Resuscitative endovascular balloon occlusion of the aorta for uncontrolled haemorrahgic shock as an adjunct to haemostatic procedures in the acute care setting

Cerebral haemodynamics and intracranial pressure during haemorrhagic shock and resuscitation with total endovascular balloon occlusion of the aorta in an animal model

PURPOSE

To assess changes of cerebral haemodynamic and intracranial pressure (ICP) in animals, with or without elevated ICP, during controlled haemorrhagic shock and resuscitation with Total REBOA (tREBOA).

METHOD

In 22 anaesthetized and normoventilated pigs, after placement of catheters for monitoring invasive proximal blood pressure (pMAP), ICP, and vital parameters, and 60 min stabilisation phase, a controlled haemorrhagic shock (HS), was conducted. In 11 pigs (EICPG), an elevated ICP of 25-30 mmHg at the end HS was achieved by simulating an epidural mass. In 11 pigs (NICPG), the ICP was normal. tREBOA was then applied for 120 min. The changes of pMAP and ICP were followed, and cerebral perfusion pressure (CPP) calculated. The integrity of the autoregulation was estimated using a calculated Modified-Long Pressure Reactivity Index (mL-PRx).

RESULTS

After stabilisation, hemodynamics and physiological parameters were similar and normal in both groups. At the end of the HS, ICP was 16 mmHg in NICPG vs. 32 in EICPG (p = 0.0010). CPP was 30 mmHg in NICPG vs. 6 mmHg in EICPG (p = 0.0254). After aorta occlusion CPP increased immediately in both groups reaching after 15 min up to104 mmHg in NICPG vs. 126 mmHg in EICPG. Cerebrovascular reactivity seems to be altered during bleeding and occlusion phases in both groups with positive mL-PRx. The alteration was more pronounced in EICPG, but reversible in both groups.

CONCLUSION

tREBOA is lifesaving by restoration the cerebral circulation defined as CPP in animals with HS with normal or elevated ICP. Despite the observation of short episodes of cerebral autoregulation impairment during the occlusion, mainly in EICPG, tREBOA seems to be an effective tool for improving cerebral perfusion in HS that extends the crucial early window sometimes known as the "golden hour" for resuscitation even after a traumatic brain injury.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) for non-trauma patients in an urban hospital: a series of two cases

Background

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is increasingly being used for temporary bleeding control in patients with trauma with non-compressible truncal hemorrhage (NCTH). In recent years, the technique is gaining popularity in postpartum hemorrhage and non-traumatic cardiac arrest, although still underutilized. In other surgical fields, however, there is not yet much awareness for the possible advantages of this technique. Consequently, for non-trauma indications, limited data are available.

Methods

Description of the use of REBOA in two patients with hemorrhagic shock due to exsanguinating non-traumatic NCTH.

Results

In the first case, REBOA was deployed at the emergency department in a patient in their 80s presenting with hemorrhagic shock due to a ruptured abdominal aortic aneurysm. Hemodynamic stability was obtained and a CT scan was subsequently performed for planning of endovascular aneurysm repair. After successful placement of the endograft, the REBOA catheter was deflated and removed. In the second case, REBOA was performed in a patient with shock due to iatrogenic epigastric artery bleeding after an umbilical hernia repair to prevent hemodynamic collapse and facilitate induction of anesthesia for definitive surgery. During laparotomy, blood pressure-guided intermittent aortic balloon occlusion was used to preserve perfusion of the abdominal organs. Patient made a full recovery.

Conclusion

REBOA deployment was successful in achieving temporary hemorrhage control and hemodynamic stability in patients with non-traumatic NCTH. REBOA facilitated diagnostic work-up, transportation to the operating room and prevented hemodynamic collapse during definitive surgical repair. In the right patient and skilled hands, this relatively simple endovascular procedure could buy precious time and prove lifesaving in a variety of non-compressible hemorrhage.

The Role for Preperitoneal Pelvic Packing in Low-to-Middle-Income Countries: A 16-Year Experience at a Johannesburg Trauma Unit

INTRODUCTION

Preperitoneal pelvic packing for early pelvic haemorrhage control reduces mortality. Bleeding noted with pelvis fractures is predominantly due to associated venous complex injuries. More studies are advocating for angiography as first-line therapy for haemodynamic instability in pelvic fractures; however, these facilities are not in abundance in middle- and low-income countries. We hypothesized that PPP improves outcomes under these circumstances.

METHODS

Retrospective analysis of data from the patients charts over a period of 16 years from 01 January, 2005 to 31 December, 2020. All patients over the age of 18 years who presented with haemodynamic instability from a pelvic fracture and required PPP were included. The demographics, physiological parameter in emergency department, blood products transfused, morbidity and mortality were analysed.

RESULTS

There were 110 patients identified in the study period who underwent pelvic preperitoneal packing for refractory shock or ongoing bleeding. The majority (75.5%) of patients were men (n = 83). The median age was 38 years. The most common mechanism of injury was pedestrian vehicle collision (51%), followed by motor vehicle collisions (27.3%). The median ISS and NISS were 35 and 40, respectively. The median RTS in ED was 4.8(3-6.8). None of our patients rebleed after pack removal and no one needed repacking or adjunct angioembolization in our study group. The in-hospital mortality rate was 43.6% (n = 48) in patients who underwent preperitoneal pelvic packing. The operating room table mortality was 20% (n = 22/110), and the mortality rate of those who survived to ICU transfer was 29.5% (n = 26/88).

CONCLUSIONS

Pelvic preperitoneal packing has a role in the acute management of haemodynamically abnormal patients with pelvic fractures in our environment. In the absence of immediate angioembolization, preperitoneal packing can be lifesaving.

Placenta Accreta Spectrum and Postpartum Hemorrhage

Placenta accreta spectrum is a group of disorders involving abnormal trophoblastic invasion to the deep layers of endometrium and myometrium. Placenta accrete spectrum is one of the major causes of severe maternal morbidity, with increasing incidence in the past decade mainly secondary to an increase in cesarean deliveries. Severity varies depending on the depth of invasion, with the most severe form, known as percreta, invading uterine serosa or surrounding pelvic organs. Diagnosis is usually achieved by ultrasound, and MRI is sometimes used to assess invasion. Management usually involves a hysterectomy at the time of delivery. Other strategies include delayed hysterectomy or expectant management.

One-dimensional analysis method of pulsatile blood flow in arterial network for REBOA operations

Based on the generalized Darcy model, here we develop a linear one-dimensional (1D) composite model to predict the effects of the inserted balloon under REBOA operations on the dynamic characteristics of blood flow in flexible arterial networks. We first consider the effect of the decrease of cardiac output under different degrees of blood loss through employing the fourth-order lumped parameter model of cardiovascular system. Then, the effect of the inserted balloon is included by developing the relation between flow resistance and occlusion ratio with the neural network approach. Finally, the accuracy of the developed 1D composite model for REBOA operations, which can be solved analytically in the frequency domain, is verified by comparing to computational fluid dynamics (CFD) simulations. It is demonstrated that the 1D model is able to reproduce main features of the systemic circulation under balloon occlusion of the aorta during REBOA surgery. The 1D composite model could substantially reduce the computational time, which makes it possible to give the instant prediction of the working parameters during RABOA operations.

