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Grechenig P, Hallmann B, Eibinger NR, Koutp A, Zajic P, Höfler G, Puchwein P. Percutaneous ultrasound-guided versus open cut-down access to femoral vessels for the placement of a REBOA catheter. Sci Rep 2024; 14:9111. [PMID: 38643229 PMCID: PMC11032382 DOI: 10.1038/s41598-024-59778-x] [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: 11/02/2023] [Accepted: 04/15/2024] [Indexed: 04/22/2024] Open
Abstract
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) may be useful in treating exsanguinating trauma patients. This study seeks to compare rates of success, complications and time required for vascular access between ultrasound-guidance and surgical cut-down for femoral sheath insertion as a prospective observational case control study. Participating clinicians from either trauma surgery or anesthesiology were allocated to surgical cut-down or percutaneous ultrasound-guided puncture on a 1:1 ratio. Time spans to vessel identification, successful puncture, and balloon inflation were recorded. 80 study participants were recruited and allocated to 40 open cut-down approaches and 40 percutaneous ultrasound-guided approaches. REBOA catheter placement was successful in 18/40 cases (45%) using a percutaneous ultrasound guided technique and 33/40 times (83%) using the open cut-down approach (p < 0.001). Median times [in seconds] compared between percutaneous ultrasound-guided puncture and surgical cut-down were 36 (18-73) versus 117(56-213) for vessel visualization (p < 0.001), 136 (97-175) versus 183 (156-219) for vessel puncture (p < 0.001), and 375 (240-600) versus 288 (244-379) for balloon inflation (p = 0.08) overall. Access to femoral vessels for REBOA catheter placement is safer when performed by cut-down and direct visualization but can be performed faster by an ultrasound-guided technique when vessels can be identified clearly and rapidly.
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Affiliation(s)
- Peter Grechenig
- Department of Orthopedics and Trauma Surgery, Medical University of Graz, Graz, Austria
| | - Barbara Hallmann
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Graz, Auenbruggerplatz 5, 8036, Graz, Austria.
| | - Nicolas Rene Eibinger
- Department of Orthopedics and Trauma Surgery, Medical University of Graz, Graz, Austria
| | - Amir Koutp
- Department of Orthopedics and Trauma Surgery, Medical University of Graz, Graz, Austria
| | - Paul Zajic
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Gerald Höfler
- Diagnostic and Research Institute of Pathology, Medical University Graz, Graz, Austria
| | - Paul Puchwein
- Department of Orthopedics and Trauma Surgery, Medical University of Graz, Graz, Austria
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2
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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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Lee G, Kim DH, Ma DS, Lee SW, Heo Y, Jo H, Chang SW. Feasibility and Clinical Outcomes of Resuscitative Endovascular Balloon Occlusion of the Aorta in Patients with Traumatic Shock: A Single-Center 5-Year Experience. J Chest Surg 2023; 56:108-116. [PMID: 36710580 PMCID: PMC10008360 DOI: 10.5090/jcs.22.105] [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: 09/22/2022] [Revised: 11/17/2022] [Accepted: 12/06/2022] [Indexed: 01/31/2023] Open
Abstract
Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) has recently gained popularity as an adjunct to resuscitation of patients with traumatic shock. However, the effectiveness of REBOA is still debated because of inconsistent indications across centers and the lack of medical records. The purpose of this study was to investigate the effectiveness and feasibility of REBOA by analyzing clinical results from a single center. Methods This study included 96 patients who underwent REBOA between August 2016 and September 2021 at a regional trauma center according to the center's treatment algorithm for traumatic shock. Medical records, including the time of the decision to conduct the REBOA procedure, time of operation, type of aortic occlusion, and clinical outcomes, were collected prospectively and analyzed retrospectively. Patients were classified by REBOA protocol (group 1, 2, or 3) and survival status (survivor or non-survivor) for analysis. Results The overall success rate of the procedure was 97.9%, and the survival rate was 32.6%. In survivors, blood pressure was higher than in non-survivors both before the REBOA procedure (p=0.002) and after aortic occlusion (p=0.03). The total aortic occlusion time was significantly shorter (p=0.001) and the proportion of partial aortic occlusion was significantly higher (p=0.014) among the survivors. The non-survivors had more acidosis (p<0.001) and higher lactate concentrations (p<0.001) than the survivors. Conclusion REBOA may be a feasible bridge therapy for resuscitation of patients with traumatic shock. Prompt and accurate decision-making to perform REBOA followed by damage control surgery could improve survival rates and clinical outcomes.
