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van de Voort JC, Kessel B, Borger van der Burg BLS, DuBose JJ, Hörer TM, Hoencamp R. Consensus on resuscitative endovascular balloon occlusion of the aorta in civilian (prehospital) trauma care: A Delphi study. J Trauma Acute Care Surg 2024; 96:921-930. [PMID: 38227678 DOI: 10.1097/ta.0000000000004238] [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: 01/18/2024]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) could prevent lethal exsanguination and support cardiopulmonary resuscitation. In prehospital trauma and medical emergency settings, a small population with high mortality rates could potentially benefit from early REBOA deployment. However, its use in these situations remains highly disputed. Since publication of the first Delphi study on REBOA, in which consensus was not reached on all addressed topics, new literature has emerged. The aim of this study was to establish consensus on the use and implementation of REBOA in civilian prehospital settings for noncompressible truncal hemorrhage and out-of-hospital cardiac arrest as well as for various in-hospital settings. METHODS A Delphi study consisting of three rounds of questionnaires was conducted based on a review of recent literature. REBOA experts with different medical specialties, backgrounds, and work environments were invited for the international panel. Consensus was reached when a minimum of 75% of panelists responded to a question and at least 75% (positive) or less than 25% (negative) of these respondents agreed on the questioned subject. RESULTS Panel members reached consensus on potential (contra)indications, physiological thresholds for patient selection, the use of ultrasound and practical, and technical aspects for early femoral artery access and prehospital REBOA. CONCLUSION The international expert panel agreed that REBOA can be used in civilian prehospital settings for temporary control of noncompressible truncal hemorrhage, provided that personnel are properly trained and protocols are established. For prehospital REBOA and early femoral artery access, consensus was reached on (contra)indications, physiological thresholds and practical aspects. The panel recommends the initiation of a randomized clinical trial investigating the use of prehospital REBOA for noncompressible truncal hemorrhage. LEVEL OF EVIDENCE Therapeutic/Care Management; Level V.
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Affiliation(s)
- Jan C van de Voort
- From the Department of Surgery (J.C.vdV., B.L.S.B.vdB., R.H.), Alrijne Hospital, Leiderdorp; Trauma Research Unit, Department of Trauma Surgery (J.C.vdV., R.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; Division of General Surgery and Trauma (B.K.), Hillel Yaffe Medical Center, Hadera; Rappaport Faculty of Medicine (B.K.), Technion-Israel Institute of Technology, Haifa, Israel; Defense Healthcare Organization (B.L.S.B.vdB., R.H.), Ministry of Defense, Utrecht, The Netherlands; Department of Surgery and Perioperative Care (J.J.DB.), Dell School of Medicine, University of Texas, Austin, Texas; Department of Surgery, Faculty of Medicine and Health (T.M.H.), and Department of Cardiothoracic and Vascular Surgery (T.M.H.), Faculty of Medicine and Health, Örebro Hospital and University, Örebro, Sweden
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2
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Smith MC, Medvecz AJ, Smith MR, Streams JR, Dennis BM. Computed tomography scanning is feasible in select patients with REBOA catheter deployment. Injury 2024; 55:111387. [PMID: 38360518 DOI: 10.1016/j.injury.2024.111387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 01/05/2024] [Accepted: 01/24/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Rapidly localizing and controlling bleeding is central to treating hemorrhagic shock. While REBOA allows temporary control, identifying the source of bleeding remains challenging. CT imaging with REBOA in place may provide information to direct hemorrhage control. The purpose of this study is to provide a descriptive summary of data comparing patients who did and did not undergo CT scan following REBOA deployment. Our hypothesis was that performing CT scan after REBOA placement in select patients is safe and can guide management of hemorrhagic shock. METHODS We queried the AAST AORTA registry for patients receiving REBOA at our level 1 trauma center from May 2017 to December 2021. Clinical data was obtained through the Trauma Registry of the American College of Surgeons (TRACS). Comparison groups were those who underwent CT scan after REBOA deployment versus those who did not undergo CT scan after REBOA deployment. The primary outcome was inhospital mortality, and secondary outcomes included hospital-, ICU-, and ventilator-free days. RESULTS 61 patients underwent CT scan with REBOA in place; 25 patients proceeded directly to hemorrhage control. Patients with REBOA prior to CT were more likely to have blunt mechanism, higher ISS, pelvic bleeding, and zone 3 REBOA placement. Mortality was not significantly different (51 % vs. 64 %). Patients who underwent CT with REBOA were more likely to undergo hemorrhage control in interventional radiology (43 % vs. 0 %). There was no difference in hospital-, ICU-, and ventilator-free days. DISCUSSION We demonstrate the feasibility of performing CT in select trauma patients who undergo REBOA. We describe a pathway to enable expeditious workup and management of these patients. Optimal hemorrhage control management is impacted by CT scans when it can be performed. It is important to note that this is a severely injured patient population, and mortality is high even when hemorrhage is controlled. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Michael C Smith
- Vanderbilt University Medical Center, Division of Acute Care Surgery 404 Medical Arts Building, 1211 21st Avenue South, Nashville, TN 37212, USA.