Emergency approach to the femoral artery

PURPOSE

The purpose of this study was to evaluate the applicability and potentially associated harms of emergency access to the femoral artery and vein in a sample of physicians working together in the emergency department of a level I trauma center. In addition, to investigate whether there are differences between participants in terms of different levels of training.

METHODS

A sample of 36 orthopedic trauma and anesthesiology assistant doctors, specialists, and senior physician was recruited from the emergency room management at a level I trauma center in Graz, Austria. Emergency approach to the femoral vessels was performed on 33 fresh cadavers. Attention was paid to time, successful clamping of the vessels, self-assessment and learning curve.

RESULTS

The approach was performed correctly in 97.2% (35/36) of all cases. 97.2% of all participants (35/36) were confident to perform the emergency access. They were proven right, since especially the resident and senior subgroups achieved satisfactory results concerning the correct performance of the approach to the femoral vessels as well as correct identification of the femoral artery and vein.

CONCLUSION

In conclusion, we evaluated the emergency access to the femoral artery (FA) and femoral vein (FV) as an easily teachable procedure including high success rates (correct performance in 97.2%).

REBOA: Expanding Applications From Traumatic Hemorrhage to Obstetrics and Cardiopulmonary Resuscitation, From the AJR Special Series on Emergency Radiology

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged over the past decade as a technique to control life-threatening hemorrhage and treat hemorrhagic shock, being increasingly used to treat noncompressible traumatic torso hemorrhage. Reports during this time also support the use of a REBOA device for an expanding range of indications including nontraumatic abdominal hemorrhage, postpartum hemorrhage, placenta accreta spectrum (PAS) disorder, and cardiopulmonary resuscitation (CPR). The strongest available evidence supports REBOA as a lifesaving adjunct to definitive surgical management in trauma and as a method to help avoid hysterectomy in select patients with postpartum hemorrhage or PAS disorder. In comparison with initial descriptions of complete REBOA inflation, techniques for partial REBOA inflation have been introduced to achieve hemodynamic stability while minimizing adverse events relating to reperfusion injuries. Fluoroscopy-free REBOA has been described in various settings, including trauma, obstetrics, and out-of-hospital cardiac arrest. As the use of REBOA expands outside the trauma setting and into nontraumatic abdominal hemorrhage, obstetrics, and CPR, it is imperative for radiologists to become familiar with this technology, its proper placement, and its potential adverse sequelae.

A comparison of mortality and indicators of treatment success of resuscitative endovascular balloon occlusion of aorta (REBOA): a systematic review and meta-analysis

Background

Emergency resuscitative thoracotomy (RT) is a recognised method of controlling non-compressible torso haemorrhage (NCTH) often in adjunct to emergency surgery. Recently, there is much debate regarding resuscitative endovascular balloon occlusion of aorta (REBOA) on its role in civilian trauma cases in controlling NCTH. This study aims to provide an updated review on in-hospital mortality rates in patients who underwent REBOA versus RT and standard care without REBOA (non-REBOA) and to identify the potential indicators of REBOA survival.

Methods

Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used to perform the study. All adult trauma cases were included, while pre-hospital, military and non-English studies were excluded. A literature search was done on studies from 01 January 2005 to 30 June 2020 using EMBASE, MEDLINE and COCHRANE databases. Risk of bias was assessed using the Methodological Index for Non-Randomised Studies (MINORS) tool. Meta-analysis was conducted using a random effects model and the DerSimonian and Laird estimation method. A significance level of p < 0.05 was used.

Results

Twenty-five studies were included in this study. The odds of in-hospital mortality of patients who underwent REBOA compared to RT was 0.18 (p < 0.01, 0.12-0.26). The odds of in-hospital survival of patients who underwent REBOA compared to non-REBOA was 1.28 (p = 0.62, 0.46-3.53). There was a significant difference found between survivors and non-survivors in terms of their pre-REBOA systolic blood pressure (SBP) (19.26 mmHg, p < 0.01), post-REBOA SBP (20.73 mmHg, p < 0.01), duration of aortic occlusion (- 40.57 min, p < 0.01) and injury severity score (- 8.50, p < 0.01).

Conclusions

REBOA has a potential for wider application in civilian settings, with our study demonstrating lower in-hospital mortality compared to RT. Prospective multi-centre studies are needed for further evaluation of the indications and feasibility of REBOA.Level of Evidence + Study Type: Level IV. Systematic review with meta-analysis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-022-01413-3.

Emerging hemostatic materials for non-compressible hemorrhage control

Non-compressible hemorrhage control is a big challenge in both civilian life and the battlefield, causing a majority of deaths among all traumatic injury mortalities. Unexpected non-compressible bleeding not only happens in pre-hospital situations but also leads to a high risk of death during surgical processes throughout in-hospital treatment. Hemostatic materials for pre-hospital treatment or surgical procedures for non-compressible hemorrhage control have drawn more and more attention in recent years and several commercialized products have been developed. However, these products have all shown non-negligible limitations and researchers are focusing on developing more effective hemostatic materials for non-compressible hemorrhage control. Different hemostatic strategies (physical, chemical and biological) have been proposed and different forms (sponges/foams, sealants/adhesives, microparticles/powders and platelet mimics) of hemostatic materials have been developed based on these strategies. A summary of the requirements, state-of-the-art studies and commercial products of non-compressible hemorrhage-control materials is provided in this review with particular attention on the advantages and limitations of their emerging forms, to give a clear understanding of the progress that has been made in this area and the promising directions for future generations.

Successful Management of Resuscitative Endovascular Balloon Occlusion of the Aorta for Hemorrhagic Shock Due to Ruptured Hepatocellular Carcinoma

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.

The Role of Prehospital REBOA for Hemorrhage Control in Civilian and Military Austere Settings: A Systematic Review

Despite the success of prehospital resuscitative endovascular balloon occlusion of the aorta (REBOA) in combat and civilian settings, the prevalence of complications and the lack of conclusive evidence has led to uncertainty and controversy. Therefore, this systematic review aimed to evaluate the role of prehospital REBOA for hemorrhage control in trauma populations. We systematically searched Cochrane, Ovid MEDLINE, EMBASE and Google Scholar for all relevant studies that investigated the efficacy of prehospital REBOA on trauma patients with massive hemorrhage. Primary outcome was evaluated by blood pressure elevation and secondary outcome was measured by 30-day mortality and complications. Our search identified 546 studies, but only six studies met the inclusion and exclusion criteria. Included studies were low to moderate quality due to limitations within the studies. However, all of the studies reported significant elevation of blood pressure and survival, demonstrating the potential benefits of REBOA. For example, the 30-day mortality rate reduced significantly after REBOA, but studies lacked long-term outcome assessments across the continuum of care. Due to the heterogeneity of the results, a meta-analysis was not possible. We conclude that prehospital REBOA is a feasible and effective resuscitative adjunct for shock patients with lethal non-compressible torso hemorrhage. However, due to the unclear causes of complications and the lack of high quality and homogeneous data, the effects of prehospital REBOA were not truly reflected and comparison between groups was not feasible. Thus, further high-quality studies are required to attest the causality between prehospital REBOA and outcomes.