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Affiliation(s)
- Gyeongho Lee
- Department of Thoracic and Cardiovascular Surgery, Dankook University Hospital, Cheonan, Korea
| | - Dong Hun Kim
- Department of Trauma Surgery, Trauma Center, Dankook University Hospital, Cheonan, Korea
| | - Dae Sung Ma
- Department of Thoracic and Cardiovascular Surgery, Trauma Center, Dankook University Hospital, Cheonan, Korea
| | - Seok Won Lee
- Department of Trauma Surgery, Trauma Center, Dankook University Hospital, Cheonan, Korea
| | - Yoonjung Heo
- Department of Trauma Surgery, Trauma Center, Dankook University Hospital, Cheonan, Korea
| | - Hancheol Jo
- Department of Trauma Surgery, Trauma Center, Dankook University Hospital, Cheonan, Korea
| | - Sung Wook Chang
- Department of Thoracic and Cardiovascular Surgery, Trauma Center, Dankook University Hospital, Cheonan, Korea
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Broome JM, Ali A, Simpson JT, Tran S, Tatum D, Taghavi S, DuBose J, Duchesne J. IMPACT OF TIME TO EMERGENCY DEPARTMENT RESUSCITATIVE AORTIC OCCLUSION AFTER NONCOMPRESSIBLE TORSO HEMORRHAGE. Shock 2022; 58:275-279. [PMID: 36256624 DOI: 10.1097/shk.0000000000001988] [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: 06/16/2023]
Abstract
Introduction: Time is an essential element in outcomes of trauma patients. The relationship of time to treatment in management of noncompressible torso hemorrhage (NCTH) with resuscitative endovascular balloon occlusion of the aorta (REBOA) or resuscitative thoracotomy (RT) has not been previously described. We hypothesized that shorter times to intervention would reduce mortality. Methods: A review of the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery registry from 2013 to 2022 was performed to identify patients who underwent emergency department aortic occlusion (AO). Multivariate logistic regression was used to examine the impact of time to treatment on mortality. Results: A total of 1,853 patients (1,245 [67%] RT, 608 [33%] REBOA) were included. Most patients were male (82%) with a median age of 34 years (interquartile range, 30). Median time from injury to admission and admission to successful AO were 31 versus 11 minutes, respectively. Patients who died had shorter median times from injury to successful AO (44 vs. 72 minutes, P < 0.001) and admission to successful AO (10 vs. 22 minutes, P < 0.001). Multivariate logistic regression demonstrated that receiving RT was the strongest predictor of mortality (odds ratio [OR], 6.6; 95% confidence interval [CI], 4.4-9.9; P < 0.001). Time from injury to admission and admission to successful AO were not significant. This finding was consistent in subgroup analysis of RT-only and REBOA-only populations. Conclusions: Despite expedited interventions, time to aortic occlusion did not significantly impact mortality. This may suggest that rapid in-hospital intervention was often insufficient to compensate for severe exsanguination and hypovolemia that had already occurred before emergency department presentation. Selective prehospital advanced resuscitative care closer to the point of injury with "scoop and control" efforts including hemostatic resuscitation warrants special consideration.
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Affiliation(s)
- Jacob M Broome
- Division of Trauma and Critical Care, Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Ayman Ali
- Division of Trauma and Critical Care, Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - John T Simpson
- Division of Trauma and Critical Care, Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Sherman Tran
- Division of Trauma and Critical Care, Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Danielle Tatum
- Division of Trauma and Critical Care, Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Sharven Taghavi
- Division of Trauma and Critical Care, Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Joseph DuBose
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - Juan Duchesne
- Division of Trauma and Critical Care, Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
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Irahara T, Oishi D, Tsuda M, Kajita Y, Mori H, Terashima T, Tanabe S, Hattori M, Kuge Y, Takeyama N. Combined, converted, and prophylactic use of resuscitative endovascular balloon occlusion of the aorta for severe torso trauma: a retrospective study. Acute Med Surg 2022; 9:e792. [PMID: 36203855 PMCID: PMC9525620 DOI: 10.1002/ams2.792] [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: 02/05/2022] [Accepted: 09/12/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used as an intra‐aortic balloon occlusion in Japan; however, protocols for its effective use in different conditions have not been established. This study aimed to summarize the strategies of REBOA use in severe torso trauma. Methods Twenty‐nine cases of REBOA for torso trauma treated at our hospital over 5 years were divided into hemodynamically unstable (HU) (n = 12), cardiac arrest (CA) (n = 13), and hemodynamically stable (HS) (n = 4) groups. We retrospectively examined patient characteristics, trauma mechanism, injury site, severity score, intervention type, and survival rates at 24 h in each group. Results In the HU group, 9 and 3 patients survived and died within 24 h, respectively; time to intervention (56.6 versus 130.7 min, P = 0.346) tended to be shorter and total occlusion time (40.2 versus 337.7 min, P = 0.009) was significantly shorter in survivors than in nonsurvivors. In the CA group, 10 patients were converted from resuscitative thoracotomy with aortic cross‐clamp (RTACC); one patient survived. All four patients in the HS group survived, having received prophylactic REBOA. Conclusion The efficacy of REBOA for severe torso trauma depends on the patient's condition. If the patients are hemodynamically unstable, time to intervention and total occlusion time could correlate with survival. The combined use of REBOA with definitive hemostasis could improve outcomes. Conversion from RTACC in the cardiac arrest patients and prophylactic use in the hemodynamically stable patients can be one of the potentially effective options, although further studies are needed.
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Affiliation(s)
- Takayuki Irahara
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
| | - Dai Oishi
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
| | - Masanobu Tsuda
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
| | - Yuka Kajita
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
| | - Hisatake Mori
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
| | - Tsuguaki Terashima
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
| | - Subaru Tanabe
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
| | - Miyuki Hattori
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
| | - Yuuji Kuge
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
| | - Naoshi Takeyama
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
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Aoki M, Abe T. Traumatic Cardiac Arrest: Scoping Review of Utilization of Resuscitative Endovascular Balloon Occlusion of the Aorta. Front Med (Lausanne) 2022; 9:888225. [PMID: 35783650 PMCID: PMC9243328 DOI: 10.3389/fmed.2022.888225] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/26/2022] [Indexed: 12/05/2022] Open
Abstract
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is increasingly used in trauma resuscitation for patients with life-threatening hemorrhage below the diaphragm and may also be used for patients with traumatic cardiac arrest (TCA). Resuscitative thoracotomy with aortic cross clamping (RT-ACC) maneuver was traditionally performed for patients with TCA due to hemorrhagic shock; however, REBOA has been substituted for RT-ACC in selected TCA cases. During cardiopulmonary resuscitation (CPR) in TCA, REBOA increases cerebral and coronary perfusion, and temporary bleeding control. Both animal and clinical studies have reported the efficacy of REBOA for TCA, and a recent observational study suggested that REBOA may contribute to the return of spontaneous circulation after TCA. Although multiple questions remain unanswered, REBOA has been applied to trauma fields as a novel technology.