| | - Andrew J Medvecz
- Vanderbilt University Medical Center, Division of Acute Care Surgery 404 Medical Arts Building, 1211 21st Avenue South, Nashville, TN 37212, USA
| | - Melissa R Smith
- Vanderbilt University Medical Center, Division of Acute Care Surgery 404 Medical Arts Building, 1211 21st Avenue South, Nashville, TN 37212, USA
| | - Jill R Streams
- Vanderbilt University Medical Center, Division of Acute Care Surgery 404 Medical Arts Building, 1211 21st Avenue South, Nashville, TN 37212, USA
| | - Bradley M Dennis
- Vanderbilt University Medical Center, Division of Acute Care Surgery 404 Medical Arts Building, 1211 21st Avenue South, Nashville, TN 37212, USA
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3
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Paran M, McGreevy D, Hörer TM, Khan M, Dudkiewicz M, Kessel B. International registry on aortic balloon occlusion in major trauma: Partial inflation does not improve outcomes in abdominal trauma. Surgeon 2024; 22:37-42. [PMID: 37652801 DOI: 10.1016/j.surge.2023.08.001] [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: 04/29/2023] [Revised: 08/05/2023] [Accepted: 08/14/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a method for temporary hemorrhage control used in haemodynamically unwell patients with severe bleeding. In haemodynamically unwell abdominal trauma patients, laparotomy remains the initial procedure of choice. Using REBOA in patients as a bridge to laparotomy is a novel option whose feasibility and efficacy remain unclear. We aimed to assess the clinical outcome in patients with abdominal injury who underwent both REBOA placement and laparotomy. METHODS This is a retrospective study, including trauma patients with an isolated abdominal injury who underwent both REBOA placement and laparotomy, during the period 2011-2019. All data were collected via the Aortic Balloon Occlusion Trauma Registry database. RESULTS One hundred and three patients were included in this study. The main mechanism of trauma was blunt injury (62.1%) and the median injury severity score (ISS) was 33 (14-74). Renal failure and multi-organ dysfunction syndrome (MODS) occurred in 15.5% and 35% of patients, respectively. Overall, 30-day mortality was 50.5%. Post balloon inflation systolic blood pressure (SBP) >80 mmHg was associated with lower 24-h mortality (p = 0.007). No differences in mortality were found among patients who underwent partial occlusion vs. total occlusion of the aorta. CONCLUSIONS Our results support the feasibility of REBOA use in patients with isolated abdominal injury, with survival rates similar to previous reports for haemodynamically unstable abdominal trauma patients. Post-balloon inflation SBP >80 mmHg was associated with a significant reduction in 24-h mortality rates, but not 30-day mortality. Total aortic occlusion was not associated with increased mortality, MODS, and complication rates compared with partial occlusion.
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Affiliation(s)
- Maya Paran
- Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Isral, Affiliated with Sackler School of Medicine, Tel-Aviv University, Tel-aviv, Israel.