Resuscitative Endovascular Balloon Occlusion of Aorta: A Systematic Review

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.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): update and insights into current practices and future directions for research and implementation

Background

In this review, we assess the state of Resuscitative Endovascular Occlusion of the Aorta (REBOA) today with respect to out-of-hospital (OOH) vs. inhospital (H) use in blunt and penetrating trauma, as well as discuss areas of promising research that may be key in further advancement of REBOA applications.

Methods

To analyze the trends in REBOA use, we conducted a review of the literature and identified articles with human or animal data that fit the respective inclusion and exclusion criteria. In separate tables, we compiled data extracted from selected articles in categories including injury type, zone and duration of REBOA, setting in which REBOA was performed, sample size, age, sex and outcome. Based on these tables as well as more detailed review of some key cases of REBOA usage, we assessed the current state of REBOA as well as coagulation and histological disturbances associated with its usage. All statistical tests were 2-sided using an alpha=0.05 for significance. Analysis was done using SAS 9.5 (Cary, NC). Tests for significance was done with a t-test for continuous data and a Chi Square Test for categorical data.

Results

In a total of 44 cases performed outside of a hospital in both military and civilian settings, the overall survival was found to be 88.6%, significantly higher than the 50.4% survival calculated from 1,807 cases of REBOA performed within a hospital (p<.0001). We observe from human data a propensity to use Zone I in penetrating trauma and Zone III in blunt injuries. We observe lower final metabolic markers in animal studies with shorter REBOA time and longer follow-up times.

Conclusions

Further research related to human use of REBOA must be focused on earlier initiation of REBOA after injury which may depend on development of rapid vascular access devices and techniques more so than on any new improvements in REBOA. Future animal studies should provide detailed multisystem organ assessment to accurately define organ injury and metabolic burden associated with REBOA application. Overall, animal studies must involve realistic models of injury with severe clinical scenarios approximating human trauma and exsanguination, especially with long-term follow-up after injury.

Estimating the radiation dose to the fetus during prophylactic internal iliac occlusion in patients with abnormal placentation

AIMS

To evaluate the estimated fetal radiation dose during prophylactic internal iliac arterial occlusion in patients with abnormal placenta and to estimate the risk of radiation induced cancer in child age.

METHODS

Prophylactic occlusion of the internal iliac arteries during Caesarean section was performed in 42 patients with placenta praevia and/or placenta accreta spectrum. Fogarty embolectomy catheters were used for prophylactic occlusion of the internal iliac arteries. All procedures were performed in the hybrid operating room using Philips Allura Xper FD 20 X-ray system. Low dose X-ray fluoroscopy (7.5 frames per second) was used. The CODE (Conceptus dose estimation) Software was used to estimate the fetal dose and the risk of radiation induced carcinoma.

RESULTS

Fluoroscopy times required for insertion of Fogarty catheters were 0.5-4.2 min (mean: 1.7 min, median: 1.5 min). The estimated radiation dose to the fetus was 0.26-3.36 mGy (mean: 1.49 mGy, median: 1.25 mGy). The risk of radiation induced cancer in child age was 0.01-0.04% (mean 0.02%, median 0.01%). One patient developed thrombosis of a common femoral artery.

CONCLUSION

Prophylactic occlusion of the internal iliac arteries is a simple and safe procedure with minimal risk of complications and with a very low estimated radiation dose to the fetus.

The Effects of the Duration of Aortic Balloon Occlusion on Outcomes of Traumatic Cardiac Arrest in a Porcine Model

Aortic balloon occlusion (ABO) facilitates the success of cardiopulmonary resuscitation (CPR) in non-traumatic cardiac arrest, and is also effective in controlling traumatic hemorrhage; however, a prolonged occlusion results in irreversible organ injury and death. In this study, we investigated the effects of ABO on CPR outcomes and its optimal duration for post-resuscitation organ protection in a porcine model of traumatic cardiac arrest (TCA).Twenty-seven male domestic pigs weighing 33 ± 4 kg were utilized. Forty percent of estimated blood volume was removed within 20 min. The animals were then subjected to 5 min of untreated ventricular fibrillation and 5 min of CPR. Coincident with the start of CPR, the animals were randomized to receive either 30-min ABO (n = 7), 60-min ABO (n = 8) or control (n = 12). Meanwhile, fluid resuscitation was initiated by the infusion of normal saline with 1.5 times of hemorrhage volume in 1 h, and finished by the reinfusion of 50% of the shed blood in another 1 h. The resuscitated animals were monitored for 6 h and observed for an additional 18 h.During CPR, coronary perfusion pressure was significantly increased followed by a higher rate of resuscitation success in the 30 and 60-min ABO groups compared with the control group. However, post-resuscitation cardiac, neurologic dysfunction, and injuries were significantly milder accompanied with less renal and intestinal injuries in the 30-min ABO group than in the other two groups.In conclusion, ABO augmented the efficacy of CPR after TCA, and furthermore a 30-min ABO improved post-resuscitation cardiac and neurologic outcomes without exacerbating the injuries of kidney and intestine.

Resuscitative endovascular balloon occlusion of the aorta may contribute to improved survival

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.

Feasibility study for implementation of resuscitative balloon occlusion of the aorta in peri-arrest, exsanguinating trauma at an adult level 1 Australian trauma centre

OBJECTIVE

This prospective, observational, interventional study sought to determine if the introduction of resuscitative balloon occlusion of the aorta (REBOA) at an Australian adult major trauma centre would improve survival for major trauma patients.

METHODS

Patients aged 18-60 years, transported directly from scene with exsanguinating, sub-diaphragmatic haemorrhage and hypovolaemic shock (systolic BP <70 mmHg or hypovolaemic cardiac arrest) were eligible for recruitment and followed up until hospital discharge (ACTRN12618000550202).

RESULTS

During the 14-month study period (17 January 2015 to 12 March 2016) 3032 patients were admitted direct from scene with an overall mortality of 97 (3.71%). Of these patients 3019 had trauma centre vital signs recorded in the data set (99.57%) and 1523 were between the ages of 18-60, including 143 patients with a shock index of >1.0 (4.74%). There were 13 (0.43%) patients with a systolic BP <70 mmHg and/or cardiorespiratory arrest on arrival. The mortality in this group was six out of 13 (46.15%). Of these 13 patients, there were two (0.07% of the total cohort) where REBOA was attempted. There were no eligible patients for whom REBOA was achieved. None of the six patients who died would have benefited from REBOA deployment.

CONCLUSIONS

Despite considerable training and resource allocation to ensure 24-h availability, the introduction of REBOA failed to effectively demonstrate any impact on patient outcome. Despite retrospective literature supporting the introduction of REBOA, in this 14-month prospective study there was no evidence of benefit. Further studies may define indications and subgroups of patients who may benefit.