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Affiliation(s)
- Makoto Aoki
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
- *Correspondence: Makoto Aoki
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan
- Department of Health Services Research, University of Tsukuba, Tsukuba, Japan
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Okada H, Koike Y, Kishimoto S, Mori K, Imaki S, Torii I, Komatsu H. Successful Management of Resuscitative Endovascular Balloon Occlusion of the Aorta for Hemorrhagic Shock Due to Ruptured Hepatocellular Carcinoma. Intern Med 2022; 61:1157-1162. [PMID: 34565775 PMCID: PMC9107971 DOI: 10.2169/internalmedicine.8133-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 68-year-old man was transferred to our hospital because of sudden right costal pain with unmeasurable hypotension. Ultrasonography revealed possible hemorrhagic shock due to ruptured hepatocellular carcinoma (HCC). As the patient was not hemodynamically stable after primary treatment, resuscitative endovascular balloon occlusion of the aorta (REBOA) was performed, and hemodynamic stability was then achieved. Contrast-enhanced computed tomography confirmed the diagnosis. Transcatheter artery embolization with gelatin sponge particles and coils eliminated the extravasation. The patient was discharged on day 36 post-procedure. Our observations suggest that REBOA may help achieve hemodynamic stability in cases of ruptured HCC.
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Affiliation(s)
- Haruka Okada
- Department of Gastroenterology, Yokohama Municipal Citizen's Hospital, Japan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Keio University, Japan
| | - Yuji Koike
- Department of Gastroenterology, Yokohama Municipal Citizen's Hospital, Japan
| | - Shotaro Kishimoto
- Department of Gastroenterology, Yokohama Municipal Citizen's Hospital, Japan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Keio University, Japan
| | - Kosuke Mori
- Department of Emergency and Critical Care Medical Center, Japan
| | - Shohei Imaki
- Department of Emergency and Critical Care Medical Center, Japan
| | - Ikuo Torii
- Department of Diagnostic Radiology, Yokohama Municipal Citizen's Hospital, Japan
| | - Hirokazu Komatsu
- Department of Gastroenterology, Yokohama Municipal Citizen's Hospital, Japan
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8
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Castellini G, Gianola S, Biffi A, Porcu G, Fabbri A, Ruggieri MP, Coniglio C, Napoletano A, Coclite D, D'Angelo D, Fauci AJ, Iacorossi L, Latina R, Salomone K, Gupta S, Iannone P, Chiara O. Resuscitative endovascular balloon occlusion of the aorta (REBOA) in patients with major trauma and uncontrolled haemorrhagic shock: a systematic review with meta-analysis. World J Emerg Surg 2021; 16:41. [PMID: 34384452 PMCID: PMC8358549 DOI: 10.1186/s13017-021-00386-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/26/2021] [Indexed: 11/17/2022] Open
Abstract
Background Multiple studies regarding the use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in patients with non-compressible torso injuries and uncontrolled haemorrhagic shock were recently published. To date, the clinical evidence of the efficacy of REBOA is still debated. We aimed to conduct a systematic review assessing the clinical efficacy and safety of REBOA in patients with major trauma and uncontrolled haemorrhagic shock. Methods We systematically searched MEDLINE (PubMed), EMBASE and CENTRAL up to June 2020. All randomized controlled trials and observational studies that investigated the use of REBOA compared to resuscitative thoracotomy (RT) with/without REBOA or no-REBOA were eligible. We followed the PRISMA and MOOSE guidelines. Two authors independently extracted data and appraised the risk of bias of included studies. Effect sizes were pooled in a meta-analysis using random-effects models. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Primary outcomes were mortality, volume of infused blood components, health-related quality of life, time to haemorrhage control and any adverse effects. Secondary outcomes were improvement in haemodynamic status and failure/success of REBOA technique. Results We included 11 studies (5866 participants) ranging from fair to good quality. REBOA was associated with lower mortality when compared to RT (aOR 0.38; 95% CI 0.20–0.74), whereas no difference was observed when REBOA was compared to no-REBOA (aOR 1.40; 95% CI 0.79–2.46). No significant difference in health-related quality of life between REBOA and RT (p = 0.766). The most commonly reported complications were amputation, haematoma and pseudoaneurysm. Sparse data and heterogeneity of reporting for all other outcomes prevented any estimate. Conclusions Our findings on overall mortality suggest a positive effect of REBOA among non-compressible torso injuries when compared to RT but no differences compared to no-REBOA. Variability in indications and patient characteristics prevents any conclusion deserving further investigation. REBOA should be promoted in specific training programs in an experimental setting in order to test its effectiveness and a randomized trial should be planned. Supplementary Information The online version contains supplementary material available at 10.1186/s13017-021-00386-9.
