Intra-aortic Balloon Occlusion Research Articles

An International Expert-Based CONsensus on Indications and Techniques for aoRtic balloOn occLusion in the Management of Ruptured Abdominal Aortic Aneurysms (CONTROL-RAAA)

Objective: To report on the recommendations of an expert-based consensus on the indications, timing, and techniques of aortic balloon occlusion (ABO) in the management of ruptured abdominal aortic aneurysms (rAAA). Methods: Eleven facilitators created appropriate statements regarding the study issues that were voted on using a 4-point Likert scale with open-comment fields, by a selected panel of international experts (vascular surgeons and interventional radiologists) using a 3-round modified Delphi consensus procedure (study period: January-April 2023). Based on the experts’ responses, only the statements reaching grade A (full agreement ≥75%) or B (overall agreement ≥80% and full disagreement <5%) were included in the final study report. The consistency of each round’s answers was also graded using Cohen’s kappa, the intraclass correlation coefficient, and, in case of double resubmission, Fleiss kappa. Results: Sixty-three experts were included in the final analysis and voted on 25 statements related to indication and timing (n=6), and techniques (n=19) of ABO in the setting of rAAA. Femoral sheath or ABO should be preferably placed in the operating room, via a percutaneous transfemoral access, on a stiff wire (grade B, consistency I), ABO placement should be suprarenal and last less than 30 minutes (grade B, consistency II), postoperative peripheral vascular status (grade A, consistency II) and laboratory testing every 6 to 12 hours (grade B, consistency) should be assessed to detect complications. Formal training for ABO should be implemented (grade B, consistency I). Most of the statements in this international expert-based Delphi consensus study might guide current choices for indications, timing, and techniques of ABO in the management of rAAA. Clinical practice guidelines should incorporate dedicated statements that can guide clinicians in decision-making. Conclusions: At arrival and during both open or endovascular procedures for rAAA, selective use of intra-aortic balloon occlusion is recommended, and it should be performed preferably by the treating physician in aortic pathology. Clinical Impact This is the first consensus study of international vascular experts aimed at defining the indications, timing, and techniques of optimal use of ABO in the clinical setting of rAAA. Aortic occlusion by endovascular means (or ABO) is a quick procedure in properly trained hands that may play an important role as a temporizing measure until the definitive aortic repair is achieved, whether by endovascular or open means. Since data on its use in hemodynamically unstable patients are limited in the literature, owing to practical challenges in the performance of well-conducted prospective studies, understanding real-world use by experts is of importance in addressing critical issues and identifying main gaps in knowledge.

Aortic valve replacement in a 41-year-old woman with uncorrected tetralogy of Fallot, pulmonary atresia, and major aortopulmonary collateral arteries: a case report

BackgroundTetralogy of Fallot (TOF) is a complex cyanotic congenital heart disease. As most patients with TOF undergo palliative or radical surgical repair during childhood, cardiac surgery under cardiopulmonary bypass (CPB) for adult survivors with unrepaired TOF is exceedingly rare.Case presentationA 41-year-old woman with unrepaired TOF, pulmonary atresia (PA), and major aortopulmonary collateral arteries (MAPCAs) developed acute infectious endocarditis (IE). As vegetation gradually increased despite intravenous antibiotic administration, she was scheduled for urgent aortic valve replacement under CPB. Pulmonary blood flow was primarily provided by the MAPCAs originating from the descending aorta. Intra-aortic balloon occlusion for MAPCAs was performed to ensure a bloodless surgical field. Aortic valve replacement was successful.ConclusionAn adult with uncorrected TOF developed acute IE and subsequently had successful cardiac surgery under CPB. Understanding TOF physiology with PA and MAPCAs, particularly pulmonary blood flow through MAPCAs, is crucial.