Catastrophic Bleeding From Gastroduodenal Artery After Whipple Procedure Managed With Resuscitative Endovascular Balloon Occlusion of the Aorta

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is designed to control traumatic intra-abdominal or pelvic hemorrhage. There are few case reports of REBOA use in nontraumatic gastrointestinal (GI) hemorrhage. A 53-year-old man with pancreatic cancer status post Whipple procedure presented with GI hemorrhage from the gastroduodenal artery. Endoscopy and angioembolization were unsuccessful at stopping the hemorrhage. REBOA was used to stabilize the patient until definitive surgical control. REBOA is a potentially lifesaving measure in cases of massive abdominal or pelvic hemorrhage. REBOA can be used as an adjunct in unstable patients with GI bleeding until definitive GI, interventional radiology, or surgical control.

The intraoperative use of aortic balloon occlusion technique for sacral and pelvic tumor resections: A case-control study

INTRODUCTION

Pelvic and sacral tumor surgery is traditionally characterized by several major complications. Bleeding is probably the most feared and dreadful complication. The aim of the study was to evaluate whether the intraoperative use of the intra-aortic balloon occlusion technique could decrease the perioperative blood loss. A secondary aim was to assess aortic balloon-related complications.

MATERIALS AND METHODS

From January 2014 to December 2017 15 patients (Group 1) treated with intra-aortic balloon inflation were prospectively enrolled and compared to a historical control group (Group 2) of 11 patients with similar surgeries. Number of blood units transfused, perioperative hemoglobin values, hours spent in intensive care unit (ICU), length of inpatient stay, and perioperative complications were evaluated.

RESULTS

Intraoperatively, a mean of 6.1 blood units per patient (BUPP) was used in Group 1 and 16.2 BUPP in Group 2. Postoperatively the averages were 2,8 and 5,4 BUPP in Group 1 and 2, respectively. Patients in Group 1 had a faster recovery in hemoglobin values, as well as a shorter length of overall inpatient stay (28,9 vs 59 days) and of ICU stay (33.9 vs 74.6 h). The most relevant complications observed in Group 1 were two thrombosis at the incannulation site that required a surgical arterial thrombectomy.

CONCLUSION

The intra-aortic balloon occlusion is an effective technique to control bleeding during the resections of huge pelvic and sacral tumors. A proper training of a multidisciplinary team and an accurate patient selection are required to prevent major complications.

Intraoperative REBOA: an analysis of the American Association for the Surgery of Trauma AORTA registry

Background

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a less-invasive technique for aortic occlusion (AO). Commonly performed in the emergency department (ED), the role of intraoperative placement is less defined. We hypothesized that operating room (OR) placement is associated with increased in-hospital mortality.

Methods

The American Association for the Surgery of Trauma AORTA registry was used to identify patients undergoing REBOA. Injury characteristics and outcomes data were compared between OR and ED groups. The primary outcome was in-hospital mortality; secondary outcomes included total AO time, transfusion requirements, and acute kidney injury.

Results

Location and timing of catheter insertion were available for 305 of 321 (95%) subjects. 58 patients underwent REBOA in the OR (19%). There were no differences with respect to sex, admission lactate, and Injury Severity Score. The OR group was younger (33 years vs. 41 years, p=0.01) and with more penetrating injuries (36% vs. 15%, p<0.001). There were significant differences with respect to admission physiology. Time from admission to AO was longer in the OR group (75 minutes vs. 23 minutes, p<0.001) as was time to definitive hemostasis (116 minutes vs. 79 minutes, p=0.01). Unadjusted mortality was lower in the OR group (36.2% vs. 68.8%, p<0.001). There were no differences in secondary outcomes. After controlling for covariates, there was no association between insertion location and in-hospital mortality (OR 1.8, 95% CI 0.30 to 11.50).

Discussion

OR REBOA placement is common and generally employed in patients with more stable admission physiology. OR placement was not associated with increased in-hospital mortality despite longer times to AO and definite hemostasis when compared with catheters placed in the ED.

Level of evidence

IV; therapeutic/care management.

[Resuscitative endovascular balloon occlusion of the aorta : Option for incompressible trunk bleeding?]

Hemorrhage is the single largest cause of avoidable death in trauma patients, whereby in civil emergency medicine in Europe most life-threatening hemorrhages occur in the abdomen and the pelvis. This is one reason why endovascular balloon occlusion of the aorta (EBOA), a procedure especially established in vascular surgery, is increasingly propagated for rapid bleeding control in these patients. This review article provides a comprehensive overview of the technique, indications, contraindications and complications of resuscitative endovascular balloon occlusion of the aorta (REBOA). Additionally, outcomes reported in in the currently available literature are summarized and discussed. From this practical and user-oriented consequences for future successful introduction of REBOA in the field of emergency medicine are deduced.

Does the conventional landmark help to place the tip of REBOA catheter in the optimal position? A non-controlled comparison study

Background

Resuscitative endovascular balloon occlusion of the aorta (REBOA) for patients with traumatic torso hemorrhagic shock is available to keep a minimum level of circulatory status as a bridge to definitive therapy. However, the trajectory for placement of REBOA in the aorta has not yet been clearly defined.

Methods

We conducted a retrospective observational cohort study in the two tertiary critical care and emergency center from December 2014 to October 2018. A total of 28 patients who underwent focused assessment with sonography for trauma (FAST) were studied via contrast computed tomography (CT), and 27 were analyzed.

Results

We divided patients into two groups based on our CT findings. The REBOA deflate group included 16 patients, and the inflate group included 11 patients. The median trace value (interquartile range) of the blood vessel center line from the common femoral artery to the tip of REBOA (blood vessel length) and the length of REBOA itself from the common femoral artery to the tip of REBOA (REBOA insertion length) were 56.2 cm (54.5-57.2) and 55.2 cm (54.2-55.6), respectively (p < 0.0001) for the deflated group, and 51.4 cm (42.1-56.6) and 50.3 cm (42.3-55.0) (p = 0.594), respectively, for the inflated group.

Conclusions

If REBOA was deflated, it was placed 1.0 cm longer than the insertion length of REBOA catheter itself, but that was not the case when inflating REBOA. The individual difference was large to the extent that the balloon inflated and the extent to which the balloon was pushed back toward the caudal depending on the degree of blood pressure. Further studies would be needed to validate the study findings.

Technical limitations of REBOA in a patient with exsanguinating pelvic crush trauma: a case report

Background

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an effective adjunct in hemodynamic unstable patients with uncontrolled and non-compressible torso hemorrhage promoting temporary stability during injury repair. The aim of our study was to analyze real life usability of REBOA based on a case report and to review the literature with respect to its possibilities and limitations.