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Affiliation(s)
- Greta Castellini
- IRCCS Istituto Ortopedico Galeazzi, Unit of Clinical Epidemiology, Milan, Italy
| | - Silvia Gianola
- IRCCS Istituto Ortopedico Galeazzi, Unit of Clinical Epidemiology, Milan, Italy.
| | - Annalisa Biffi
- National Centre for Healthcare Research and Pharmacoepidemiology, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy.,Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Gloria Porcu
- National Centre for Healthcare Research and Pharmacoepidemiology, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy.,Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Andrea Fabbri
- Emergency Department, AUSL della Romagna, Forlì, Italy
| | | | - Carlo Coniglio
- Department of Anesthesiology, Intensive Care and Pre-Hospital Emergency Services, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Antonello Napoletano
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Daniela Coclite
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Daniela D'Angelo
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Alice Josephine Fauci
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Laura Iacorossi
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Roberto Latina
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Katia Salomone
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Shailvi Gupta
- University of Maryland, Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Primiano Iannone
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Osvaldo Chiara
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,General Surgery and Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, University of Milan, Milano, Piazza Ospedale Maggiore, Milan, Italy
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9
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Stokes SC, Theodorou CM, Zakaluzny SA, DuBose JJ, Russo RM. Resuscitative endovascular balloon occlusion of the aorta in combat casualties: The past, present, and future. J Trauma Acute Care Surg 2021; 91:S56-S64. [PMID: 33797487 PMCID: PMC8324517 DOI: 10.1097/ta.0000000000003166] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Noncompressible torso hemorrhage is a leading cause of preventable death on the battlefield. Intra-aortic balloon occlusion was first used in combat in the 1950s, but military use was rare before Operation Iraqi Freedom and Operation Enduring Freedom. During these wars, the combination of an increasing number of deployed vascular surgeons and a significant rise in deaths from hemorrhage resulted in novel adaptations of resuscitative endovascular balloon occlusion of the aorta (REBOA) technology, increasing its potential application in combat. We describe the background of REBOA development in response to a need for minimally invasive intervention for hemorrhage control and provide a detailed review of all published cases (n = 47) of REBOA use for combat casualties. The current limitations of REBOA are described, including distal ischemia and reperfusion injury, as well as ongoing research efforts to adapt REBOA for prolonged use in the austere setting. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Sarah C. Stokes
- Department of Surgery, University of California-Davis, Sacramento, California
| | | | - Scott A. Zakaluzny
- Department of Surgery, University of California-Davis, Sacramento, California
- Department of General Surgery, David Grant USAF Medical Center, Travis, California
| | - Joseph J. DuBose
- Department of Vascular Surgery, R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
- Department of Vascular Surgery, United States Air Force, Baltimore, Maryland
| | - Rachel M. Russo
- Department of Surgery, University of California-Davis, Sacramento, California
- Department of General Surgery, David Grant USAF Medical Center, Travis, California
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10
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Iida A, Naito H, Nojima T, Yumoto T, Yamada T, Fujisaki N, Nakao A, Mikane T. State-of-the-art methods for the treatment of severe hemorrhagic trauma: selective aortic arch perfusion and emergency preservation and resuscitation-what is next? Acute Med Surg 2021; 8:e641. [PMID: 33791103 PMCID: PMC7995927 DOI: 10.1002/ams2.641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/17/2021] [Accepted: 03/03/2021] [Indexed: 01/30/2023] Open
Abstract
Trauma is a primary cause of death globally, with non‐compressible torso hemorrhage constituting an important part of “potentially survivable trauma death.” Resuscitative endovascular balloon occlusion of the aorta has become a popular alternative to aortic cross‐clamping under emergent thoracotomy for non‐compressible torso hemorrhage in recent years, however, it alone does not improve the survival rate of patients with severe shock or traumatic cardiac arrest from non‐compressible torso hemorrhage. Development of novel advanced maneuvers is essential to improve these patients’ survival, and research on promising methods such as selective aortic arch perfusion and emergency preservation and resuscitation is ongoing. This review aimed to provide physicians in charge of severe trauma cases with a broad understanding of these novel therapeutic approaches to manage patients with severe hemorrhagic trauma, which may allow them to develop lifesaving strategies for exsanguinating trauma patients. Although there are still hurdles to overcome before their clinical application, promising research on these novel strategies is in progress, and ongoing development of synthetic red blood cells and techniques that reduce ischemia‐reperfusion injury may further maximize their effects. Both continuous proof‐of‐concept studies and translational clinical evaluations are necessary to clinically apply these hemostasis approaches to trauma patients.
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Affiliation(s)
- Atsuyoshi Iida
- Department of Emergency Medicine Japanese Red Cross Okayama Hospital 2-1-1 Aoe, Kita ward Okayama Okayama 7008607 Japan
| | - Hiromichi Naito
- Department of Emergency, Critical Care, and Disaster Medicine Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences 2-5-1 Sikatatyo Okayama Okayama 7008558 Japan
| | - Tsuyoshi Nojima
- Department of Emergency, Critical Care, and Disaster Medicine Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences 2-5-1 Sikatatyo Okayama Okayama 7008558 Japan
| | - Tetsuya Yumoto
- Department of Emergency, Critical Care, and Disaster Medicine Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences 2-5-1 Sikatatyo Okayama Okayama 7008558 Japan
| | - Taihei Yamada
- Department of Emergency, Critical Care, and Disaster Medicine Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences 2-5-1 Sikatatyo Okayama Okayama 7008558 Japan
| | - Noritomo Fujisaki
- Department of Emergency, Critical Care, and Disaster Medicine Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences 2-5-1 Sikatatyo Okayama Okayama 7008558 Japan
| | - Atsunori Nakao
- Department of Emergency, Critical Care, and Disaster Medicine Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences 2-5-1 Sikatatyo Okayama Okayama 7008558 Japan
| | - Takeshi Mikane
- Department of Emergency Medicine Japanese Red Cross Okayama Hospital 2-1-1 Aoe, Kita ward Okayama Okayama 7008607 Japan
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11
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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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12
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Chang SW, Ma DS, Chang YR, Kim DH. Practical tips for performing resuscitative endovascular balloon occlusion of the aorta. HONG KONG J EMERG ME 2021. [DOI: 10.1177/1024907921994422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Hemorrhage is the leading cause of death in trauma settings. Non-compressible torso hemorrhage, which is caused by abdominopelvic and thoracic injuries, is an important cause of subsequent organ dysfunction and poor outcomes in multiple trauma patients. The management of hemodynamically unstable patients with non-compressible torso hemorrhage has changed, and the concept of damage control resuscitation has been developed in the last decades. Currently, resuscitative endovascular balloon occlusion of the aorta (REBOA) as a method of temporary stabilization is the modern evolution of bleeding control, and it is in the middle of a paradigm shift as a treatment for non-compressible torso hemorrhage. Despite its effectiveness in patients with hemorrhagic shock, the application of REBOA remains limited because of lack of experience and troubleshooting guidelines. Objectives: The aim of study was to provide useful tips for the implementing a step-by-step procedure for REBOA in various hospital settings and capabilities. Methods: We introduced REBOA procedures using a REBOA-customized 7 Fr balloon catheter through the animation models or radiography from preparation to access, catheter management, and device removal after procedure completed. Results: We have described REBOA procedures as follows: identification of the common femoral artery, arterial access for placement of a guidewire, precautions during a sheath insertion, guidewire and balloon positioning in the aorta, occlusion zones and adjustment of balloon location, REBOA strategy for extending the occlusion time, balloon deflation and removal, sheath removal, and medical records. Conclusion: We believe that the practical tips mentioned in this article will help in performing the REBOA procedure systematically and developing an effective REBOA framework.