Hemorrhagic gastric ulcer in which intra-aortic balloon occlusion was useful for improving endoscopic visibility and hemostasis

Hemorrhagic gastric ulcer in which intra-aortic balloon occlusion was useful for improving endoscopic visibility and hemostasis

Anesthetic management of cesarean hysterectomy using intra-aortic balloon occlusion in a patient with Fontan circulation and placenta increta: a case report

BackgroundIn patients with Fontan circulation, hemorrhage can cause life-threatening circulatory collapse, since Fontan circulation strongly depends on the preload. Furthermore, parturients with placenta accreta spectrum are at a high risk of rapid and massive hemorrhage. Herein, we report the case of an intra-aortic balloon occlusion used for a Fontan-palliated parturient with placenta increta with successful anesthetic management.Case presentationA 35-year-old-female with Fontan circulation diagnosed with placenta increta underwent a cesarean hysterectomy. The main goal during anesthetic management was to maintain sufficient preload. Infrarenal intra-aortic balloon occlusion was used to reduce intraoperative hemorrhage. The hemodynamic changes caused were well tolerated in this case.ConclusionsIntra-aortic balloon occlusion was used in a Fontan-palliated parturient with placenta increta with successful anesthetic management.

Case report: Resuscitative endovascular balloon occlusion after iatrogenic injury of the common iliac artery during neurosurgical dorsal lumbar microdiscectomy.

This case report describes resuscitative endovascular balloon occlusion (REBOA) of the aorta in a patient with life-threatening iatrogenic bleeding of the right common iliac artery during elective dorsal lumbar spine surgery. REBOA is an emergency procedure for temporary intra-aortic balloon occlusion being increasingly reported and published since its inauguration in 1954. The interdisciplinary management of hemorrhage and technical notes for a successful REBOA procedure will be presented. A 53-year-old female patient was admitted to the neurosurgery clinic suffering from left-sided L5 radiculopathy. During surgery, the anterior longitudinal ligament was perforated and an arterial vessel was lacerated. The patient became hemodynamically unstable demanding prompt supine repositioning and cardiopulmonary resuscitation (CPR). REBOA enabled cardiovascular stabilization after 90 min of CPR and laparotomy with vascular reconstruction and contributed to the survival of the patient without major clinical deficits. The patient was discharged from the ICU after 7 days. Resuscitative endovascular balloon occlusion of the aorta is an emergency procedure to control life-threatening hemorrhage. REBOA should be available on-scene and applied by well-trained vascular surgery personnel to control vascular complications or extend to emergency laparotomy and thoracotomy with aortic cross-clamping in case of in-hospital non-controllable hemorrhages. In case of ongoing CPR, we recommend surgical groin incision, open puncture of the pulseless common femoral artery, and aortic balloon inflation in REBOA zone I. Hereby, fast access and CPR optimization for heart and brain perfusion are maintained. Training for REBOA is the decisive factor to control selected cases of in-house and outpatient massive arterial abdominal bleeding complications.

Acceptable Intra-aortic Balloon Occlusion Duration Affecting the Regional Saturation Oxygen of Lower Limbs Using Near-infrared Spectroscopy for Abnormally Adherent Placentation

Objective: To investigate the utility of regional saturation oxygen (rSO2) using near-infrared spectroscopy (NIRS) in the lower limbs and to estimate the safe occlusion duration in patients with abnormally adherent placentation who underwent intra-aortic balloon occlusion (IABO) during a cesarean hysterectomy by comparing them with infrarenal aortic clamping. Methods: The researchers classified 15 lower limbs of patients with abnormally adherent placentation with IABO during a cesarean hysterectomy as the balloon group and 20 lower limbs of patients with cross-clamping on the infrarenal aorta during the aneurysmal repair as the clamping group. The rSO2 measurement of the limbs was performed using a near-infrared spectrometer. In addition, the aortic occlusion duration, rSO2 before and during occlusion, and after blood resumption were analyzed. Results: Continuous rSO2 measurement was possible in all patients. The median aortic occlusion durations in the balloon and clamping groups were 68 and 92.5 min, and the median minimum rSO2 during occlusion was 60% and 17.5%, respectively. The clamping group was found to have stronger occlusion for a longer time than the balloon group. No complications associated with aortic occlusion were observed in both groups. Conclusions: rSO2 measurement using a near-infrared spectrometer effectively monitors lower-limb blood flow during IABO in patients with abnormally adherent placentation. An IABO duration of approximately 90 min was believed to be relatively acceptable in a cesarean hysterectomy under heparin administration.