Case presentation

We present the case of a 17-years old female patient who sustained a severe roll-over trauma and pelvic crush injury as a bicyclist by a truck. Upon arrival of the first responders, the patient was awake, alert, and following commands.Subsequent to lifting the truck, the patient became hypotensive and required cardiopulmonary resuscitation, application of a pelvic binder, and endotracheal intubation at the accident scene. She was then admitted by ambulance to our trauma center under ongoing resuscitative measures. After primary survey, it was decided to perform a REBOA with surgical approach to the left femoral artery. Initial insertion of the catheter was successful but could not be advanced beyond the inguinal region. Hence, the patient was transferred to the operating room (OR) but died despite maximum therapy. In the OR and later autopsy, we found a long-distance ruptured and dehiscent external iliac artery with massive bleeding into the pelvis in the context of a bilateral vertical shear fractured pelvic bone.

Conclusion

REBOA can be a useful adjunct but there is a major limitation with potential vascular injury after pelvic trauma. In these situations, cross-clamping the proximal aorta or pre-peritoneal pelvic packing as "traditional" approaches of hemorrhage control during resuscitation may be the most considerable methods for temporary stabilization in severely injured trauma patients. More clinical and cadaveric studies are needed to further understand indications and limitations of REBOA after severe pelvic trauma.

Resuscitative endovascular balloon occlusion of the aorta: an option for noncompressible torso hemorrhage?

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.

Resuscitative Endovascular Balloon Occlusion of the Aorta: A Review for Emergency Clinicians

BACKGROUND

Non-compressible torso hemorrhage (NCTH) is difficult to control and associated with significant mortality. Resuscitative endovascular balloon occlusion of the aorta (REBOA) utilizes an infra-diaphragmatic approach to control NCTH and is less invasive than resuscitative thoracotomy (RT). This article highlights the evidence for REBOA and provides an overview of the indications, procedural steps, and complications in adults for emergency clinicians.

DISCUSSION

Traumatic hemorrhage can be life threatening. Patients in extremis, whether from NCTH or exsanguination from other sites, may require RT with aortic cross-clamping. REBOA offers another avenue for proximal hemorrhage control and can be completed by emergency clinicians. The American College of Surgeons Committee on Trauma and the American College of Emergency Physicians recently released a joint statement detailing the indications for REBOA in adults. The evidence behind its use remains controversial, with significant heterogeneity among studies. Most studies demonstrate improved blood pressure without a significant improvement in mortality. Procedural steps include arterial access (most commonly the common femoral artery), positioning the initial sheath, balloon preparation and positioning, balloon inflation, securing the balloon/sheath, subsequent hemorrhage control, balloon deflation, and balloon/sheath removal. Several major complications can occur with REBOA placement. Future studies should evaluate training protocols, the role of simulation, and which target populations would benefit most from REBOA.

CONCLUSIONS

REBOA can provide proximal hemorrhage control and can be performed by emergency clinicians. This article evaluates the evidence, indications, procedure, and complications for emergency clinicians.

Three cases of resuscitative endovascular balloon occlusion of the aorta (REBOA) in austere pre-hospital environment-technical and methodological aspects

Background

The present paper describes three cases where ER-REBOA® was used with partial aorta occlusion (AO), by performing a partial resuscitative endovascular balloon occlusion of the aorta or pREBOA, in an austere pre-hospital military environment.

In addition, because no specific REBOA algorithm for pre-hospital environment exists yet, this paper seeks to fill this gap, proposing a new pragmatic REBOA algorithm.

Methods

Belgian Special Operations Surgical Team applied REBOA in three patients according to a decisional algorithm, based on the MIST acronym used for trauma patients. Only 3 ml, in the first instance, was inflated in the balloon to get AO. The balloon was then progressively deflated, and reperfusion was tracked through changes of end-tidal carbon dioxide (EtCO₂).

Results

Systolic blood pressure (SBP) before ER-REBOA® placement was not higher than 60 mmHg. However, within the first 5 min after AO, SBP improved in all three cases. Due to the aortic compliance, a self-made pREBOA was progressively achieved while proximal SBP was raising with intravenous fluid infusion. Afterwards, during deflation, a steep inflection point was observed in SBP and EtCO₂.

Conclusions

ER-REBOA® is suitable for use in an austere pre-hospital environment. The MIST acronym can be helpful to select the patients for which it could be beneficial. REBOA can also be performed with pREBOA in a dynamic approach, inflating only 3 mL in the balloon and using the aortic compliance. Furthermore, while proximal SBP can be convenient to follow the occlusion, EtCO₂ can be seen as an easy and interesting marker to follow the reperfusion.

The utilization of resuscitative endovascular balloon occlusion of the aorta: preparation, technique, and the implementation of a novel approach to stabilizing hemorrhage

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.

Resuscitative Endovascular Balloon Occlusion of the Aorta for Hemorrhage Control in Trauma Patients: An Evidence-Based Review

Traditionally, resuscitative efforts for uncontrolled noncompressible torso hemorrhage are achieved by cross-clamping the proximal aorta via thoracotomy to deliver temporary hemodynamic stability during injury repair. A less commonly used method of promoting early resuscitation and hemorrhagic control in trauma patients is resuscitative endovascular balloon occlusion of the aorta (REBOA). The focus of this literature review is to examine the effectiveness of REBOA in the management of noncompressible pelvic hemorrhage when compared with traditional methods of hemorrhage control in trauma patients. A literature search was performed by using the PubMed database to explore studies that defined the efficacy of REBOA or compared the use of REBOA with resuscitative thoracotomy with aortic cross-clamping for hemorrhage control. Studies encompassed in the review included 3 experimental studies utilizing swine, 2 retrospective studies that reviewed data collected from procedures performed in empirical situations, and a case series that described the implementation of REBOA. Trauma patients with noncompressible torso hemorrhage that is intervened with REBOA have higher mean arterial pressures and systolic blood pressures, require fewer boluses of intravenous fluids and vasopressors, avoid severe acidosis and ischemia, and have significantly lower rates of mortality, thus ensuring enhanced long-term outcomes. Evidence suggests that hemodynamic stability, physiological effects, and mortality rates are improved in patients who receive REBOA for torso hemorrhage control when compared with traditional methods.

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.

Resuscitative endovascular balloon occlusion of the aorta for non-traumatic intra-abdominal hemorrhage

BACKGROUND

Hemorrhagic shock is the second leading cause of death in blunt trauma and a significant cause of mortality in non-trauma patients. The increased use of resuscitative endovascular balloon occlusion of the aorta (REBOA) as a bridge to definitive control for massive hemorrhage has provided promising results in the trauma population. We describe an extension of this procedure to our hemodynamically unstable non-trauma patients.

METHODS

This is a retrospective review of patients requiring REBOA for end stage non-traumatic abdominal hemorrhage from our tertiary care facility. After excluding patients with trauma, supradiaphragmatic bleed and thoracic/abdominal aortic aneurysms, demographics, etiology of bleed, REBOA placement specifics, complications and outcomes were reviewed.