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Affiliation(s)
- Sung Wook Chang
- Department of Thoracic and Cardiovascular Surgery, Trauma Center, Dankook University Hospital, Cheonan, Republic of Korea
| | - Dae Sung Ma
- Department of Thoracic and Cardiovascular Surgery, Trauma Center, Dankook University Hospital, Cheonan, Republic of Korea
| | - Ye Rim Chang
- Department of Trauma Surgery, Trauma Center, Dankook University Hospital, Cheonan, Republic of Korea
| | - Dong Hun Kim
- Department of Trauma Surgery, Trauma Center, Dankook University Hospital, Cheonan, Republic of Korea
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13
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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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14
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Park CY, Kim OH, Chang SW, Choi KK, Lee KH, Kim SY, Kim M, Lee GJ. Part 3. Clinical Practice Guideline for Airway Management and Emergency Thoracotomy for Trauma Patients from the Korean Society of Traumatology. JOURNAL OF TRAUMA AND INJURY 2020. [DOI: 10.20408/jti.2020.0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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15
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Aoki M, Abe T, Hagiwara S, Saitoh D, Oshima K. Resuscitative endovascular balloon occlusion of the aorta may contribute to improved survival. Scand J Trauma Resusc Emerg Med 2020; 28:62. [PMID: 32605626 PMCID: PMC7325257 DOI: 10.1186/s13049-020-00757-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 06/24/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an increasingly used trauma resuscitation procedure, however, there are no reports of whether or not the survival of patients treated with REBOA increases over time. METHODS This retrospective cohort study from a nationwide trauma registry in Japan was conducted between 2004 and 2015. Patients treated with REBOA were divided into three calendar year periods: early-period (2004-2007), mid-period (2008-2011), and late-period (2012-2015). The primary outcome of in-hospital survival was compared between the periods (early-period: reference) using mixed effects logistic regression analysis after adjustment for characteristics, trauma severity, and therapeutic choices. RESULTS Of 236,698 trauma patients, 633 patients treated with REBOA were analyzed. Distribution of the patients across periods was as follows: early-period (91), mid-period (276), and late-period (266). In-hospital survival was 39, 49, and 60% in the early-period, mid-period, and late-period, respectively. In regression modeling, the late-period (OR = 2.976, 95% CI = 1.615-5.482) was associated with improved in-hospital survival compared to the early-period, however, the mid-period (OR = 1.614, 95% CI = 0.898-2.904) was not associated with improved survival. CONCLUSIONS Survival of patients treated with REBOA during the late-period improved compared with survival during the early-period, after adjustment for characteristics, trauma severity, and therapeutic choices. REBOA may be one of the important factors related to progression of modern trauma treatment.
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Affiliation(s)
- Makoto Aoki
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan.
| | - Toshikazu Abe
- Department of General Medicine, Juntendo University, Tokyo, Japan.,Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Shuichi Hagiwara
- Department of Emergency Medicine, National Hospital Organization Takasaki General Medical Center, Takasaki, Japan
| | - Daizoh Saitoh
- Department of Traumatology and Emergency Medicine, National Defense Medical College, Tokorozawa, Japan
| | - Kiyohiro Oshima
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
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16
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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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17
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Selective aortic arch perfusion with fresh whole blood or HBOC-201 reverses hemorrhage-induced traumatic cardiac arrest in a lethal model of noncompressible torso hemorrhage. J Trauma Acute Care Surg 2020; 87:263-273. [PMID: 31348400 DOI: 10.1097/ta.0000000000002315] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hemorrhage-induced traumatic cardiac arrest (HiTCA) has a dismal survival rate. Previous studies demonstrated selective aortic arch perfusion (SAAP) with fresh whole blood (FWB) improved the rate of return of spontaneous circulation (ROSC) after HiTCA, compared with resuscitative endovascular balloon occlusion of the aorta and cardiopulmonary resuscitation (CPR). Hemoglobin-based oxygen carriers, such as hemoglobin-based oxygen carrier (HBOC)-201, may alleviate the logistical constraints of using FWB in a prehospital setting. It is unknown whether SAAP with HBOC-201 is equivalent in efficacy to FWB, whether conversion from SAAP to extracorporeal life support (ECLS) is feasible, and whether physiologic derangement post-SAAP therapy is reversible. METHODS Twenty-six swine (79 ± 4 kg) were anesthetized and underwent HiTCA which was induced via liver injury and controlled hemorrhage. Following arrest, swine were randomly allocated to resuscitation using SAAP with FWB (n = 12) or HBOC-201 (n = 14). After SAAP was initiated, animals were monitored for a 20-minute prehospital period prior to a 40-minute damage control surgery and resuscitation phase, followed by 260 minutes of critical care. Primary outcomes included rate of ROSC, survival, conversion to ECLS, and correction of physiology. RESULTS Baseline physiologic measurements were similar between groups. ROSC was achieved in 100% of the FWB animals and 86% of the HBOC-201 animals (p = 0.483). Survival (t = 320 minutes) was 92% (11/12) in the FWB group and 67% (8/12) in the HBOC-201 group (p = 0.120). Conversion to ECLS was successful in 100% of both groups. Lactate peaked at 80 minutes in both groups, and significantly improved by the end of the experiment in the HBOC-201 group (p = 0.001) but not in the FWB group (p = 0.104). There was no significant difference in peak or end lactate between groups. CONCLUSION Selective aortic arch perfusion is effective in eliciting ROSC after HiTCA in a swine model, using either FWB or HBOC-201. Transition from SAAP to ECLS after definitive hemorrhage control is feasible, resulting in high overall survival and improvement in lactic acidosis over the study period.