| | - David McGreevy
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Tal M Hörer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Department of General Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Mansoor Khan
- Brighton and Sussex Medical School, Brighton, UK
| | - Mickey Dudkiewicz
- Hillel Yaffe Medical Center, Affiliated with The Rappaport Medical School, Technion, Haifa, Israel
| | - Boris Kessel
- Division of General Surgery and Trauma, Hillel Yaffe Medical Center, Affiliated with The Rappaport Medical School, Technion, Haifa, Israel
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4
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Ordoñez CA, Parra MW, Caicedo Y, Rodríguez-Holguín F, García AF, Serna JJ, Serna C, Franco MJ, Salcedo A, Padilla-Londoño N, Herrera-Escobar JP, Zogg C, Orlas CP, Palacios H, Saldarriaga L, Granados M, Scalea T, McGreevy DT, Kessel B, Hörer TM, Dubose J, Brenner M. Critical systolic blood pressure threshold for endovascular aortic occlusion-A multinational analysis to determine when to place a REBOA. J Trauma Acute Care Surg 2024; 96:247-255. [PMID: 37853558 DOI: 10.1097/ta.0000000000004160] [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: 10/20/2023]
Abstract
BACKGROUND Systolic blood pressure (SBP) is a potential indicator that could guide when to use a resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma patients with life-threatening injuries. This study aims to determine the optimal SBP threshold for REBOA placement by analyzing the association between SBP pre-REBOA and 24-hour mortality in severely injured hemodynamically unstable trauma patients. METHODS We performed a pooled analysis of the aortic balloon occlusion (ABO) trauma and AORTA registries. These databases record the details related to the use of REBOA and include data from 14 countries worldwide. We included patients who had suffered penetrating and/or blunt trauma. Patients who arrived at the hospital with a SBP pre-REBOA of 0 mm Hg and remained at 0 mm Hg after balloon inflation were excluded. We evaluated the impact that SBP pre-REBOA had on the probability of death in the first 24 hours. RESULTS A total of 1,107 patients underwent endovascular aortic occlusion, of these, 848 met inclusion criteria. The median age was 44 years (interquartile range [IQR], 27-59 years) and 643 (76%) were male. The median injury severity score was 34 (IQR, 25-45). The median SBP pre-REBOA was 65 mm Hg (IQR, 49-88 mm Hg). Mortality at 24 hours was reported in 279 (32%) patients. Math modeling shows that predicted probabilities of the primary outcome increased steadily in SBP pre-REBOA below 100 mm Hg. Multivariable mixed-effects analysis shows that when SBP pre-REBOA was lower than 60 mm Hg, the risk of death was more than 50% (relative risk, 1.5; 95% confidence interval, 1.17-1.92; p = 0.001). DISCUSSION In patients who do not respond to initial resuscitation, the use of REBOA in SBPs between 60 mm Hg and 80 mm Hg may be a useful tool in resuscitation efforts before further decompensation or complete cardiovascular collapse. The findings from our study are clinically important as a first step in identifying candidates for REBOA. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Carlos A Ordoñez
- From the Division of Trauma and Acute Care Surgery, Department of Surgery (C.A.O., F.R.-H., A.F.G., J.J.S., C.S., M.J.F., A.S., H.P.), Fundación Valle del Lili; Universidad Icesi (C.A.O., Y.C., A.F.G., J.J.S., C.S., A.S., L.S.), Cali, Colombia; Division of Trauma and Acute Care Surgery, Department of Surgery (C.A.O., A.F.G., J.J.S.), Universidad del Valle, Cali, Colombia; Department of Trauma Critical Care (M.W.P.), Broward General Level I Trauma Center, Fort Lauderdale, Florida; Centro de Investigaciones Clínicas (CIC) (Y.C., N.P.-L.), Fundación Valle del Lili, Cali, Colombia; Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital (J.P.H.-E., C.P.O.), Harvard Medical School & Harvard T.H. Chan School of Public Health; Center for Surgery and Public Health (C.Z.), Boston, Massachusetts; Yale School of Medicine (C.Z.), New Haven, Connecticut; Department of Intensive Care (M.G.), Fundación Valle del Lili, Cali, Colombia; R Adams Cowley Shock Trauma Center (T.S.), University of Maryland Medical Center, Baltimore, Maryland; Faculty of Medicine and Health, Department of Cardiothoracic and Vascular Surgery and Department of Surgery (D.T.M.G., T.M.H.), Örebro University, Örebro, Sweden; Surgical Division (B.K.), Hillel Yaffe Medical Center, Hadera, Israel; Dell School of Medicine (J.D.), University of Texas, Austin, Texas; and Department of Surgery (M.B.), UCLA David Geffen School of Medicine, Los Angeles, California
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5
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Guan Y, Chen P, Zhou H, Hong J, Yan Y, Wang Y. Common complications and prevention strategies for resuscitative endovascular balloon occlusion of the aorta: A narrative review. Medicine (Baltimore) 2023; 102:e34748. [PMID: 37653766 PMCID: PMC10470747 DOI: 10.1097/md.0000000000034748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/15/2023] [Accepted: 07/24/2023] [Indexed: 09/02/2023] Open
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is considered a key measure of treatment due to its use in stabilizing patients in shock through temporary inflow occlusion for noncompressible torso hemorrhage as well as its supportive role in myocardial and cerebral perfusion. Although its clinical efficacy in trauma has been widely recognized, concerns over related complications, such as vascular access and ischemia-reperfusion, are on the rise. This paper aims to investigate complications associated with REBOA and identify current and emerging prevention or mitigation strategies through a literature review based on human or animal data. Common complications associated with REBOA include ischemia/reperfusion injuries, vessel injuries, venous thromboembolism, and worsening proximal bleeding. REBOA treatment outcomes can be improved substantially with the help of precise selection of patients, better visualization tools, improvement in balloon catheters, blockage strategies, and medication intervention measures. Better understanding of REBOA-related complications and further research on the strategies to mitigate the occurrence of such complications will be of vital importance for the optimization of the clinical outcomes in patients.
