Partial Resuscitative Endovascular Balloon Occlusion Research Articles

Distal pressure monitoring and titration with percent balloon volume: feasible management of partial resuscitative endovascular balloon occlusion of the aorta (P-REBOA).

Resuscitative endovascular balloon occlusion of the aorta (REBOA) increases proximal arterial pressure, but may also induce life-threatening distal ischemia. Partial REBOA (P-REBOA) is thought to mitigate distal ischemia during aortic occlusion. However, feasible indicators of the degree of P-REBOA remain inconsistent. We hypothesised percent balloon volume could be a substitute for pressure measurements of gradients during P- REBOA. This study aimed to compare balloon volume and arterial pressure gradient, and analysed with intra-balloon pressure and balloon shape. Proximal (carotid) and distal (femoral) arterial pressures were recorded and a 7-Fr REBOA catheter was placed in four swine. Total REBOA was defined as a cessation of distal pulse pressure and maximum balloon volume was documented. The balloon volume was titrated by 20% increments of maximum capacity to adjust the degree of P-REBOA. The distal/proximal arterial pressure gradient and the intra-balloon pressures were also recorded. The changes in shape and the cross-sectional area of the balloon were evaluated with computed tomography (CT) images. The proximal mean arterial pressure (MAP) plateaued after 60% balloon volume; meanwhile, distal pulse pressure was still left. The balloon pressure was traced with proximal MAP before contact with aortic wall. The balloon shape changed unevenly from "cone" to "spindle" shape, although the balloon cross-sectional area of the mid-segment linearly increased. Monitoring distal pressure and titrating percent balloon volume is feasible to manage P-REBOA. In this experiment, 60% balloon volume was enough inflation to elevate central pressure allowing distal perfusion. The intra-balloon pressure was not reliable due to the strong influence of proximal MAP and uneven change of the balloon shape.

Pre-Hospital Zone 1 Partial Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

Pre-Hospital Zone 1 Partial Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

Titrate to equilibrate and not exsanguinate! Characterization and validation of a novel partial resuscitative endovascular balloon occlusion of the aorta catheter in normal and hemorrhagic shock conditions.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a significant advancement in the control of noncompressible truncal hemorrhage. However, its ischemic burden and reperfusion injury following balloon deflation limits its utilization. Partial restoration of aortic flow during REBOA has the potential to balance hemorrhage control and ischemia. This study validates the mechanics, physiology, and optimal partial flow rates using a prototype partial REBOA (pREBOA) device. Twenty-five swine underwent placement of aortic flow probes and zone 1 pREBOA. Experiment 1 (N = 5) animals were not injured and assessed the tested the catheters ability to titrate and control flow. Experiment 2 (N = 10) added 20% hemorrhage and either solid organ, or abdominal vascular injury to compare flow rate and rebleeding from injuries. Experiment 3 (N = 10) swine were similarly prepared, hemorrhaged, and underwent pREBOA at set partial flow rates for 2 hours followed by complete deflation for 30 minutes. Balloon volume at minimum flow (mean, 0.09 L/min) was 3.5 mL to 6.0 mL. Half maximal flow was achieved with 56.5% of maximum balloon inflation. Partial REBOA allowed very fine titration of flow rates. Rebleeding occurred at 0.45 L/min to 0.83 L/min. Distal flow of 0.7 L/min had 50% survival, 0.5 had 100% survival, and 0.3 L had 50% survival with mean end lactates of 9.6, 12.6, and 13.3, respectively. There was a trend toward hyperkalemia and hypocalcemia in nonsurvivors. The pREBOA device demonstrated a high level of titratability for restoration of aortic flow. An optimal partial flow of 0.5 L/min was effective at hemorrhage control while limiting the burden of ischemic injury, and extending the tolerable duration of zone 1 occlusion. Aggressive calcium supplementation prior to and during partial occlusion and reperfusion may be warranted to prevent hyperkalemic arrest.

Successful Partial Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in an Octogenarian Trauma Patient

- Background: To demonstrate how to perform successful REBOA/ABO in extreme elderly patient
 - Materials and methods: A case report
 - Results:
 A 86-year old male, he was struck by car and transferred to Level I Trauma center at Siriraj hospital after injury for 30 minutes. Arrival clinical signs were coma and hypotension, lowest SBP was 50 mmHg. Primary survey found unstable pelvic fracture and severe head injury. We did REBOA at Zone I via left common femoral artery which aim to do partial balloon technique by inflation with 15-18 mL and arterial line monitoring for goal SBP around 100-120 mmHg due to his extreme age and associated traumatic brain injury. After CT scan showed no intra-abdominal injury, we did reposition the balloon to zone III under fluoroscopy. Unexpectedly, during deflation the balloon before removal, we found fresh blood through the balloon port, then ruptured balloon was suspected and confirmed with aortography. We immediately converted to remove by open technique due to balloon was failed to shrinkage through 7-Fr sheath. We reviewed the CT scan was shown calcified plaque along aorta and arteries which could be the cause of ruptured balloon. Throughout all procedures to stop bleeding which are pelvic external fixation, preperitoneal pelvic packing and embolization at right internal iliac artery, patient was given PRC only 4 units and no inotropic support to stabilizing patient. Total inflation time was 167 minutes with partial and intermittent REBOA technique. ICU Admission lab showed normal renal and liver function.
 - Conclusion :
 To perform ABO/REBOA in extreme elderly trauma patient, the partial balloon technique with goal SBP to balance between associated injury in polytrauma patient is very essential. The specific concern in this group would be related with reserve function and the changing of vascular access. Techniques for detection and solving the uneventful conditions should be prepared and learnt to successfully save the elderly patient.