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18
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Matsumura Y, Higashi A, Izawa Y, Hishikawa S, Kondo H, Reva V, Oda S, Matsumoto J. Distal pressure monitoring and titration with percent balloon volume: feasible management of partial resuscitative endovascular balloon occlusion of the aorta (P-REBOA). Eur J Trauma Emerg Surg 2019; 47:1023-1029. [DOI: 10.1007/s00068-019-01257-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 10/25/2019] [Indexed: 11/29/2022]
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19
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Hoareau GL, Tibbits EM, Beyer CA, Simon MA, DeSoucy ES, Faulconer ER, Neff LP, Grayson JK, Stewart IJ, Williams TK, Johnson MA. Resuscitative Endovascular Balloon Occlusion of the Aorta: Review of the Literature and Applications to Veterinary Emergency and Critical Care. Front Vet Sci 2019; 6:197. [PMID: 31275952 PMCID: PMC6594359 DOI: 10.3389/fvets.2019.00197] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 06/03/2019] [Indexed: 11/13/2022] Open
Abstract
While hemorrhagic shock might be the result of various conditions, hemorrhage control and resuscitation are the corner stone of patient management. Hemorrhage control can prove challenging in both the acute care and surgical settings, especially in the abdomen, where no direct pressure can be applied onto the source of bleeding. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as a promising replacement to resuscitative thoracotomy (RT) for the management of non-compressible torso hemorrhage in human trauma patients. By inflating a balloon at specific levels (or zones) of the aorta to interrupt blood flow, hemorrhage below the level of the balloon can be controlled. While REBOA allows for hemorrhage control and augmentation of blood pressure cranial to the balloon, it also exposes caudal tissue beds to ischemia and the whole body to reperfusion injury. We aim to introduce the advantages of REBOA while reviewing known limitations. This review outlines a step-by-step approach to REBOA implementation, and discusses common challenges observed both in human patients and during translational large animal studies. Currently accepted and debated indications for REBOA in humans are discussed. Finally, we review possible applications for veterinary patients and how REBOA has the potential to be translated into clinical veterinary practice.
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Affiliation(s)
- Guillaume L Hoareau
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States
| | - Emily M Tibbits
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States.,Department of Surgery, University of California Davis Medical Center, Sacramento, CA, United States
| | - Carl A Beyer
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States.,Department of Surgery, University of California Davis Medical Center, Sacramento, CA, United States
| | - Meryl A Simon
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States.,Department of Surgery, University of California Davis Medical Center, Sacramento, CA, United States
| | - Erik S DeSoucy
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States.,Department of Surgery, University of California Davis Medical Center, Sacramento, CA, United States
| | | | - Lucas P Neff
- Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States
| | - J Kevin Grayson
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States
| | - Ian J Stewart
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States.,Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Timothy K Williams
- Department of Vascular and Endovascular Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States
| | - M Austin Johnson
- Clinical Investigation Facility, David Grant USAF Medical Center, Travis Air Force Base, Travis, CA, United States.,Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, CA, United States
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20
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Resuscitative endovascular balloon occlusion of the aorta: an option for noncompressible torso hemorrhage? Curr Opin Anaesthesiol 2019; 32:213-226. [PMID: 30817398 DOI: 10.1097/aco.0000000000000699] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW Hemorrhage is the major cause of early death in severely injured patients. In civilian emergency medical services, the majority of life-threatening bleedings are found in noncompressible body regions (e.g. abdomen and pelvis). Resuscitative endovascular balloon occlusion of the aorta (REBOA) has therefore been discussed in recent years as a possible lifesaving procedure and numerous studies, meta-analyses and guidelines have been published. In this review, the data situation of REBOA in the management of bleeding trauma patients is discussed and practical implementation is depicted. RECENT FINDINGS The typical indication for REBOA is a traumatic life-threatening hemorrhage below the diaphragm in patients unresponsive or only transiently responsive to the usual conservative therapeutic measures. REBOA appears to be a safe and effective procedure to reduce blood loss and stabilize the patient's hemodynamic status. However, surgical hemostasis has to be achieved within 30-60 min after occlusion of the aorta. Data on clear advantages of REBOA over resuscitative thoracostomy are inconclusive. SUMMARY REBOA could play an important role in the management of the severely bleeding patient in the future. Together with transfusion and therapy of coagulation disorders, REBOA may be an additional tool in the anesthetist's hands for trauma management in interprofessional care concepts.