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Affiliation(s)
- Yi Guan
- College of Pediatrics, Hainan Medical University, Haikou, China
| | - Pinghao Chen
- College of Pediatrics, Hainan Medical University, Haikou, China
| | - Hao Zhou
- College of Pediatrics, Hainan Medical University, Haikou, China
| | - Jiaxiang Hong
- College of Pediatrics, Hainan Medical University, Haikou, China
| | - Yanggang Yan
- College of Pediatrics, Hainan Medical University, Haikou, China
| | - Yong Wang
- Department of Emergency, Hainan Clinical Research Center for Acute and Critical Diseases, the Second Affiliated Hospital of Hainan Medical University, Haikou, China
- Department of Interventional Radiology and Vascular Surgery, the Second Affiliated Hospital of Hainan Medical University, Haikou, China
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6
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Ferrada P, Dissanaike S. Circulation First for the Rapidly Bleeding Trauma Patient-It Is Time to Reconsider the ABCs of Trauma Care. JAMA Surg 2023; 158:884-885. [PMID: 37195675 DOI: 10.1001/jamasurg.2022.8436] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
This Surgical Innovation describes the advantages of prioritizing circulation in patients with compressible bleeding sources and in those with noncompressible torso injuries.
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Affiliation(s)
- Paula Ferrada
- University of Virginia School of Medicine, Charlottesville
- Division of Acute Care Surgery, Inova Health System, Falls Church, Virginia
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Stene Hurtsén A, McGreevy DT, Karlsson C, Frostell CG, Hörer TM, Nilsson KF. A randomized porcine study of hemorrhagic shock comparing end-tidal carbon dioxide targeted and proximal systolic blood pressure targeted partial resuscitative endovascular balloon occlusion of the aorta in the mitigation of metabolic injury. Intensive Care Med Exp 2023; 11:18. [PMID: 37032421 PMCID: PMC10083152 DOI: 10.1186/s40635-023-00502-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/16/2023] [Indexed: 04/11/2023] Open
Abstract
BACKGROUND The definition of partial resuscitative endovascular balloon occlusion of the aorta (pREBOA) is not yet determined and clinical markers of the degree of occlusion, metabolic effects and end-organ injury that are clinically monitored in real time are lacking. The aim of the study was to test the hypothesis that end-tidal carbon dioxide (ETCO2) targeted pREBOA causes less metabolic disturbance compared to proximal systolic blood pressure (SBP) targeted pREBOA in a porcine model of hemorrhagic shock. MATERIALS AND METHODS Twenty anesthetized pigs (26-35 kg) were randomized to 45 min of either ETCO2 targeted pREBOA (pREBOAETCO2, ETCO2 90-110% of values before start of occlusion, n = 10) or proximal SBP targeted pREBOA (pREBOASBP, SBP 80-100 mmHg, n = 10), during controlled grade IV hemorrhagic shock. Autotransfusion and reperfusion over 3 h followed. Hemodynamic and respiratory parameters, blood samples and jejunal specimens were analyzed. RESULTS ETCO2 was significantly higher in the pREBOAETCO2 group during the occlusion compared to the pREBOASBP group, whereas SBP, femoral arterial mean pressure and abdominal aortic blood flow were similar. During reperfusion, arterial and mesenteric lactate, plasma creatinine and plasma troponin concentrations were higher in the pREBOASBP group. CONCLUSIONS In a porcine model of hemorrhagic shock, ETCO2 targeted pREBOA caused less metabolic disturbance and end-organ damage compared to proximal SBP targeted pREBOA, with no disadvantageous hemodynamic impact. End-tidal CO2 should be investigated in clinical studies as a complementary clinical tool for mitigating ischemic-reperfusion injury when using pREBOA.
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Affiliation(s)
- Anna Stene Hurtsén
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
- Centre for Clinical Research and Education, County Council of Värmland, Karlstad, Sweden.