Traumatic brain injury may worsen clinical outcomes after prolonged partial resuscitative endovascular balloon occlusion of the aorta in severe hemorrhagic shock model.

The use of partial resuscitative endovascular balloon occlusion of the aorta (pREBOA) in combined hemorrhagic shock (HS) and traumatic brain injury (TBI) has not been well studied. We hypothesized that the use of pREBOA in the setting of TBI would be associated with worse clinical outcomes. Female Yorkshire swine were randomized to the following groups: HS-TBI, HS-TBI-pREBOA, and HS-pREBOA (n = 5/cohort). Animals in the HS-TBI group were left in shock for a total of 2 hours, whereas animals assigned to pREBOA groups were treated with supraceliac pREBOA deployment (60 minutes) 1 hour into the shock period. All animals were then resuscitated, and physiologic parameters were monitored for 6 hours. Further fluid resuscitation and vasopressors were administered as needed. At the end of the observation period, brain hemispheric swelling (%) and lesion size (mm) were assessed. Mortality was highest in the HS-TBI-pREBOA group (40% [2/5] vs. 0% [0/5] in the other groups, p = 0.1). Severity of shock was greatest in the HS-TBI-pREBOA group, as defined by peak lactate levels and pH nadir (p < 0.05). Fluid resuscitation and norepinephrine requirements were significantly higher in the HS-TBI-pREBOA group (p < 0.05). No significant differences were noted in brain hemispheric swelling and lesion size between the groups. Prolonged application of pREBOA in the setting of TBI does not contribute to early worsening of brain lesion size and edema. However, the addition of TBI to HS-pREBOA may worsen the severity of shock. Providers should be aware of the potential physiologic sequelae induced by TBI.

Three cases of resuscitative endovascular balloon occlusion of the aorta (REBOA) in austere pre-hospital environment\u2014technical and methodological aspects

BackgroundThe 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.MethodsBelgian 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).ResultsSystolic 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.ConclusionsER-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.

Potential benefit of early operative utilization of low profile, partial resuscitative endovascular balloon occlusion of the aorta (P-REBOA) in major traumatic hemorrhage.

A 28-year-old man with multiple gunshot wounds to the chest and upper extremities was transported by private vehicle to a community hospital with limited trauma capabilities. On arrival he developed pulseless electrical activity and cardiopulmonary resuscitation was initiated. He was intubated, transfused with 4 units of packed red blood cells, and resuscitated with 2 L of crystalloid prior to regaining spontaneous circulation. Left-sided tube thoracostomy immediately drained 1600 mL of bright red blood. He was transiently stable for a short transport to the nearest level 1 trauma center. On arrival the patient was normotensive with tachycardia. Chest X-ray demonstrated persistent left-sided hemothorax despite a well-positioned chest tube. Focused Assessment with Sonography for Trauma (FAST) examination was negative for pericardial fluid, but positive for intra-abdominal fluid. During the secondary examination the patient became hypotensive with systolic blood pressure (SBP) in the 70 s. A massive transfusion protocol was initiated, tranexamic acid was administered, and the patient was promptly transported to the operating room. The patient transiently responded to the massive transfusion. While instruments were being opened in the operating room, he again became hypotensive with SBP in the 50 s. The patient was acidotic (pH of 6.87, base excess −14.6), coagulopathic (international normalized ratio of 1.5) and …

Partial Resuscitative Endovascular Balloon Occlusion of the Aorta in Swine Model of Hemorrhagic Shock