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21
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Wasicek PJ, Li Y, Yang S, Teeter WA, Scalea TM, Hu P, Brenner ML. Examination of hemodynamics in patients in hemorrhagic shock undergoing Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). Injury 2019; 50:1042-1048. [PMID: 30591227 DOI: 10.1016/j.injury.2018.12.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 12/10/2018] [Accepted: 12/21/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND The objective of this study was to investigate the hemodynamic effects of aortic occlusion (AO) during Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) using a sophisticated continuous vital sign (CVS) monitoring tool. METHODS Patients admitted between February 2013 and May 2017 at a tertiary center that received REBOA were included. Patients in cardiac arrest before or at the time of REBOA were excluded. Time of AO was documented by time-stamped videography and correlated with CVS data. RESULTS 28 patients were included, mean (standard deviation) ISS was 38 (11). 18 received Zone 1 (distal thoracic aorta) and 10 received Zone 3 (distal abdominal aorta) AO. Among Zone 1 patients the pre-AO systolic blood pressure (SBP) nadir was 64 (19) mmHg, which increased to a mean of 124 (29) mmHg within 5 min after AO (p < 0.01). Among Zone 3 patients the pre-AO SBP nadir was 75 (19) mmHg, which increased to a mean of 98 (14) mmHg within 5 min after AO (p < 0.01). 72% of Zone 1 patients had episodes during AO where SBP was less than 90 mmHg as compared to 80% of Zone 3 patients (p = 0.51). 100% of Zone 1 patients had periods during AO where SBP was greater than 140 mmHg as compared to 70% Zone 3 patients (p = 0.04). The overall mean decrease in SBP after balloon deflation was 13 (20) mmHg (p < 0.01), with similar decreases among groups (14 (21) mmHg vs 12 (18) mmHg for Zone 1 and 3 patients, respectively (p = 0.85)). Patients undergoing Zone 1 AO were more likely to have an acute change (increase or decrease) in their heart rate immediately after AO as compared to Zone 3 AO (p = 0.048). CONCLUSIONS Significant hemodynamic alterations occur before, during, and after AO. The effects of Zone 1 AO on blood pressure and heart rate appear different than Zone 3 AO. This may have important implications for cardiac or cerebral function and perfusion goals, particularly with concomitant injuries such as cardiac contusion or traumatic brain injury.
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Affiliation(s)
- Philip J Wasicek
- University of Maryland School of Medicine, Program in Trauma/Critical Care RA Cowley Shock Trauma Center, 22 S. Greene Street, Baltimore, MD 21201, United States.
| | - Yao Li
- University of Maryland School of Medicine, Program in Trauma/Critical Care RA Cowley Shock Trauma Center, 22 S. Greene Street, Baltimore, MD 21201, United States
| | - Shiming Yang
- University of Maryland School of Medicine, Program in Trauma/Critical Care RA Cowley Shock Trauma Center, 22 S. Greene Street, Baltimore, MD 21201, United States
| | - William A Teeter
- University of Maryland School of Medicine, Program in Trauma/Critical Care RA Cowley Shock Trauma Center, 22 S. Greene Street, Baltimore, MD 21201, United States
| | - Thomas M Scalea
- University of Maryland School of Medicine, Program in Trauma/Critical Care RA Cowley Shock Trauma Center, 22 S. Greene Street, Baltimore, MD 21201, United States
| | - Peter Hu
- University of Maryland School of Medicine, Program in Trauma/Critical Care RA Cowley Shock Trauma Center, 22 S. Greene Street, Baltimore, MD 21201, United States
| | - Megan L Brenner
- University of Maryland School of Medicine, Program in Trauma/Critical Care RA Cowley Shock Trauma Center, 22 S. Greene Street, Baltimore, MD 21201, United States
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22
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Gray S, Dieudonne B. Resuscitative Endovascular Balloon Occlusion of the Aorta as an Adjunct in a Patient with Neurogenic Shock. Cureus 2018; 10:e3375. [PMID: 30510884 PMCID: PMC6257711 DOI: 10.7759/cureus.3375] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Aortic occlusion is used during trauma resuscitation for patients with profound shock and cardiac arrest. Aortic occlusion increases coronary and cerebral perfusion permitting time for interventions in an attempt to salvage moribund patients. Resuscitative endovascular occlusion of the aorta (REBOA) is a less invasive method of aortic occlusion and its indications are being defined, but it is used primarily for noncompressible torso hemorrhage. This case is the first report of the use of REBOA for neurogenic shock in a trauma patient. The patient presented after a motorcycle accident with altered mental status and hypotension. The patient was resuscitated with blood products and REBOA used as an adjunct to maintain cardiac and cerebral perfusion. The patient underwent stabilization of his spinal injuries and is currently undergoing rehabilitation. There were no complications related to the REBOA.
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Affiliation(s)
- Sanjiv Gray
- Surgery, University of Central Florida, Orlando, USA
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23
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Kim DH, Chang SW, Matsumoto J. The utilization of resuscitative endovascular balloon occlusion of the aorta: preparation, technique, and the implementation of a novel approach to stabilizing hemorrhage. J Thorac Dis 2018; 10:5550-5559. [PMID: 30416806 DOI: 10.21037/jtd.2018.08.71] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Noncompressible torso hemorrhage (NCTH), if not controlled promptly, leads to death. In the acute setting, aortic occlusion can be performed as damage control surgery (DCS) for hemorrhage originating from the abdomen and pelvis. With the development of endovascular technology, an intra-aortic balloon can be used to achieve aortic occlusion and decrease hemorrhage. Recently, resuscitative endovascular balloon occlusion of the aorta (REBOA) has been accepted as a salvage technique for the temporary stabilization of patients with NCTH. However, balloon occlusion is not easily performed in trauma patients. In this article, we described preparation, technical description, and conceptual understanding of REBOA.