- School of Medical Sciences, Örebro University, Örebro, Sweden.
| | - David T McGreevy
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | | | - Claes G Frostell
- Anesthesiology and Intensive Care, Department of Clinical Sciences, Karolinska Institute at Danderyd Hospital, Stockholm, Sweden
| | - Tal M Hörer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Kristofer F Nilsson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- School of Medical Sciences, Örebro University, Örebro, Sweden
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8
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Caicedo Y, Gallego LM, Clavijo HJ, Padilla-Londoño N, Gallego CN, Caicedo-Holguín I, Guzmán-Rodríguez M, Meléndez-Lugo JJ, García AF, Salcedo AE, Parra MW, Rodríguez-Holguín F, Ordoñez CA. Resuscitative endovascular balloon occlusion of the aorta in civilian pre-hospital care: a systematic review of the literature. Eur J Med Res 2022; 27:202. [PMID: 36253841 PMCID: PMC9575194 DOI: 10.1186/s40001-022-00836-3] [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: 08/04/2022] [Accepted: 09/22/2022] [Indexed: 11/25/2022] Open
Abstract
Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a damage control tool with a potential role in the hemodynamic resuscitation of severely ill patients in the civilian pre-hospital setting. REBOA ensures blood flow to vital organs by early proximal control of the source of bleeding. However, there is no consensus on the use of REBOA in the pre-hospital setting. This article aims to perform a systematic review of the literature about the feasibility, survival, indications, complications, and potential candidates for civilian pre-hospital REBOA. Methods A literature search was conducted using Medline, EMBASE, LILACS and Web of Science databases. Primary outcome variables included overall survival and feasibility. Secondary outcome variables included complications and potential candidates for endovascular occlusion. Results The search identified 8 articles. Five studies described the use of REBOA in pre-hospital settings, reporting a total of 47 patients in whom the procedure was attempted. Pre-hospital REBOA was feasible in 68–100% of trauma patients and 100% of non-traumatic patients with cardiac arrest. Survival rates and complications varied widely. Pre-hospital REBOA requires a coordinated and integrated emergency health care system with a well-trained and equipped team. The remaining three studies performed a retrospective analysis identifying 784 potential REBOA candidates. Conclusions Pre-hospital REBOA could be a feasible intervention for a significant portion of severely ill patients in the civilian setting. However, the evidence is limited. The impact of pre-hospital REBOA should be assessed in future studies. Supplementary Information The online version contains supplementary material available at 10.1186/s40001-022-00836-3.
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Affiliation(s)
- Yaset Caicedo
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Cra. 98 No. 18 - 49, Valle del Cauca, Cali, Colombia
| | - Linda M Gallego
- Facultad de Medicina, Universidad Icesi, Cl. 18 No. 122 - 135, Valle del Cauca, Cali, Colombia
| | - Hugo Jc Clavijo
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Cra. 98 No. 18 - 49, Valle del Cauca, Cali, Colombia
| | - Natalia Padilla-Londoño
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Cra. 98 No. 18 - 49, Valle del Cauca, Cali, Colombia
| | - Cindy-Natalia Gallego
- Facultad de Medicina, Universidad Icesi, Cl. 18 No. 122 - 135, Valle del Cauca, Cali, Colombia
| | - Isabella Caicedo-Holguín
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Cra. 98 No. 18 - 49, Valle del Cauca, Cali, Colombia
| | - Mónica Guzmán-Rodríguez
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Av. Libertador Bernardo O'Higgins 1058, Santiago de Chile, Región Metropolitana, Chile
| | - Juan J Meléndez-Lugo
- Department of Surgery, Caja Costarricense del Seguro Social, Av. 2nda - 4rta Cl. 5nta - 7tima, San José, Costa Rica
| | - Alberto F García
- Facultad de Medicina, Universidad Icesi, Cl. 18 No. 122 - 135, Valle del Cauca, Cali, Colombia.,Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra. 98 No. 18 - 49, Valle del Cauca, 760032, Cali, Colombia.,Division of Trauma and Acute Care Surgery, Department of Surgery, Universidad del Valle, Cl. 13 # 100 - 00, Valle del Cauca, Cali, Colombia
| | - Alexander E Salcedo
- Facultad de Medicina, Universidad Icesi, Cl. 18 No. 122 - 135, Valle del Cauca, Cali, Colombia.,Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra. 98 No. 18 - 49, Valle del Cauca, 760032, Cali, Colombia.,Division of Trauma and Acute Care Surgery, Department of Surgery, Universidad del Valle, Cl. 13 # 100 - 00, Valle del Cauca, Cali, Colombia.,Division of Trauma and Acute Care Surgery, Department of Surgery, Hospital Universitario del Valle, Cl. 5 # 36 - 08, Valle del Cauca, Cali, Colombia
| | - Michael W Parra
- Department of Trauma Critical Care, Broward General Level I Trauma Center, 1600 S Andrews Ave, Fort Lauderdale, FL, USA
| | - Fernando Rodríguez-Holguín
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra. 98 No. 18 - 49, Valle del Cauca, 760032, Cali, Colombia
| | - Carlos A Ordoñez
- Facultad de Medicina, Universidad Icesi, Cl. 18 No. 122 - 135, Valle del Cauca, Cali, Colombia. .,Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra. 98 No. 18 - 49, Valle del Cauca, 760032, Cali, Colombia. .,Division of Trauma and Acute Care Surgery, Department of Surgery, Universidad del Valle, Cl. 13 # 100 - 00, Valle del Cauca, Cali, Colombia.