Association between intraoperative fluid overload and postoperative debridement in major sacrum tumor resection: A propensity score matching study.

Intra-aortic balloon occlusion (IABO) is used to reduce intraoperative bleeding and facilitate successful sacrum tumor resection. Up to 20% of patients experience postoperative wound healing problems, but the risk factors related to this complication have not been clearly defined. The anesthetic database of Peking University People’s Hospital, Beijing, China, was searched for all patients (aged 14‐70 years old) who underwent sacrum tumor surgery with the application of IABO from 2014 to 2017. Data from 278 patients with an aortic occlusion duration of 72 ± 33 minutes were collected. Fifty-six patients required postoperative debridement because of wound infection. The independent risk factor identified by logistic regression was fluid excess (calculated as volume infused minus blood loss and urine output divided by body weight [kg]), and decision tree analysis revealed that the cutoff point for fluid excess was 38.5 mL/kg. Then patients were then divided into high fluid excess group (fluid excess > 38.5 mL/kg) and low fluid excess group (fluid excess ≤ 38.5 mL/kg) and 91 pairs of patients were generated through propensity score matching (PSM). Fluid excess was significantly higher in the high fluid excess group (46 vs 30 mL/kg, P < .001), and more patients required postoperative debridement than in the low fluid excess group (24 (26.3%) vs 12 (13.1%), P < .001). In this retrospective PSM study on sacrum tumor resection, fluid overload was related to postoperative debridement and further studies are needed to improve the clinical prognosis.

Effectiveness of Intra-Aortic Ballooning Occlusion for Bleeding Control in Gravida Patients with Placenta Accreta

Introduction: &#x0D; Placenta previa and morbidly adherent placenta cause significant maternal morbidity and mortality from postpartum hemorrhage. Intra-aortic balloon occlusion has been shown to reduce intraoperative hemorrhage effectively.&#x0D; Cases Presentation&#x0D; We reported four cases of women who underwent cesarean section and hysterectomy with IABO. All four were multigravida, gestational age range was 37-39 weeks, MAP score range 6-8. Ultrasound examination showed placenta accreta. After the cesarean section and hysterectomy procedure with IABO, the bleeding was 600-800 cc.&#x0D; Conclusions&#x0D; Intra-Aortic Ballooning Occlusion is an effective method to reduce bleeding complications during and after cesarean section in pregnancies with placenta accreta.&#x0D;

Treatment Strategies for Improving the Surgical Outcomes of Ruptured Abdominal Aortic Aneurysm: Single-Center Experience in Japan

Objective: We aimed to examine the surgical outcomes of ruptured abdominal aortic aneurysm cases at our hospital and considered strategies for improvement.Material and Methods: We examined the preoperative characteristics of hospital mortality, postoperative complications, and long-term outcomes of 91 surgical cases of ruptured abdominal aortic aneurysm performed between January 2009 and December 2020 at our hospital.Results: Of the 91 cases, 24 died at the hospital (mortality, 26.3%). Mortality was mostly due to hemorrhage/disseminated intravascular coagulation and intestinal necrosis. Ten patients required preoperative aortic clamp by thoracotomy or insertion of intra-aortic balloon occlusion, and eight of them died. Ten patients required open abdominal management due to abdominal compartment syndrome, and five of them died. There was no significant difference between the two groups in terms of the long-term results of the open repair and abdominal endovascular aneurysm repair (EVAR).Conclusion: To improve the surgical outcomes of ruptured abdominal aortic aneurysms, it is necessary to start surgery immediately. Therefore, the choice of surgical method (open surgery or EVAR) should be based on the resources and discretion of the hospital. To prevent postoperative intestinal necrosis, risk factors for acute compartment syndrome should be considered, and open abdominal management should be introduced.

