg 2021; 48:1945-1953. [PMID: 34019107 DOI: 10.1007/s00068-021-01686-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/28/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) can timely prevent the wounded from fatal hemorrhage. However, blind insertion of REBOA in field or emergency room may result in catheter malposition and serious complications. We aim to develop a new method based on surface landmarks to guide the accurate placement of REBOA in zone III of aorta without fluoroscopy. METHODS A retrospective study was conducted in a university hospital, including 57 subjects who underwent computed tomography angiography (CTA) from April to December in 2019. External distances and intravascular lengths were measured by three-dimensional reconstruction of CT images, including the distances from the insertion site of femoral artery to the xiphoid process (FA-Xi), the midpoint between the xiphoid process and the umbilicus (FA-mXU), the umbilicus (FA-Ui), the midpoint of the zone III of aorta (FA-mZIII), the lowest renal artery (FA-LRA), and aortic bifurcation (FA-AB). The distal and proximal ideal margin and predicted accuracy were calculated by curvature plane reconstruction. The predicted probability of balloon positioning in zone III by different methods was compared. RESULTS The mean age of all patients was 60 years (SD = 9.4). The average length of zone III of aorta was 9.4 cm (SD = 1.0), and the length of FA-mZIII on the right and left sides were 24.4 cm (SD = 2.1), 23.8 cm (SD = 2.1), respectively. FA-Xi was longer than FA-LRA, and FA-Ui was shorter than FA-AB (paired two-tailed test, p < 0.001). Using three methods including the optimal quartering distances, the optimal distances below the xiphoid and above the umbilicus to predict the length of REBOA catheter positioning in zone III showed no statistically significant difference. The predicted accuracy of catheter positioning in zone III on the left and right sides guided by FA-mXU were 84.2% and 86%. CONCLUSIONS The midpoint between the xiphoid process and the umbilicus may be a new surface landmark for people of normal weight to guide rapid positioning REBOA in zone III of aorta without fluoroscopy.
Collapse
Affiliation(s)
- Danlei Weng
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang road, Hangzhou, 310009, China.,Institute of Emergency Medicine, Zhejiang University, Hangzhou, 310009, China
| | - Anyu Qian
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang road, Hangzhou, 310009, China.,Institute of Emergency Medicine, Zhejiang University, Hangzhou, 310009, China
| | - Qijing Zhou
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang road, Hangzhou, 310009, China.,Department of Radiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
| | - Jiefeng Xu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang road, Hangzhou, 310009, China.,Institute of Emergency Medicine, Zhejiang University, Hangzhou, 310009, China
| | - Shanxiang Xu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang road, Hangzhou, 310009, China. .,Institute of Emergency Medicine, Zhejiang University, Hangzhou, 310009, China.
| | - Mao Zhang
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang road, Hangzhou, 310009, China. .,Institute of Emergency Medicine, Zhejiang University, Hangzhou, 310009, China.
| |
Collapse
|
9
|
Thrailkill MA, Gladin KH, Thorpe CR, Roberts TR, Choi JH, Chung KK, Necsoiu CN, Rasmussen TE, Cancio LC, Batchinsky AI. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): update and insights into current practices and future directions for research and implementation. Scand J Trauma Resusc Emerg Med 2021; 29:8. [PMID: 33407759 PMCID: PMC7789715 DOI: 10.1186/s13049-020-00807-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 11/03/2020] [Indexed: 02/07/2023] Open
Abstract
Background In this review, we assess the state of Resuscitative Endovascular Occlusion of the Aorta (REBOA) today with respect to out-of-hospital (OOH) vs. inhospital (H) use in blunt and penetrating trauma, as well as discuss areas of promising research that may be key in further advancement of REBOA applications. Methods To analyze the trends in REBOA use, we conducted a review of the literature and identified articles with human or animal data that fit the respective inclusion and exclusion criteria. In separate tables, we compiled data extracted from selected articles in categories including injury type, zone and duration of REBOA, setting in which REBOA was performed, sample size, age, sex and outcome. Based on these tables as well as more detailed review of some key cases of REBOA usage, we assessed the current state of REBOA as well as coagulation and histological disturbances associated with its usage. All statistical tests were 2-sided using an alpha=0.05 for significance. Analysis was done using SAS 9.5 (Cary, NC). Tests for significance was done with a t-test for continuous data and a Chi Square Test for categorical data. Results In a total of 44 cases performed outside of a hospital in both military and civilian settings, the overall survival was found to be 88.6%, significantly higher than the 50.4% survival calculated from 1,807 cases of REBOA performed within a hospital (p<.0001). We observe from human data a propensity to use Zone I in penetrating trauma and Zone III in blunt injuries. We observe lower final metabolic markers in animal studies with shorter REBOA time and longer follow-up times. Conclusions Further research related to human use of REBOA must be focused on earlier initiation of REBOA after injury which may depend on development of rapid vascular access devices and techniques more so than on any new improvements in REBOA. Future animal studies should provide detailed multisystem organ assessment to accurately define organ injury and metabolic burden associated with REBOA application. Overall, animal studies must involve realistic models of injury with severe clinical scenarios approximating human trauma and exsanguination, especially with long-term follow-up after injury.