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A 12-year experience of endovascular repair for ruptured Abdominal Aortic Aneurysms in all patients. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.10.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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10
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Tran S, Wilks M, Dawson J. Endovascular Management of Splenic Trauma. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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11
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Ordoñez CA, Caicedo Y, Parra MW, Rodríguez-Holguín F, Serna JJ, Salcedo A, Franco MJ, Toro LE, Pino LF, Guzmán-Rodríguez M, Orlas C, Herrera-Escobar JP, González-Hadad A, Herrera MA, Aristizábal G, García A. Evolution of damage control surgery in non-traumatic abdominal pathology: a light in the darkness. Colomb Med (Cali) 2021; 52:e4194809. [PMID: 34908626 PMCID: PMC8634274 DOI: 10.25100/cm.v52i2.4809] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 04/30/2021] [Accepted: 06/07/2021] [Indexed: 11/11/2022] Open
Abstract
Damage control surgery is based on temporal control of the injury, physiologic recovery and posterior deferred definitive management. This strategy began in the 1980s and became a formal concept in 1993. It has proven to be a strategy that reduces mortality in severely injured trauma patients. Nevertheless, the concept of damage control in non-traumatic abdominal pathology remains controversial. This article aims to gather historical experiences in damage control surgery performed in non-traumatic abdominal emergency pathology patients and present a novel management algorithm. This strategy could be a surgical option to treat hemodynamically unstable patients in catastrophic scenarios such as hemorrhagic and septic shock caused by peritonitis, pancreatitis, acute mesenteric ischemia, among others. Therefore, damage control surgery is light amid better short- and long-term results.
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Affiliation(s)
- Carlos A Ordoñez
- Fundación Valle del Lili. Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL - USA
| | - Fernando Rodríguez-Holguín
- Fundación Valle del Lili. Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - José Julián Serna
- Fundación Valle del Lili. Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Alexander Salcedo
- Fundación Valle del Lili. Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - María Josefa Franco
- Fundación Valle del Lili. Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Luis Eduardo Toro
- Fundación Valle del Lili. Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Mónica Guzmán-Rodríguez
- Universidad de Chile, Facultad de Medicina,Instituto de Ciencias Biomédicas, Santiago de Chile, Chile
| | - Claudia Orlas
- Harvard Medical School & Harvard T.H. Chan School of Public Health, Department of Surgery, Center for Surgery and Public Health, Brigham & Women's Hospital, Boston - USA
| | - Juan Pablo Herrera-Escobar
- Harvard Medical School & Harvard T.H. Chan School of Public Health, Department of Surgery, Center for Surgery and Public Health, Brigham & Women's Hospital, Boston - USA
| | - Adolfo González-Hadad
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Mario Alain Herrera
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Gonzalo Aristizábal
- Fundación Valle del Lili. Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Alberto García
- Fundación Valle del Lili. Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
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12
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McGreevy DT, Sadeghi M, Nilsson KF, Hörer TM. Low profile REBOA device for increasing systolic blood pressure in hemodynamic instability: single-center 4-year experience of use of ER-REBOA. Eur J Trauma Emerg Surg 2021; 48:307-313. [PMID: 33515268 PMCID: PMC8825639 DOI: 10.1007/s00068-020-01586-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 12/27/2020] [Indexed: 11/29/2022]
Abstract
Background Hemodynamic instability due to torso hemorrhage can be managed with the assistance of resuscitative endovascular balloon occlusion of the aorta (REBOA). This is a report of a single-center experience using the ER-REBOA™ catheter for traumatic and non-traumatic cases as an adjunct to hemorrhage control and as part of the EndoVascular resuscitation and Trauma Management (EVTM) concept. The objective of this report is to describe the clinical usage, technical success, results, complications and outcomes of the ER-REBOA™ catheter at Örebro University hospital, a middle-sized university hospital in Europe. Methods Data concerning patients receiving the ER-REBOA™ catheter for any type of hemorrhagic shock and hemodynamic instability at Örebro University hospital in Sweden were collected prospectively from October 2015 to May 2020. Results A total of 24 patients received the ER-REBOA™ catheter (with the intention to use) for traumatic and non-traumatic hemodynamic control; it was used in 22 patients. REBOA was performed or supervised by vascular surgeons using 7–8 Fr sheaths with an anatomic landmark or ultrasound guidance. Systolic blood pressure (SBP) increased significantly from 50 mmHg (0–63) to 95 mmHg (70–121) post REBOA. In this cohort, distal embolization and balloon rupture due to atherosclerosis were reported in one patient and two patients developed renal failure. There were no cases of balloon migration. Overall 30-day survival was 59%, with 45% for trauma patients and 73% for non-traumatic patients. Responders to REBOA had a significantly lower rate of mortality at both 24 h and 30 days. Conclusions Our clinical data and experience show that the ER-REBOA™ catheter can be used for control of hemodynamic instability and to significantly increase SBP in both traumatic and non-traumatic cases, with relatively few complications. Responders to REBOA have a significantly lower rate of mortality.