Combined, converted, and prophylactic use of resuscitative endovascular balloon occlusion of the aorta for severe torso trauma: a retrospective study.

IntroductionResuscitative endovascular balloon occlusion of the aorta (REBOA) is used as an intra‐aortic balloon occlusion in Japan; however, protocols for its effective use in different conditions have not been established. This study aimed to summarize the strategies of REBOA use in severe torso trauma.MethodsTwenty‐nine cases of REBOA for torso trauma treated at our hospital over 5 years were divided into hemodynamically unstable (HU) (n = 12), cardiac arrest (CA) (n = 13), and hemodynamically stable (HS) (n = 4) groups. We retrospectively examined patient characteristics, trauma mechanism, injury site, severity score, intervention type, and survival rates at 24 h in each group.ResultsIn the HU group, 9 and 3 patients survived and died within 24 h, respectively; time to intervention (56.6 versus 130.7 min, P = 0.346) tended to be shorter and total occlusion time (40.2 versus 337.7 min, P = 0.009) was significantly shorter in survivors than in nonsurvivors. In the CA group, 10 patients were converted from resuscitative thoracotomy with aortic cross‐clamp (RTACC); one patient survived. All four patients in the HS group survived, having received prophylactic REBOA.ConclusionThe efficacy of REBOA for severe torso trauma depends on the patient's condition. If the patients are hemodynamically unstable, time to intervention and total occlusion time could correlate with survival. The combined use of REBOA with definitive hemostasis could improve outcomes. Conversion from RTACC in the cardiac arrest patients and prophylactic use in the hemodynamically stable patients can be one of the potentially effective options, although further studies are needed.

Resuscitative endovascular balloon occlusion of the aorta in combat casualties: The past, present, and future.

Noncompressible torso hemorrhage is a leading cause of preventable death on the battlefield. Intra-aortic balloon occlusion was first used in combat in the 1950s, but military use was rare before Operation Iraqi Freedom and Operation Enduring Freedom. During these wars, the combination of an increasing number of deployed vascular surgeons and a significant rise in deaths from hemorrhage resulted in novel adaptations of resuscitative endovascular balloon occlusion of the aorta (REBOA) technology, increasing its potential application in combat. We describe the background of REBOA development in response to a need for minimally invasive intervention for hemorrhage control and provide a detailed review of all published cases (n = 47) of REBOA use for combat casualties. The current limitations of REBOA are described, including distal ischemia and reperfusion injury, as well as ongoing research efforts to adapt REBOA for prolonged use in the austere setting. Level V.

Open Surgical Repair for a Giant Common Hepatic Artery Aneurysm with Difficulty in Proximal Arterial Clamping: A Case Report.

Hepatic artery aneurysm has been considered as a rare, life-threatening disease. In this study, we report on a patient requiring surgical treatment for a giant hepatic artery aneurysm by aneurysmectomy without revascularization. A 70-year-old woman who complained of epigastric pain was referred to our hospital. Enhanced computed tomography scan has revealed a giant (11×9 cm) common hepatic artery aneurysm. She then underwent emergency surgery; the intra-aortic balloon occlusion technique was applied in order to control the blood inflow into the aneurysm. The aneurysm was then incised, and direct closure of the inflow and outflow orifices was performed safely without evidence of ischemic change in the liver.