RESULTS

From August 2013 to August 2016, 11 patients were identified requiring REBOA placement for hemodynamic instability from non-traumatic abdominal hemorrhage. Average patient age was 54.9 (SD 15.2). Sixty-four percent suffered cardiac arrest prior to REBOA, with mean shock index of 1.29. Average time from diagnosis of shock (MAP ≤ 65) or signs of bleeding to placement of REBOA was 177 min. The leading etiologies of hemorrhage were ruptured visceral aneurysm and massive upper gastrointestinal bleed. REBOA was placed by both acute care and vascular surgeons. The procedure was mainly completed in the operating room in 82% of the patients and at the bedside in 18%. One patient expired before operative repair. Definitive surgical control of the source of bleeding was obtained by open surgical approach (n = 6) and combined surgical and endovascular approach (n = 4). In-hospital survival was 64%. There were no local complications related to REBOA placement.

CONCLUSION

Similar to the trauma population, REBOA is an adjunctive technique for proximal control of bleeding as well as resuscitation in end stage non-traumatic intra-abdominal hemorrhage. We propose an algorithmic approach to REBOA use in this population and a larger prospective review is necessary to determine both the timing of REBOA placement and which non-traumatic patients may benefit from this technique.

LEVEL OF EVIDENCE

V.

STUDY TYPE

Brief report.

Life over Limb: Lower Extremity Ischemia in the Setting of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a temporizing maneuver used to decrease hemorrhage, and thus perfusion, below the level of aortic occlusion (AO). We sought to investigate lower extremity ischemia in patients who received REBOA. Between February 2013 and September 2016 patients at a tertiary center that received REBOA and survived more than six hours were enrolled. Thirty-one patients were identified, the mean ISS was 40 ± 14 and inhospital mortality was 39 per cent. Twenty received REBOA in zone 1 (distal thoracic aorta). Three (15%) developed lower extremity compartment syndrome (LECS) after zone 1 REBOA. Injury of iliofemoral arteries and veins was each associated with calf fasciotomies (both P = 0.005). A longer duration of AO at zone 1 was associated with calf and thigh fasciotomy (P = 0.046 and P = 0.048, respectively). Iliofemoral arterial injury was associated with thigh fasciotomy (P = 0.04). Eleven patients received REBOA in zone 3 (distal abdominal aorta). Five (45%) patients underwent fasciotomy; four (36%) due to LECS. Femoral arterial injury was associated with calf fasciotomies (P = 0.02). There was no association with sheath size or laterality and need for fas-ciotomy. Neither groin access for REBOA or AO solely caused limb loss or LECS. The contribution to distal ischemia by REBOA remains unclear in patients with lower extremity injury.

The complications associated with Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

Non-compressible torso hemorrhage (NCTH) remains a significant cause of morbidity and mortality in the field of trauma and emergency medicine. In recent times, there has been a resurgence in the adoption of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for patients who present with NCTH. Like all medical procedures, there are benefits and risks associated with the REBOA technique. However, in the case of REBOA, these complications are not unanimously agreed upon with varying viewpoints and studies. This article aims to review the current knowledge surrounding the complications of the REBOA technique at each step of its application.

Resuscitative endovascular balloon occlusion of the aorta: promise, practice, and progress?

PURPOSE OF REVIEW

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive damage control procedure for life-threatening abdominal or pelvic haemorrhage. The purpose of this review is to summarize the current understanding and experience with REBOA, outline potential future applications of this technology, and highlight priority areas for further research.

RECENT FINDINGS

REBOA is a feasible method of achieving temporary aortic occlusion and can be performed rapidly, with a high degree of success, in the emergency setting (including at the scene of injury) by appropriately trained clinicians. The procedure supports central perfusion, controls noncompressible haemorrhage, and may improve survival in certain profoundly shocked patient groups; but is also associated with significant risks, including ischaemic tissue damage and procedural complications. Evolutions of this strategy are being explored, with promising proof-of-concept studies in the fields of partial aortic occlusion and the combination of REBOA with extracorporeal support.

SUMMARY

Noncompressible torso haemorrhage is the leading cause of preventable trauma deaths. The majority of these deaths occur soon after injury, often before any opportunity for definitive haemorrhage control. For a meaningful reduction in trauma mortality, novel methods of rapid haemorrhage control are required.

Resuscitative Endovascular Balloon Occlusion of the Aorta: Implementation and Preliminary Results at an Academic Level I Trauma Center

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a novel method of controlling subdiaphragmatic hemorrhage while improving hemodynamic stability. This procedure achieves many of the goals of resuscitative thoracotomy (RT), but is less invasive. Here, we present the initial experience with REBOA at a level 1 academic trauma center.

STUDY DESIGN

We performed a retrospective review. Orientation of surgeons and residents to REBOA was accomplished by an educational program including a hands-on simulation session (1.5 hours). Surgeons were not required to attend an external training course. Operating room personnel were oriented with a slide presentation. Initially, a 12-Fr introducer and aortic occlusion balloon were used. Subsequently, a 7-Fr device was used. All REBOAs were performed in a dedicated hybrid operating room. Resuscitative thoracotomy was performed in the trauma bays and operating room.

RESULTS

During a 21-month period (June 2015 to March 2017), 16 patients (Injury Severity Score [ISS] 38.6 ± 22.3, Glasgow Coma Scale [GCS] 8.9 ± 5.9, lactate 4.91 ± 3.26 mmol/L) had REBOA placed. All patients were hemodynamically unstable (systolic blood pressure 96.5 ± 9.3 mmHg) due to hemorrhage. Preoperative hemoglobin ranged from 5 to 14.4 mg/dL. Etiology of hemorrhage was blunt trauma (n = 11), penetrating injury (n = 2), and nontraumatic mechanisms (n = 3). After REBOA, hemodynamic status improved in 10 of 16 patients. Fourteen patients survived the initial operative intervention and 6 survived 30 days; REBOA was successfully performed in all patients. One survivor developed a common femoral pseudoanuerysm. Survival for RT (ISS 31.3 ± 11.25) during same period was 0%.

CONCLUSIONS

Resuscitative endovascular balloon occlusion of the aorta is an effective method of improving hemodynamic status in patients with sub-diaphragmatic hemorrhage. Extensive training is not required to implement a REBOA program, and REBOA is a useful technique for trauma surgeons.

Resuscitative endovascular balloon occlusion of the aorta (REBOA): an updated review

In a current scenario where trauma injury and its consequences account for 9% of the worlds causes of death, the management of non-compressible torso hemorrhage can be problematic. With the improvement of medicine, the approach of these patients must be accurate and immediate so that the consequences may be minimal. Therefore, aiming the ideal method, studies have led to the development of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). This procedure has been used at select trauma centers as a resuscitative adjunct for trauma patients with non-compressible torso hemorrhage. Although the use of this technique is increasing, its effectiveness is still not clear. This article aims, through a detailed review, to inform an updated view about this procedure, its technique, variations, benefits, limitations and future.

Assessment of Blood Flow Patterns Distal to Aortic Occlusion Using CT in Patients with Resuscitative Endovascular Balloon Occlusion of the Aorta

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used to decrease hemorrhage below the level of aortic occlusion (AO); however, the amount of collateral blood flow below the level of occlusion is unknown. Our aim was to investigate blood flow patterns during complete AO in patients who underwent CT scan after REBOA.

