Stent grafting a ruptured para-anastomotic iliac aneurysm

A systematic review and meta-analysis of the use of resuscitative endovascular balloon occlusion of the aorta in the management of major exsanguination

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.

Percutaneous balloon-expandable stent graft repair of a ruptured iliac aneurysm

Elective stent graft repair of iliac aneurysm is successful and safe. There are, however, few published data on stent grafting unstable patients with acute iliac aneurysm rupture. Iliac diameter mismatch can also present a challenge to emergency endovascular treatment. We report the treatment of an unstable patient with iliac aneurysm rupture and diameter mismatch using a percutaneous balloon-expandable polytetrafluoroethylene (PTFE) stent graft. Outcomes were satisfactory up to 12-month follow-up. Treatment of iliac aneurysm rupture using a balloon-expandable stent graft can be successful in selected patients. A percutaneous approach and targeted stent graft postdilatation enable prompt repair in the presence of diameter mismatch, facilitating emergency therapy.