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Affiliation(s)
- David T McGreevy
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro University Hospital, 701 85, Örebro, Sweden.
| | - Mitra Sadeghi
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro University Hospital, 701 85, Örebro, Sweden
| | - Kristofer F Nilsson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro University Hospital, 701 85, Örebro, Sweden
| | - Tal M Hörer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro University Hospital, 701 85, Örebro, Sweden.,Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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13
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Power A, Parekh A, Scallan O, Smith S, Novick T, Parry N, Moore L. Size matters: first-in-human study of a novel 4 French REBOA device. Trauma Surg Acute Care Open 2021; 6:e000617. [PMID: 33490605 PMCID: PMC7798668 DOI: 10.1136/tsaco-2020-000617] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/11/2020] [Accepted: 12/22/2020] [Indexed: 12/21/2022] Open
Abstract
Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emerging technique used for non-compressible torso hemorrhage. However, its current use continues to be limited and there is a need for a simple, fast, and low profile REBOA device. Our objective was to evaluate the feasibility of a novel 4 French REBOA device called the COBRA-OS (Control of Bleeding, Resuscitation, Arterial Occlusion System). Methods This study is the first-in-human feasibility trial of the COBRA-OS. Due to the difficulty of trialing the device in the trauma setting, we performed a feasibility study using organ donors (due to the potential usefulness of the COBRA-OS for normothermic regional perfusion) after neurological determination of death (NDD) prior to organ retrieval. Bilateral 4 French introducer sheaths were placed in both femoral arteries and the COBRA-OS was advanced up the right side and deployed in the thoracic aorta (Zone 1). Once aortic occlusion was confirmed via the left-sided arterial line, the device was deflated, moved to the infrarenal aorta (Zone 3), and redeployed. Results A total of 7 NDD organ donors were entered into the study, 71% men, with a mean age 46.6 years (range 26 to 64). The COBRA-OS was able to occlude the aorta in Zones 1 and 3 in all patients. The mean time of placing a 4 French sheath was 47.7 seconds (n=13, range 28 to 66 seconds). The mean time from skin to Zone 1 aortic occlusion was 70.1 seconds (range 58 to 105 seconds); mean balloon volumes were 15 mL for Zone 1 (range 13 to 20 mL) and 9 mL for Zone 3 (range 6 to 15 mL); there were no complications and visual inspection of the aorta in all patients revealed no injury. Discussion The COBRA-OS is a novel 4 French REBOA device that has demonstrated fast and safe aortic occlusion in this first-in-human feasibility study. Level of evidence Level V, therapeutic.
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Affiliation(s)
- Adam Power
- Surgery, Western University, London, Canada
| | | | | | | | | | - Neil Parry
- Surgery, Western University, London, Canada
| | - Laura Moore
- Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
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14
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Ordoñez CA, Parra MW, Caicedo Y, Padilla N, Rodríguez-Holguín F, Serna JJ, Salcedo A, García A, Orlas C, Pino LF, Del Valle AM, Mejia D, Salamea-Molina JC, Brenner M, Hörer T. REBOA as a New Damage Control Component in Hemodynamically Unstable Noncompressible Torso Hemorrhage Patients. COLOMBIA MEDICA (CALI, COLOMBIA) 2020; 51:e4064506. [PMID: 33795901 PMCID: PMC7968426 DOI: 10.25100/cm.v51i4.4422.4506] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Noncompressible torso hemorrhage is one of the leading causes of preventable death worldwide. An efficient and appropriate evaluation of the trauma patient with ongoing hemorrhage is essential to avoid the development of the lethal diamond (hypothermia, coagulopathy, hypocalcemia, and acidosis). Currently, the initial management strategies include permissive hypotension, hemostatic resuscitation, and damage control surgery. However, recent advances in technology have opened the doors to a wide variety of endovascular techniques that achieve these goals with minimal morbidity and limited access. An example of such advances has been the introduction of the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), which has received great interest among trauma surgeons around the world due to its potential and versatility in areas such as trauma, gynecology & obstetrics and gastroenterology. This article aims to describe the experience earned in the use of REBOA in noncompressible torso hemorrhage patients. Our results show that REBOA can be used as a new component in the damage control resuscitation of the severely injured trauma patient. To this end, we propose two new deployment algorithms for hemodynamically unstable noncompressible torso hemorrhage patients: one for blunt and another for penetrating trauma. We acknowledge that REBOA has its limitations, which include a steep learning curve, its inherent cost and availability. Although to reach the best outcomes with this new technology, it must be used in the right way, by the right surgeon with the right training and to the right patient.