STUDY DESIGN

Between February 2013 and January 2017, patients who received REBOA and underwent CT scan with intravenous contrast during full AO were included. Patients were excluded if they had a CT scan performed with the balloon partially or fully deflated.

RESULTS

Nine patients (8 men) were included; all had blunt trauma. Mean Injury Severity Score (±SD) was 48 ± 8 and mean age was 45 ± 19 years. Four had supra-celiac AO, and 5 had infra-renal AO. Arterial contrast enhancement was noted below the level of AO in all patients, and distal to REBOA sheath placement in 5. Collateralization from arteries above and below the AO was identified in all patients. Contrast extravasation distal to AO was identified in 4 patients, and hematomas in 8. Distal vascular enhancement patterns varied by level of AO and contrast administration site.

CONCLUSIONS

Aortic occlusion appears to dramatically decrease, but does not completely impede, distal perfusion during REBOA due to multiple pathways of collateralization. Active extravasation and hematomas can still be detected in the setting of full AO, with purposefully timed contrast and image acquisition. Blood flow persists below the level of both the AO and in-dwelling sheath. Dynamic flow studies are needed to determine the contribution of AO and sheath placement to distal tissue ischemia.

REBOA for the IVC? Resuscitative balloon occlusion of the inferior vena cava (REBOVC) to abate massive hemorrhage in retrohepatic vena cava injuries

BACKGROUND

The use of resuscitative endovascular balloon occlusion as a maneuver for occlusion of the aorta is well described. This technique has life-saving potential in other cases of traumatic hemorrhage. Retrohepatic inferior vena cava (IVC) injuries have a high rate of mortality, in part, due to the difficulty in achieving total vascular isolation. The purpose of this study was to investigate the ability of resuscitative balloon occlusion of the IVC to control suprahepatic IVC hemorrhage in a swine model of trauma.

METHODS

Thirteen swine were randomly assigned to control (seven animals) versus intervention (six animals). In both groups, an injury was created to the IVC. Hepatic inflow control was obtained via clamping of the hepatoduodenal ligament and infrahepatic IVC. In the intervention group, suprahepatic IVC control was obtained via a resuscitative balloon occlusion of the IVC placed through the femoral vein. In the control group, no suprahepatic IVC control was established. Vital signs, arterial blood gases, and lactate were monitored until death. Primary end points were blood loss and time to death. Lactate, pH, and vital signs were secondary end points. Groups were compared using the χ and the Student t test with significance at p < 0.05.

RESULTS

Intervention group's time to death was significantly prolonged: 59.3 ± 1.6 versus 33.4 ± 12.0 minutes (p = 0.001); and total blood loss was significantly reduced: 333 ± 122 vs 1,701 ± 358 mL (p = 0.001). In the intervention group, five of the six swine (83.3%) were alive at 1 hour compared to zero of seven (0%) in the control group (p = 0.002). There was a trend toward worsening acidosis, hypothermia, elevated lactate, and hemodynamic instability in the control group.

CONCLUSIONS

Resuscitative balloon occlusion of the IVC demonstrates superior hemorrhage control and prolonged time to death in a swine model of liver hemorrhage. This technique may be considered as an adjunct to total hepatic vascular isolation in severe liver hemorrhage and could provide additional time needed for definitive repair.

LEVEL OF EVIDENCE

Therapeutic study, level II.

Resuscitative Endovascular Balloon Occlusion of the Aorta in trauma: a systematic review of the literature

AIMS

Resuscitative endovascular balloon occlusion of the aorta has been a hot topic in trauma resuscitation during these last years. The aims of this systematic review are to analyze when, how, and where this technique is performed and to evaluate preliminary results.

METHODS

The literature search was performed on online databases in December 2016, without time limits. Studies citing endovascular balloon occlusion of the aorta in trauma were retrieved for evaluation.

RESULTS

Sixty-one articles met the inclusion criteria and were selected for the systematic review. Overall, they included 1355 treated with aortic endovascular balloon occlusion, and 883 (65%) patients died after the procedure. In most of the included cases, a shock state seemed to be present before the procedure. Time of death and inflation site was not described in the majority of included studies. Procedure-related and shock-related complications are described. Introducer sheath size and comorbidity seems to play the role of risk factors.

CONCLUSIONS

Resuscitative endovascular balloon occlusion of the aorta is increasingly used in trauma victim resuscitation all over the world, to elevate blood pressure and limit fluid infusion, while other procedures aimed to stop the bleeding are performed. High mortality rate is probably due to the severity of the injuries. Time and place of balloon insertion, zone of balloon inflation, and inflation cutoff time are very heterogeneous.

The effect of resuscitative endovascular balloon occlusion of the aorta, partial aortic occlusion and aggressive blood transfusion on traumatic brain injury in a swine multiple injuries model

BACKGROUND

Despite clinical reports of poor outcomes, the degree to which resuscitative endovascular balloon occlusion of the aorta (REBOA) exacerbates traumatic brain injury (TBI) is not known. We hypothesized that combined effects of increased proximal mean arterial pressure (pMAP), carotid blood flow (Qcarotid), and intracranial pressure (ICP) from REBOA would lead to TBI progression compared with partial aortic occlusion (PAO) or no intervention.

METHODS

Twenty-one swine underwent a standardized TBI via computer Controlled cortical impact followed by 25% total blood volume rapid hemorrhage. After 30 minutes of hypotension, animals were randomized to 60 minutes of continued hypotension (Control), REBOA, or PAO. REBOA and PAO animals were then weaned from occlusion. All animals were resuscitated with shed blood via a rapid blood infuser. Physiologic parameters were recorded continuously and brain computed tomography obtained at specified intervals.

RESULTS

There were no differences in baseline physiology or during the initial 30 minutes of hypotension. During the 60-minute intervention period, REBOA resulted in higher maximal pMAP (REBOA, 105.3 ± 8.8; PAO, 92.7 ± 9.2; Control, 48.9 ± 7.7; p = 0.02) and higher Qcarotid (REBOA, 673.1 ± 57.9; PAO, 464.2 ± 53.0; Control, 170.3 ± 29.4; p < 0.01). Increases in ICP were greatest during blood resuscitation, with Control animals demonstrating the largest peak ICP (Control, 12.8 ± 1.2; REBOA, 5.1 ± 0.6; PAO, 9.4 ± 1.1; p < 0.01). There were no differences in the percentage of animals with hemorrhage progression on CT (Control, 14.3%; 95% confidence interval [CI], 3.6-57.9; REBOA, 28.6%; 95% CI, 3.7-71.0; and PAO, 28.6%; 95% CI, 3.7-71.0).

CONCLUSION

In an animal model of TBI and shock, REBOA increased Qcarotid and pMAP, but did not exacerbate TBI progression. PAO resulted in physiology closer to baseline with smaller increases in ICP and pMAP. Rapid blood resuscitation, not REBOA, resulted in the largest increase in ICP after intervention, which occurred in Control animals. Continued studies of the cerebral hemodynamics of aortic occlusion and blood transfusion are required to determine optimal resuscitation strategies for multi-injured patients.

