Resuscitative Balloon Occlusion Of The Aorta Research Articles

MILD THERAPEUTIC HYPOTHERMIA REDUCES ISCHEMIA-REPERFUSION INJURY AFTER ZONE 1 REBOA IN A SWINE HEMORRHAGIC SHOCK MODEL.

Background: Resuscitative balloon occlusion of the aorta (REBOA) is an endovascular hemostasis method used for the management of traumatic abdominal and pelvic hemorrhages. However, REBOA-associated ischemia-reperfusion injury complication limits its blocking time. We hypothesized that mild therapeutic hypothermia would relieve ischemia-reperfusion injury caused by prolonged zone 1 REBOA. Methods: Ten pigs were anesthetized, intubated, and subsequently struck with the experimental sliding-chamber ballistic gun to inflict liver damage. Animals were randomized to hypothermia (60 min of zone 1 REBOA with external cooling for 180 min, n = 5) or control (60 min of zone 1 REBOA with no external cooling, n = 5). Physiological and laboratory parameters were monitored and assessed. Distal organs were obtained for histologic analysis. Results: At 180 min, compared with the control, the hypothermia animals exhibited significantly increased pH and significantly reduced lactate, hemoglobin, and hematocrit (all P < 0.05). The change of lactate from 0 to 180 min in hypothermia animals was less than that in the control ( P = 0.02). The total bleeding in the control group was significantly less than the hypothermia ( P < 0.01). In the hypothermia group, prothrombin time at 120 and 180 min was significantly longer than that at baseline (all P < 0.05). Compared with the control, animals in the hypothermia group showed slighter pathological injury of the distal organs and significantly lower overall injury score (all P < 0.05). Conclusions: Mild therapeutic hypothermia during prolonged zone 1 REBOA offered extraordinary distal organ preservation and decreased metabolic acidosis.

Trends in Isolated Pelvic Fracture and 30-Day Survival during a Recent 15-Year Period: A Nationwide Study of the Japan Trauma Data Bank.

The epidemiology and treatment of isolated pelvic fracture in Japan are not well understood. This study evaluated epidemiological trends in isolated pelvic trauma and in-hospital survival rates during a recent 15-year period. This retrospective cohort study analyzed data from the Japan Trauma Data Bank for 2004-2018. Patients of any age with isolated pelvic fracture were grouped according to time period, as follows: 2004-2008 (Phase 1), 2009-2013 (Phase 2), and 2014-2018 (Phase 3). The main outcome was 30-day in-hospital survival rate. The data were analyzed using the chi-square, Kruskal-Wallis, and Mantel-Haenszel trend tests. We analyzed change in the main outcome over time in multiple logistic regression analysis fitted with a generalized estimating equation, accounting for within-cluster association. In total, 5,348 isolated pelvic fractures were identified during the study period. There was no significant between-phase difference in proportions of patients who underwent resuscitative balloon occlusion of the aorta or external fixation. The proportion of patients who underwent transcatheter arterial embolization significantly increased with time (p=0.003), as did the survival rate (Phase 1, 77%; Phase 2, 86%; and Phase 3, 91%; p<0.001). The 30-day in-hospital mortality rate was significantly lower in Phase 3 than in Phase 1 and Phase 2, even after adjustment for hospital clustering and other confounders (p<0.01). The 30-day in-hospital survival rate after isolated pelvic fracture improved over a 15-year period in Japan.

Zone-dependent acute circulatory changes in abdominal organs and extremities after resuscitative balloon occlusion of the aorta (REBOA): an experimental model

IntroductionResuscitative endovascular balloon occlusion of the aorta (REBOA) may be used in severely injured patients with uncontrollable bleeding. However, zone-dependent effects of REBOA are rarely described. We compared the short-term zone- and organ-specific microcirculatory changes in abdominal organs and the extremity during occlusion of the aorta in a standardized porcine model.MethodsMale pigs were placed under general anesthesia, for median laparotomy to expose intra-abdominal organs. REBOA placement occurred in Zone 1 (from origin left subclavian artery to celiac trunk), Zone 2 (between the coeliac trunk and most caudal renal artery) and Zone 3 (distal most caudal renal artery to aortic bifurcation). Local microcirculation of the intra-abdominal organs were measured at the stomach, colon, small intestine, liver, and kidneys. Furthermore, the right medial vastus muscle was included for assessment. Microcirculation was measured using oxygen-to-see device (arbitrary units, A.U). Invasive blood pressure measurements were recorded in the carotid and femoral artery (ipsilateral). Ischemia/Reperfusion (I/R)-time was 10 min with complete occlusion.ResultsAt baseline, microcirculation of intra-abdominal organs differed significantly (p < 0.001), the highest flow was in the kidneys (208.3 ± 32.9 A.U), followed by the colon (205.7 ± 36.2 A.U.). At occlusion in Zone 1, all truncal organs showed significant decreases (p < 0.001) in microcirculation, by 75% at the colon, and 44% at the stomach. Flow-rate changes at the extremities were non-significant (n.s). During occlusion in Zone 2, a significant decrease (p < 0.001) in microcirculation was observed at the colon (− 78%), small intestine (− 53%) and kidney (− 65%). The microcirculatory changes at the extremity were n.s. During occlusion in Zone 3, truncal and extremity microcirculatory changes were n.s.ConclusionAll abdominal organs showed significant changes in microcirculation during REBOA. The intra-abdominal organs react differently to the same occlusion, whereas local microcirculation in extremities appeared to be unaffected by short-time REBOA, regardless of the zone of occlusion.