Collapse
Affiliation(s)
- Marianne A Thrailkill
- Glacier Technical Solutions, El Paso, TX, USA.,Extracorporeal Life Support Capability Area, United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, 78234, USA
| | | | - Catherine R Thorpe
- Extracorporeal Life Support Capability Area, United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, 78234, USA.,Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA
| | - Teryn R Roberts
- Extracorporeal Life Support Capability Area, United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, 78234, USA.,Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, San Antonio, TX, USA
| | - Jae H Choi
- Extracorporeal Life Support Capability Area, United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, 78234, USA.,Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, San Antonio, TX, USA
| | - Kevin K Chung
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Corina N Necsoiu
- Prolonged Field Care Capability Area, United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, USA
| | - Todd E Rasmussen
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, USA
| | - Andriy I Batchinsky
- Extracorporeal Life Support Capability Area, United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, 78234, USA. .,Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, San Antonio, TX, USA.
| |
Collapse
|
10
|
Wortmann M, Engelhart M, Elias K, Popp E, Zerwes S, Hyhlik-Dürr A. [Resuscitative endovascular balloon occlusion of the aorta (REBOA) : Current aspects of material, indications and limits: an overview]. Chirurg 2020; 91:934-942. [PMID: 32514942 PMCID: PMC7581582 DOI: 10.1007/s00104-020-01180-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Hintergrund „Resuscitative endovascular balloon occlusion of the aorta“ (REBOA) stellt ein endovaskuläres Verfahren dar, bei dem ein Blockballon in die Aorta eingeführt wird, um eine distal des Ballons gelegene Blutung zu verringern und gleichzeitig die kardiale und zerebrale Oxygenierung zu verbessern. Ziel der Arbeit Vorstellung der REBOA-Technik, der möglichen Indikationen, der benötigen Materialien und der möglichen Komplikationen des Verfahrens. Material und Methoden Nichtsystematischer Übersichtsartikel über die aktuelle Literatur. Ergebnisse REBOA stellt gerade bei traumatisch bedingten Blutungen und rupturierten Aortenaneurysmen ein mögliches additives Verfahren zur hämodynamischen Stabilisierung dar. Die Komplikationsrate des Verfahrens liegt bei ungefähr 5 %, wobei Zugangskomplikationen im Vordergrund stehen, jedoch auch letale Komplikationen möglich sind. Diskussion Eine aortale Ballonblockade wird bei der Versorgung rupturierter Aortenaneurysmen standardmäßig eingesetzt. Es gibt wachsende Evidenz, dass REBOA bei der Versorgung polytraumatisierter Patienten mit einem hämorrhagischen Schock aufgrund einer abdominellen oder viszeralen Blutung eine vergleichsweise minimal-invasive Alternative zur offen chirurgischen Aortenklemmung mittels Thorakotomie darstellt. Mit der Entwicklung neuer Ballonkatheter, die ohne Führungsdraht und mit geringeren Schleusendurchmessern auskommen, wird auch ein Einsatz bei anderen Krankheitsbildern wie postoperativen abdominellen Nachblutungen, gynäkologischen Blutungen oder als additives Verfahren bei der kardiopulmonalen Reanimation diskutiert.