Complete resuscitative endovascular balloon occlusion of the aorta (C-REBOA) increases proximal mean arterial pressure (MAP) at the cost of distal organ ischemia, limiting the duration of intervention. We hypothesized that partial aortic occlusion (P-REBOA) would maintain a more physiologic proximal MAP and reduce distal tissue ischemia. We investigated the hemodynamic and physiologic effects of P-REBOA vs C-REBOA. Fifteen swine were anesthetized, instrumented, splenectomized, and subjected to rapid 25% blood volume loss. They were randomized to C-REBOA, P-REBOA, or no intervention (controls). Partial REBOA was created by partially inflating an aortic balloon catheter to generate a 50% blood pressure gradient across the balloon. Hemodynamics were recorded and serum makers of ischemia and inflammation were measured. After 90 minutes of treatment, balloons were deflated to evaluate the immediate effects of reperfusion. End organs were histologically examined. Complete REBOA produced supraphysiologic increases in proximal MAP after hemorrhage compared with more modest augmentation in the P-REBOA group (p < 0.01), with both groups significantly greater than controls (p < 0.01). Less rebound hypotension after balloon deflation was seen in the P-REBOA compared with C-REBOA groups. Complete REBOA resulted in higher serum lactate than both P-REBOA and controls (p < 0.01). Histology revealed early necrosis and disruption of duodenal mucosa in all C-REBOA animals, but none in P-REBOA animals. In a porcine hemorrhagic shock model, P-REBOA resulted in more physiologically tolerable hemodynamic and ischemic changes compared with C-REBOA. Additional work is needed to determine whether the benefits associated with P-REBOA can both extend the duration ofintervention and increase survival.

Extending the golden hour: Partial resuscitative endovascular balloon occlusion of the aorta in a highly lethal swine liver injury model.

Combat-injured patients may require rapid and sustained support during transport; however, the prolonged aortic occlusion produced by conventional resuscitative endovascular balloon occlusion of the aorta (REBOA) may lead to substantial morbidity. Partial REBOA (P-REBOA) may permit longer periods of occlusion by allowing some degree of distal perfusion. However, the ability of this procedure to limit exsanguination is unclear. We evaluated the impact of P-REBOA on immediate survival and ongoing hemorrhage in a highly lethal swine liver injury model. Fifteen Yorkshire-cross swine were anesthetized, instrumented, splenectomized, and subjected to rapid 10% total blood loss followed by 30% liver amputation. Coagulopathy was created through colloid hemodilution. Randomized swine received no intervention (control), P-REBOA, or complete REBOA (C-REBOA). Central mean arterial pressure (cMAP), carotid blood flow, and blood loss were recorded. Balloons remained inflated in the P-REBOA and C-REBOA groups for 90 minutes followed by graded deflation. The study ended at 180 minutes from onset of hemorrhage or death of the animal. Survival analysis was performed, and data were analyzed using repeated-measures analysis of variance with post hoc pairwise comparisons. Mean survival times in the control, P-REBOA, and C-REBOA groups were, 25 ± 21, 86 ± 40, and 163 ± 20 minutes, respectively (p < 0.001). Blood loss was greater in the P-REBOA group than the C-REBOA or control groups, but this difference was not significant (4,722 ± 224, 3,834 ± 319, 3,818 ± 37 mL, respectively, p = 0.10). P-REBOA resulted in maintenance of near-baseline carotid blood flow and cMAP, while C-REBOA generated extreme cMAP and prolonged supraphysiologic carotid blood flow. Both experimental groups experienced profound decreases in cMAP following balloon deflation. In the setting of severe ongoing hemorrhage, P-REBOA increased survival time beyond the golden hour while maintaining cMAP and carotid flow at physiologic levels.

Aero-medical Considerations in Casualty Air Evacuation (CASAEVAC)

One of the advantages of partial Resuscitative Endovascular Balloon Occlusion of the Aorta (pREBOA) compared to the original model is the mitigation of reperfusion injury. The safety and efficacy of pREBOA have not been demonstrated in the setting of aeromedical evacuation. We hypothesized that the pREBOA would result in less ischemia-reperfusion injury after altitude exposure.Twenty-four swine underwent femur fracture with hemorrhage for 20 min, followed by resuscitative endovascular balloon occlusion of the aorta (REBOA) deployment to Zone 1 and were randomized to pREBOA-PRO (Prytime Medical Devices Inc) full inflation, partial inflation, or sham inflation and then an altitude exposure of ground level or 8000 ft for 15 min. The primary endpoint was to examine if the balloon functioned at altitude. Our secondary endpoint was investigating evidence of ischemia-reperfusion by hemodynamic instability, electrolyte derangements, and acidosis. Comparisons were made by ANOVA.After deflation, the partially inflated group maintained a higher mean arterial pressure (MAP) compared to fully inflated group (P = 0.026). Full REBOA pigs were more tachycardic compared to sham pREBOA at ground (P < 0.001) and this was exacerbated at altitude (P < 0.001). Full REBOA pigs were more acidotic than sham and pREBOA at ground pigs (P = 0.0006 and P = 0.0002, respectively). Altitude increased the acidosis in full REBOA pigs, resulting in a greater base deficit (P < 0.0001), lactate (P < 0.0001), and IL-6 (P = 0.006).PREBOA resulted in less severe ischemia-reperfusion injury at both altitude and ground, while full balloon inflation at altitude exacerbated acidosis and ischemia-reperfusion injury. Efforts should therefore be made to utilize partial balloon occlusion when employing the REBOA catheter.