Resuscitative endovascular balloon occlusion of the aorta in trauma patients in youth

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has received increasing attention for critically uncontrolled hemorrhagic shock. However, the efficacy of REBOA in patients in youth is unknown.

OBJECTIVES

The aim of this study was to evaluate the mortality and characteristics of patients of age ≤18 years with severe traumatic injury who received REBOA.

METHODS

We retrospectively analyzed observational cohort data from the Japan Trauma Data Bank (JTDB) from 2004 to 2015. All patients ≤18 years old who underwent REBOA were included. Clinical characteristics and mortalities were analyzed and compared among patients ≤15 years old (young children) and 16-18 years old (adolescents).

RESULTS

Of the 236,698 patients in the JTDB (2004-2015), 22,907 patients were 18 years old or younger. A total of 3,440 patients without survival data were excluded. Of the remaining 19,467, 54 (0.3%) patients underwent REBOA, among which 15 (27.8%) were young children. Both young children and adolescents who underwent REBOA were seriously injured (median Injury Severity Score [ISS], 41 and 38, respectively). Also, 53.3% of young children and 38.5% of adolescents survived to discharge after undergoing REBOA.

CONCLUSION

In a cohort of young trauma patients from the JTDB who underwent REBOA to control hemorrhage, we found that both young children and adolescents who underwent REBOA were seriously injured and had an equivalent survival rate compared to the reported survival rate from studies in adults. REBOA treatment may be a reasonable option in severely injured young patients in the appropriate clinical settings. Further prospective studies are needed to confirm our findings.

LEVEL OF EVIDENCE

Epidemiologic study, level III; therapeutic study, level IV.

Availability of on-site acute vascular interventional radiology techniques performed by trained acute care specialists: A single-emergency center experience

INTRODUCTION

Comprehensive treatment of a patient in acute medicine and surgery requires the use of both surgical techniques and other treatment methods. Recently, acute vascular interventional radiology techniques (AVIRTs) have become increasingly popular, enabling adequately trained in-house experts to improve the quality of on-site care.

METHODS

After obtaining approval from our institutional ethics committee, we conducted a retrospective study of AVIRT procedures performed by acute care specialists trained in acute medicine and surgery over a 1-year period, including those conducted out of hours. Trained acute care specialists were required to be certified by the Japanese Association of Acute Medicine and to have completed at least 1 year of training as a member of the endovascular team in the radiology department of another university hospital. The study was designed to ensure that at least one of the physicians was available to perform AVIRT within 1 h of a request at any time. Femoral sheath insertion was usually performed by the resident physicians under the guidance of trained acute care specialists.

RESULTS

The study sample comprised 77 endovascular procedures for therapeutic AVIRT (trauma, n = 29, and nontrauma, n = 48) among 62 patients (mean age, 64 years; range, 9–88 years), of which 55% were male. Of the procedures, 47% were performed out of hours (trauma, 52%; and nontrauma, 44%). Three patients underwent resuscitative endovascular balloon occlusion of the aorta in the emergency room. No major device-related complications were encountered, and the overall mortality rate within 60 days was 8%. The recorded causes of death included exsanguination (n = 2), pneumonia (n = 2), sepsis (n = 1), and brain death (n = 1).

CONCLUSION

When performed by trained acute care specialists, AVIRT seems to be advantageous for acute on-site care and provides good technical success. Therefore, a standard training program should be established for acute care specialists or trauma surgeons to make these techniques a part of the standard regimen.

LEVEL OF EVIDENCE

Therapy/care management study, level V.

Fixed-Distance Model for Balloon Placement During Fluoroscopy-Free Resuscitative Endovascular Balloon Occlusion of the Aorta in a Civilian Population

Importance

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an innovative procedure in the treatment of noncompressible truncal hemorrhage. However, readily available fluoroscopy remains a limiting factor in its widespread implementation. Several methods have been proposed to perform REBOA without fluoroscopic guidance, and these methods were adapted predominantly from the military theater.

Objective

To develop a method for performing REBOA in a civilian population using a standardized distance from a set point of entry.

Design, Setting, and Participants

A retrospective study of whole-body computed tomographic (CT) scans from a cohort of 280 consecutive civilian trauma patients from University Hospitals of Lyon, France, was used to calculate the endovascular distances from both femoral arteries at the level of the upper border of the symphysis pubis to aortic zone I (descending thoracic aorta) and zone III (infrarenal aorta). These whole-body CT scans were performed between 2013 and 2015. Data were analyzed from July 16 to December 7, 2015.

Main Outcomes and Measures

Two segments (1 per zone) common to all CT scans were isolated, and their location, length, prevalence in the cohort, and predicted prevalence in the general population were calculated by inverting 99% certainty tolerance limits.

Results

Among the 280 trauma patients (140 men and 140 women) in this study, the mean (SD) height was 170.7 (8.7) cm, and the mean (SD) age was 38.8 (16.5) years. The common segment in zone I (414-474 mm) existed in all CT scans. The common segment in zone III (236-256 mm) existed in 99.6% and 97.9% of CT scans from the right and left femoral arteries, respectively. These segments are expected to exist in 98.7% (zone I) and 94.9% (zone III) of the general population.

Conclusions and Relevance

Target distances for blind placement of REBOA exist with more than 94% prevalence in a civilian population. These findings support the expanded use of REBOA in emergency department and prehospital settings. Validation for safety and efficacy on cadaveric and clinical models is necessary.

High-grade traumatic torso visceral injury with hemodynamic instability: effectiveness of transarterial embolization using n-butyl cyanoacrylate

Trauma patients with uncontrolled hemorrhage encountering coagulopathy are often associated with poor outcome. Recently, the concept of damage control interventional radiology, which focuses on "speedy stoppage of bleeding" by interventional radiology among trauma patients with hemodynamic instability and acute traumatic coagulopathy, was proposed as an alternative to damage control surgery. N-butyl cyanoacrylate (NBCA) has been used as a liquid embolic agent in various non-traumatic situations, where it has been shown to have a high technical success rate and low recurrent bleeding rate, especially in patients with coagulopathy. In this case, we treated a young patient with hemodynamic instability caused by a high-grade hepatic injury, who underwent arterial embolization (AE) using NBCA assisted with resuscitative endovascular balloon occlusion of the aorta and achieved successful hemostasis. A review of published works using PUBMED was carried out, and 10 published reports involving 23 trauma patients who underwent AE using NBCA were identified. Among them, only four reports involving five trauma patients with torso visceral injuries were identified. Three of five patients who were hemodynamically unstable underwent AE using NBCA, resulting in the stabilization of hemodynamics. We concluded that AE with resuscitative endovascular balloon occlusion of the aorta as a damage control interventional radiology procedure might be acceptable for the hemodynamically unstable hepatic injury, and NBCA could be one of the effective hemostatic agents for this purpose, in cases of trauma-induced coagulopathy.