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Affiliation(s)
| | | | - Junichi Matsumoto
- Department of Emergency and Critical Care Medicine, Saint-Marianna University School of Medicine, Kawasaki, Japan
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24
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Resuscitative endovascular balloon occlusion of the aorta (REBOA) and endovascular resuscitation and trauma management (EVTM): a paradigm shift regarding hemodynamic instability. Eur J Trauma Emerg Surg 2018; 44:487-489. [PMID: 30084088 DOI: 10.1007/s00068-018-0983-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 07/10/2018] [Indexed: 10/28/2022]
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Borger van der Burg BLS, van Dongen TTCF, Morrison JJ, Hedeman Joosten PPA, DuBose JJ, Hörer TM, Hoencamp R. A systematic review and meta-analysis of the use of resuscitative endovascular balloon occlusion of the aorta in the management of major exsanguination. Eur J Trauma Emerg Surg 2018; 44:535-550. [PMID: 29785654 PMCID: PMC6096615 DOI: 10.1007/s00068-018-0959-y] [Citation(s) in RCA: 99] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 04/18/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Circulatory collapse is a leading cause of mortality among traumatic major exsanguination and in ruptured aortic aneurysm patients. Approximately 40% of patients die before hemorrhage control is achieved. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct designed to sustain the circulation until definitive surgical or endovascular repair. A systematic review was conducted for the current clinical use of REBOA in patients with hemodynamic instability and to discuss its potential role in improving prehospital and in-hospital outcome. METHODS Systematic review and meta-analysis (1900-2017) using MEDLINE, Cochrane, EMBASE, Web of Science and Central and Emcare using the keywords "aortic balloon occlusion", "aortic balloon tamponade", "REBOA", and "Resuscitative Endovascular Balloon Occlusion" in combination with hemorrhage control, hemorrhage, resuscitation, shock, ruptured abdominal or thoracic aorta, endovascular repair, and open repair. Original published studies on human subjects were considered. RESULTS A total of 490 studies were identified; 89 met criteria for inclusion. Of the 1436 patients, overall reported mortality was 49.2% (613/1246) with significant differences (p < 0.001) between clinical indications. Hemodynamic shock was evident in 79.3%, values between clinical indications showed significant difference (p < 0.001). REBOA was favored as treatment in trauma patients in terms of mortality. Pooled analysis demonstrated an increase in mean systolic pressure by almost 50 mmHg following REBOA use. CONCLUSION REBOA has been used in trauma patients and ruptured aortic aneurysm patients with improvement of hemodynamic parameters and outcomes for several decades. Formal, prospective study is warranted to clarify the role of this adjunct in all hemodynamic unstable patients.
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Affiliation(s)
| | - Thijs T. C. F. van Dongen
- Department of Surgery, Alrijne Hospital, Simon Smitweg 1, 2353 GA Leiderdorp, The Netherlands
- Defense Healthcare Organization, Ministry of Defense, Utrecht, The Netherlands
| | - J. J. Morrison
- R. Adam Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, USA
| | | | - J. J. DuBose
- Division of Vascular Surgery, David Grant Medical Center, Travis AFB, California, USA
| | - T. M. Hörer
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro University, Örebro, Sweden
| | - R. Hoencamp
- Department of Surgery, Alrijne Hospital, Simon Smitweg 1, 2353 GA Leiderdorp, The Netherlands
- Defense Healthcare Organization, Ministry of Defense, Utrecht, The Netherlands
- Division of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
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Non-traumatic hemorrhage is controlled with REBOA in acute phase then mortality increases gradually by non-hemorrhagic causes: DIRECT-IABO registry in Japan. Eur J Trauma Emerg Surg 2017; 44:503-509. [PMID: 28831501 DOI: 10.1007/s00068-017-0829-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 08/16/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Resuscitative endovascular balloon occlusion of the aorta (REBOA) is now a feasible and less invasive resuscitation procedure. This study aimed to compare the clinical course of trauma and non-trauma patients undergoing REBOA. METHODS Patient demographics, etiology, bleeding sites, hemodynamic response, length of critical care, and cause of death were recorded. Characteristics and outcomes were compared between non-trauma and trauma patients. Kaplan-Meier survival analysis was then conducted. RESULTS Between August 2011 and December 2015, 142 (36 non-trauma; 106 trauma) cases were analyzed. Non-traumatic etiologies included gastrointestinal bleeding, obstetrics and gynecology-derived events, visceral aneurysm, abdominal aortic aneurysm, and post-abdominal surgery. The abdomen was a common bleeding site (69%), followed by the pelvis or extra-pelvic retroperitoneum. None of the non-trauma patients had multiple bleeding sites, whereas 45% of trauma patients did (P < 0.001). No non-trauma patients required resuscitative thoracotomy compared with 28% of the trauma patients (P < 0.001). Non-trauma patients presented a lower 24-h mortality than trauma patients (19 vs. 51%, P = 0.001). The non-trauma cases demonstrated a gradual but prolonged increased mortality, whereas survival in trauma cases rapidly declined (P = 0.009) with similar hospital mortality (68 vs. 64%). Non-trauma patients who survived for 24 h had 0 ventilator-free days and 0 ICU-free days vs. a median of 19 and 12, respectively, for trauma patients (P = 0.33 and 0.39, respectively). Non-hemorrhagic death was more common in non-trauma vs. trauma patients (83 vs. 33%, P < 0.001). CONCLUSIONS Non-traumatic hemorrhagic shock often resulted from a single bleeding site, and resulted in better 24-h survival than traumatic hemorrhage among Japanese patients who underwent REBOA. However, hospital mortality increased steadily in non-trauma patients affected by non-hemorrhagic causes after a longer period of critical care.
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