The use of aortic balloon occlusion in traumatic shock: first report from the ABO trauma registry

PURPOSE

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a technique for temporary stabilization of patients with non-compressible torso hemorrhage. This technique has been increasingly used worldwide during the past decade. Despite the good outcomes of translational studies, clinical studies are divided. The aim of this multicenter-international study was to capture REBOA-specific data and outcomes.

METHODS

REBOA practicing centers were invited to join this online register, which was established in September 2014. REBOA cases were reported, both retrospective and prospective. Demographics, injury patterns, hemodynamic variables, REBOA-specific data, complications and 30-days mortality were reported.

RESULTS

Ninety-six cases from 6 different countries were reported between 2011 and 2016. Mean age was 52 ± 22 years and 88% of the cases were blunt trauma with a median injury severity score (ISS) of 41 (IQR 29-50). In the majority of the cases, Zone I REBOA was used. Median systolic blood pressure before balloon inflation was 60 mmHg (IQR 40-80), which increased to 100 mmHg (IQR 80-128) after inflation. Continuous occlusion was applied in 52% of the patients, and 48% received non-continuous occlusion. Occlusion time longer than 60 min was reported as 38 and 14% in the non-continuous and continuous groups, respectively. Complications, such as extremity compartment syndrome (n = 3), were only noted in the continuous occlusion group. The 30-day mortality for non-continuous REBOA was 48%, and 64% for continuous occlusion.

CONCLUSIONS

This observational multicenter study presents results regarding continuous and non-continuous REBOA with favorable outcomes. However, further prospective studies are needed to be able to draw conclusions on morbidity and mortality.

High-b-value diffusion-weighted MR imaging of suspected brain infarction

BACKGROUND AND PURPOSE

Recent technological advances in MR instrumentation allow acquisition of whole-brain diffusion-weighted MR scans to be obtained with b values greater than 1,000. Our purpose was to determine whether high-b-value diffusion-weighted MR imaging improved contrast and detection of signal changes in acute and chronic brain infarction.

METHODS

We prospectively evaluated the MR scans of 30 subjects with a history of possible brain infarction on a 1.5-T MR imager with 40 mT/meter gradients (slew rate 150 T/m/s) by use of the following single-shot echo-planar diffusion-weighted MR sequences: 1) 7,999/ 71.4/1 (TR/TE/excitations, b = 1,000; 2) 999/ 88.1/3, b = 2,500; and 3) 7,999/ 92.1/4, b = 3,000. Diffusion-weighted MR imaging was performed in three orthogonal directions during all sequences. All subjects were scanned with fast fluid-attenuated inversion recovery (FLAIR) (10,006/145/2,200/1 [TR/TE/TI/excitations]) and fast spin-echo T2-weighted (3,650/95/3 [TR/TE/excitations], echo train length, 8). The diagnosis of brain infarction was established by clinical criteria.

RESULTS

Twenty women and 10 men with a mean age of 67.7 years were enrolled in the study. One subject was excluded owing to poor image quality. Twelve of 29 subjects had a clinical diagnosis of acute infarction. All 12 had lesions that were hyperintense on diffusion-weighted images at all three b values; five were cortical and seven subcortical. There was increased contrast of all lesions on high-b-value scans (b = 2,500 and 3,000). Lesions that were hypointense on diffusion-weighted images were identified and evaluated at the three different b values. At b = 1,000, there were 19 hypointense lesions, whereas at b = 2,500 and 3,000 there were 48 and 55 lesions, respectively. On FLAIR and T2-weighted images, these low-signal lesions were predominantly chronic, subcortical, ischemic lesions and lacunar infarcts, but four chronic cortical infarcts, one porencephalic cyst, and one primary brain tumor were also found. Low-signal lesions were also noted to have increased contrast on high-b-value diffusion-weighted scans.

CONCLUSION

High-b-value diffusion-weighted MR imaging (b = 2,500 or b = 3,000) had no impact on diagnosis of acute infarction. High-b-value diffusion-weighted MR imaging (b = 2,500) combined with diffusion-weighted MR imaging at b = 1,000 improves tissue characterization by increasing the spectrum of observed imaging abnormalities in patients with suspected brain infarction.

Interlocking stents for improving stent fixation at graft-venous anastomosis

To lower the risk of stent migration in a graft-venous anastomosis stenosis following failed percutaneous transluminal angioplasty, two Strecker stents of different caliber were placed in partly overlapping fashion across the stenosis. In contrast to other methods, stent "floating" on the venous side was eliminated by using a stent with a caliber matching the tapering postanastomotic vein and anchoring it to both the venous wall and the second stent. Using this method we believe we accomplished better fixation of the stent placed mostly in the venous side of the anastomosis, thus lowering its risk of migration. At 6 months follow-up the stents are in place and the anastomosis is patent.