Collapse
Affiliation(s)
- M Wortmann
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M Engelhart
- Klinik für Gefäßchirurgie und Endovasku-läre Chirurgie, Bundeswehrkrankenhaus Ulm, Ulm, Deutschland
| | - K Elias
- Abteilung für Gefäßchirurgie, Bundeswehrkrankenhaus Westerstede/Ammerland Klinik, Westerstede, Deutschland
| | - E Popp
- Sektion Notfallmedizin, Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - S Zerwes
- Gefäßchirurgie und endovaskuläre Chirurgie, Medizinische Fakultät, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland
| | - Alexander Hyhlik-Dürr
- Gefäßchirurgie und endovaskuläre Chirurgie, Medizinische Fakultät, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
| |
Collapse
|
11
|
Nakajima K, Taniguchi H, Abe T, Yamaguchi K, Doi T, Takeuchi I, Morimura N. Does the conventional landmark help to place the tip of REBOA catheter in the optimal position? A non-controlled comparison study. World J Emerg Surg 2019; 14:35. [PMID: 31346347 PMCID: PMC6635992 DOI: 10.1186/s13017-019-0255-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 07/08/2019] [Indexed: 11/10/2022] Open
Abstract
Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) for patients with traumatic torso hemorrhagic shock is available to keep a minimum level of circulatory status as a bridge to definitive therapy. However, the trajectory for placement of REBOA in the aorta has not yet been clearly defined. Methods We conducted a retrospective observational cohort study in the two tertiary critical care and emergency center from December 2014 to October 2018. A total of 28 patients who underwent focused assessment with sonography for trauma (FAST) were studied via contrast computed tomography (CT), and 27 were analyzed. Results We divided patients into two groups based on our CT findings. The REBOA deflate group included 16 patients, and the inflate group included 11 patients. The median trace value (interquartile range) of the blood vessel center line from the common femoral artery to the tip of REBOA (blood vessel length) and the length of REBOA itself from the common femoral artery to the tip of REBOA (REBOA insertion length) were 56.2 cm (54.5-57.2) and 55.2 cm (54.2-55.6), respectively (p < 0.0001) for the deflated group, and 51.4 cm (42.1-56.6) and 50.3 cm (42.3-55.0) (p = 0.594), respectively, for the inflated group. Conclusions If REBOA was deflated, it was placed 1.0 cm longer than the insertion length of REBOA catheter itself, but that was not the case when inflating REBOA. The individual difference was large to the extent that the balloon inflated and the extent to which the balloon was pushed back toward the caudal depending on the degree of blood pressure. Further studies would be needed to validate the study findings.
Collapse
Affiliation(s)
- Kento Nakajima
- 1Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, 4-57 Urafunecho, Minami-ku, Yokohama, Kanagawa 232-0024 Japan.,2Department of Emergency Medicine, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa 236-0004 Japan
| | - Hayato Taniguchi
- 2Department of Emergency Medicine, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa 236-0004 Japan.,3Department of Surgery Intensive Care, Nippon Medical School Hospital, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603 Japan
| | - Takeru Abe
- 1Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, 4-57 Urafunecho, Minami-ku, Yokohama, Kanagawa 232-0024 Japan.,2Department of Emergency Medicine, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa 236-0004 Japan
| | - Keishi Yamaguchi
- 1Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, 4-57 Urafunecho, Minami-ku, Yokohama, Kanagawa 232-0024 Japan.,2Department of Emergency Medicine, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa 236-0004 Japan
| | - Tomoki Doi
- 2Department of Emergency Medicine, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa 236-0004 Japan.,4Critical Care and Emergency Center, Yokosuka Kyosai Hospital, Yonegahama Street 1-16, Yokosuka, Kanagawa 238-8558 Japan
| | - Ichiro Takeuchi
- 1Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, 4-57 Urafunecho, Minami-ku, Yokohama, Kanagawa 232-0024 Japan.,2Department of Emergency Medicine, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa 236-0004 Japan
| | - Naoto Morimura
- 5Department of Acute Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
| |
Collapse
|
12
|
Osborn LA, Brenner ML, Prater SJ, Moore LJ. Resuscitative endovascular balloon occlusion of the aorta: current evidence. Open Access Emerg Med 2019; 11:29-38. [PMID: 30666171 PMCID: PMC6336022 DOI: 10.2147/oaem.s166087] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) has recently gained popularity as a minimally invasive alternative to open aortic cross-clamping in the management of patients with non-compressible hemorrhage arising below the diaphragm. The purpose of this review is to provide a description of the technical aspects of REBOA use along with an overview of the current animal and clinical data regarding its use.
Collapse
Affiliation(s)
- Lesley A Osborn
- Department of Emergency Medicine, The University of Texas Health Science Center, McGovern Medical School, Houston, TX, USA,
| | - Megan L Brenner
- Department of Surgery, The University of California - Riverside, Moreno Valley, CA, USA
| | - Samuel J Prater
- Department of Emergency Medicine, The University of Texas Health Science Center, McGovern Medical School, Houston, TX, USA,
| | - Laura J Moore
- Department of Surgery, The University of Texas Health Science Center, McGovern Medical School, Houston, TX, USA
| |
Collapse
|