Case Series of Zone III Resuscitative Endovascular Balloon Occlusion of the Aorta in Traumatic Shock Patients

Purpose There is increasing evidence in the literature regarding resuscitative endovascular balloon occlusion of the aorta (REBOA) globally, but few cases have been reported in Korea. We aimed to describe our experience of successful Zone III REBOA and to discuss its algorithm, techniques, and related complications. Methods We reviewed consecutive cases who survived from hypovolemic shock after Zone III REBOA placement for 4 years. We reviewed patients’ baseline characteristics, physiological status, procedural data, and outcomes. Results REBOA was performed in 44 patients during the study period, including 10 patients (22.7%) who underwent Zone III REBOA, of whom seven (70%) survived. Only one patient was injured by a penetrating mechanism and survived after cardiopulmonary resuscitation. All patients underwent interventions to stop bleeding immediately after REBOA placement. Conclusions This case series suggests that Zone III REBOA is a safe and feasible procedure that could be applied to traumatic shock patients with normal FAST findings who receive a chest X-ray examination at the initial resuscitation. Keywords: Trauma; Trauma centers; Shock, hemorrhagic; Intra-aortic balloon occlusion

Intraoperative balloon occlusion of the aorta for blood management in sacral and pelvic tumor resection: A systematic review and meta-analysis

BackgroundNeoplasms of the sacrum and pelvis are challenging to manage due to their complex vascularity and size and are at high risk of bleeding during resection. Intra-aortic balloon occlusion (IABO) has been used in trauma to control massive blood loss, but its efficacy and safety in oncologic sacral and pelvic surgery are unknown. The primary objective of this systematic review and meta-analysis was to assess the effectiveness of IABO in providing hemorrhage control during resection of sacral and pelvic tumors. MethodsThis PROSPERO pre-registered study meta-analyzed all studies reporting on the use of IABO in the setting of pelvic and sacral tumour resection, in accordance with the PRISMA guidelines. The primary outcome of the meta-analysis was intraoperative blood loss, with secondary outcomes consisting of transfusion volume, post-operative blood loss, operative time, complication rate, and mortality. ResultsAcross studies, IABO was associated with a large, significant reduction in intraoperative blood loss (SMD -0.81, 95% CI -1.01 to −0.60, P < 0.0001) and transfused red blood cell volume (SMD 0.92, 95% CI -1.30 to −0.53, P < 0.0001). Two studies reported that complication rates were comparable between patients receiving IABO and patient receiving conventional surgery (Odds ratio = 1.29, 95% CI: 0.59 to 2.83, P = 0.52). All studies descriptively reported improved visualization of the operative field with IABO. ConclusionsOur findings demonstrated that IABO is an effective technique to decrease blood loss and transfusion requirements during sacral and pelvic tumor surgery. Future clinical trials should be conducted to establish the safety of this method and explore potential contraindications.

Spontaneous rupture of the pancreatic arcade artery caused by neurofibromatosis type 1 successfully treated using emergency transcatheter arterial embolization, partial intra-aortic balloon occlusion, and stent graft placement: a case report and review of the literature

BackgroundVascular abnormalities in neurofibromatosis type 1 (NF1) are rare, but are the second leading cause of death in persons with NF1. In NF1 vasculopathy (NF-V), fatal bleeding due to a spontaneous arterial rupture sometimes occurs. Ruptured extracranial arteries in patients with NF1 often involve thoracic vessels, such as the intercostal and subclavian arteries; very few reports exist regarding the abdominal region. Herein, we present the first case of intraperitoneal bleeding due to spontaneous pancreatic arcade artery (PAA) rupture associated with NF1, successfully treated by transcatheter arterial embolization (TAE) combined with stent-graft placement and partial intra-aortic balloon occlusion (IABO).Case presentationA 40-year-old woman complained of back and abdominal pain. Upon admission, her blood pressure was 85/41 mmHg and heart rate was 129 beats/min. Computed tomography (CT) showed large intraperitoneal bleeding due to PAA rupture. After CT scanning, her systolic blood pressure decreased to 50 mmHg. Therefore, we performed emergency TAE with partial IABO. She was treated by TAE of the anterior superior pancreaticoduodenal artery, anterior inferior pancreaticoduodenal artery, and inferior pancreaticoduodenal artery. However, even after TAE, minor extravasation around the superior mesenteric artery continued, and her vital signs remained unstable. Stent-graft placement was selected to stop the haemorrhage, preserving normal blood flow of the superior mesenteric artery trunk. Excellent patency of the stent graft was confirmed on follow-up CT, and she was discharged on postoperative day 56.ConclusionPAA rupture associated with NF1 can be successfully treated by TAE combined with partial intra-aortic balloon occlusion, and stent-graft placement.