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Affiliation(s)
- Carlos A Ordoñez
- Fundación Valle del Lili, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL - USA
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Natalia Padilla
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Fernando Rodríguez-Holguín
- Fundación Valle del Lili, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia
| | - José Julián Serna
- Fundación Valle del Lili, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia
| | - Alexander Salcedo
- Fundación Valle del Lili, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia
| | - Alberto García
- Fundación Valle del Lili, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Claudia Orlas
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, USA.,Harvard Medical School & Harvard T.H. Chan School of Public Health, Boston, USA
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Hospital Universitario del Valle, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia
| | | | - David Mejia
- Hospital Pablo Tobon Uribe, Department of Surgery, Medellin, Colombia.,Universidad de Antioquia, Department of Surgery, Medellin, Colombia
| | - Juan Carlos Salamea-Molina
- Hospital Vicente Corral Moscoso, Division of Trauma and Acute Care Surgery. Cuenca, Ecuador.,Universidad del Azuay, Escuela de Medicina. Cuenca, Ecuador
| | - Megan Brenner
- University of California, Department of Surgery Riverside University Health Systems. Riverside, CA, USA
| | - Tal Hörer
- 15 Örebro University Hospital, Faculty of Medicine, Department of Cardiothoracic and Vascular Surgery, Örebro, Sweden
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15
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Hilbert-Carius P, McGreevy D, Abu-Zidan FM, Hörer TM. Successfully REBOA performance: does medical specialty matter? International data from the ABOTrauma Registry. World J Emerg Surg 2020; 15:62. [PMID: 33228705 PMCID: PMC7685615 DOI: 10.1186/s13017-020-00342-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 11/05/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive procedure being increasingly utilized to prevent patients with non-compressible torso hemorrhage from exsanguination. The increased use of REBOA is giving rise to discussion about "Who is and who should be performing it?" METHODS Data from the international ABO (aortic balloon occlusion) Trauma Registry from between November 2014 and April 2020 were analyzed concerning the question: By who, how, and where is REBOA being performed? The registry collects retrospective and prospective data concerning use of REBOA in trauma patients. RESULTS During the study period, 259 patients had been recorded in the registry, 72.5% (n = 188) were males with a median (range) age of 46 (10-96) years. REBOA was performed in the ER in 50.5%, in the OR in 41.5%, and in the angiography suite in 8% of patients. In 54% of the patients REBOA was performed by surgeons (trauma surgeons 28%, vascular surgeons 22%, general surgeons 4%) and in 46% of the patients by non-surgeons (emergency physicians 31%, radiologists 9.5%, anesthetists 5.5%). Common femoral artery (CFA) access was achieved by use of external anatomic landmarks and palpation alone in 119 patients (51%), by cutdown in 57 patients (24%), using ultrasound in 49 patients (21%), and by fluoroscopy in 9 patients (4%). Significant differences between surgeons and non-surgeons were found regarding patient's age, injury severity, access methods, place where REBOA was performed, location patients were taken to from the emergency room, and mortality. CONCLUSION A substantial number of both surgical and non-surgical medical disciplines are successfully performing REBOA to an almost equal extent. Surgical cutdown is used less frequently as access to the CFA compared with reports in older literature and puncture by use of external anatomic landmarks and palpation alone is used with a high rate of success. Instead of discussing "Who should be performing REBOA?" future research should focus on "Which patient benefits most from REBOA?"
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Affiliation(s)
- Peter Hilbert-Carius
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Bergmannstrost Hospital Halle, Mersbuegerstraße 165, 06112, Halle (Saale), Germany.
| | - David McGreevy
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Science, UAE University, Al-Ain, United Arab Emirates
| | - Tal M Hörer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.,Department of General Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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