Successful Open Surgical Repair and Postoperative Complications for Ruptured Abdominal Aortic Aneurysm Transferred with Intra-aortic Balloon Occlusion Catheter

Successful Open Surgical Repair and Postoperative Complications for Ruptured Abdominal Aortic Aneurysm Transferred with Intra-aortic Balloon Occlusion Catheter

Safety and Efficacy of Aortic Vs Internal Iliac Balloon Occlusion for Cesarean Delivery in Coexisting Placenta Accreta and Placenta Previa.

To investigate safety and efficacy of intra-aortic balloon occlusion (IABO) versus internal iliac artery balloon occlusion (IIABO) for cesarean delivery in coexisting placenta accreta and placenta previa. From 2006 to 2019, 60 pregnant women who had undergone preoperative IABO (n = 28) and IIABO (n = 32) for cesarean delivery in coexisting placenta accreta and placenta previa were retrospectively identified, and their medical records and relevant imaging were reviewed. Maternal characteristics (age, gravidity, previous cesarean delivery, gestational age, and neonatal weight) were similar in both groups. Estimated blood loss, volume of blood transfusion, length of hospitalization, and rate of hysterectomy were not significantly different between the groups. Operation time (the duration of cesarean delivery and hysterectomy, p < 0.05), total time of balloon occlusion (p < 0.01), and fetal radiation dose (p < 0.001) in the IABO group were less than in the IIABO group. No severe complications related to the balloon occlusion procedure were noted in either group. IABO and IIABO are safe and effective options for cesarean delivery in patients with combined placenta accreta and placenta previa. The average operation time, balloon occlusion time, and fetal radiation dose in patients with IABO are less than in patients with IIABO. There were no complications related to balloon occlusion of the aorta or internal iliac artery.

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

IntroductionPelvic 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 methodsFrom 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. ResultsIntraoperatively, 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. ConclusionThe 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.

A Case of Hepatic Artery Aneurysm with Obstructive Jaundice, Resected and Reconstructed Safely Using an Intra-aortic Balloon Occlusion Catheter

A Case of Hepatic Artery Aneurysm with Obstructive Jaundice, Resected and Reconstructed Safely Using an Intra-aortic Balloon Occlusion Catheter

Intra-Aortic Balloon Occlusion Decreases Blood Loss During Open Reduction and Internal Fixation for Delayed Acetabular Fractures: A Retrospective Study of 43 Patients

Aim: It is difficult to treat delayed acetabular fractures due to massive blood loss during operation. Temporary balloon occlusion of the abdominal aorta was introduced into sacral tumor surgery to reduce intraoperative hemorrhage. The aim of this study was to investigate the effect of this method on reduction of intraoperative blood loss and analyze the complications of this technique in the treatment of delayed acetabular fracture. Methods: We retrospectively reviewed 43 patients with delayed acetabular fracture who were surgically treated through combined approaches. Nineteen patients underwent temporary balloon occlusion of the abdominal aorta; 10 patients had type B fracture and 9 patients had type C fracture according to the Müller AO classification. The remaining 24 patients were classified into a control group; 14 patients had type B fracture and 10 patients had type C fracture. Surgical time, intraoperative blood loss, blood transfusion, satisfactory reduction rate, and functional recovery were recorded and compared between two groups. Merle d'Aubigné and Postel scoring was applied to evaluate the patients. Results: The patients treated with intra-aortic balloon occlusion had a shorter surgical time (p = 0.008), less intraoperative blood loss (p = 0.005), and less transfused blood units (p = 0.001). No complications caused by balloon occlusion. No significant difference were observed in the outcomes and the complications related to acetabular fractures between two groups. Conclusions: Temporary balloon occlusion of the abdominal aorta is a reliable technique to control bleeding for the surgery of delayed acetabular fracture.