Damage control resuscitation: REBOA as the new fourth pillar.

Damage Control Resuscitation (DCR) seeks to combat metabolic decompensation of the severely injured trauma patient by battling on three major fronts: Permissive Hypotension, Hemostatic Resuscitation, and Damage Control Surgery (DCS). The aim of this article is to perform a review of the history of DCR/DCS and to propose a new paradigm that has emerged from the recent advancements in endovascular technology: The Resuscitative Balloon Occlusion of the Aorta (REBOA). Thanks to the advances in technology, a bridge has been created between Pre-hospital Management and the Control of Bleeding described in Stage I of DCS which is the inclusion and placement of a REBOA. We have been able to show that REBOA is not only a tool that aids in the control of hemorrhage, it is also a vital tool in the hemodynamic resuscitation of a severely injured blunt and/or penetrating trauma patient. That is why we propose a new paradigm “The Fourth Pillar”: Permissive Hypotension, Hemostatic Resuscitation, Damage Control Surgery and REBOA.

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

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. 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). 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. 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.

REBOA - new era of bleeding control, literature review.

It is extremely difficult to provide non-compressible torso hemorrhage control particularly in trauma setting. A vast majority of cases present inability of successful exsanguination arrest, leading to cardiovascular collapse, myocardial and cerebral hypoperfusion and death eventually. The only possible treatment for these patients is prompt bleeding control, either open or endovascular. Aortic occlusion seems to be the most rapid and convenient way to restrain blood loss and possibly increase survival. However, it is not proven yet. Traditional aortic occlusion for trauma consisted of supradiaphragmatic thoracic aorta cross-clamping through resuscitative thoracotomy (RT). This complicated and devastating procedure triggered the necessity to work on a simpler, less invasive resuscitation bridge which can be implemented in emergency departments or even in prehospital setting. Resuscitative balloon occlusion of the aorta (REBOA) provides a novel method of hemorrhagic shock stabilization in bleeding below the diaphragm. The mechanism lies in improving myocardial and cerebral perfusion and ceasing major bleeding itself. This method together with invasive endovascular and surgical procedures creates a new approach of choice for trauma patients. It is called Endovascular Hybrid Trauma and Resuscitation Management (EVTM) and introduces this concept to modern clinical practice. Through a detailed review, this article aims to introduce REBOA procedure to a broader recipient and present REBOA details, benefits and limitations.

Use of resuscitative balloon occlusion of the aorta in a swine model of prolonged cardiac arrest

AimWe examined the use of a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) catheter during cardiopulmonary resuscitation (CPR) after cardiac arrest (CA) to assess its effect on haemodynamics such as coronary perfusion pressure (CPP), common carotid artery blood flow (CCA-flow) and end-tidal CO2 (PetCO2) which are associated with increased return of spontaneous circulation (ROSC). MethodsSix male swine were instrumented to measure CPP, CCA-Flow, and PetCO2. A 7Fr REBOA was advanced into zone-1 of the aorta through the femoral artery. Ventricular fibrillation was induced and untreated for 8 min. CPR (manual then mechanical) was initiated for 24 min. Continuous infusion of adrenaline (epinephrine) was started at minute-4 of CPR. The REBOA balloon was inflated at minute-16 for 3 min and then deflated/inflated every 3 min for 3 cycles. Animals were defibrillated up to 6 times after the final cycle. Animals achieving ROSC were monitored for 25 min. ResultsData showed significant differences between balloon deflation and inflation periods for CPP, CCA-Flow, and PetCO2 (p < 0.0001) with an average difference (SD) of 13.7 (2.28) mmHg, 15.5 (14.12) mL min−1 and −4 (2.76) mmHg respectively. Three animals achieved ROSC and had significantly higher mean CPP (54 vs. 18 mmHg), CCA-Flow (262 vs. 135 mL min−1) and PetCO2 (16 vs. 8 mmHg) (p < 0.0001) throughout inflation periods than No-ROSC animals. Aortic histology did not reveal any significant changes produced by balloon inflation. ConclusionREBOA significantly increased CPP and CCA-Flow in this model of prolonged CA. These increases may contribute to the ability to achieve ROSC.

The effect of hemorrhage control adjuncts on outcome in severe pelvic fracture: A multi-institutional study.

Hemodynamically unstable patients with severe pelvic fracture are a significant challenge to trauma surgeons and have high mortality. Significant variability across institutions in hemorrhage control adjuncts used to quell pelvic bleeding has been demonstrated. However, the effect of these methods on time to definitive bleeding control, type of resuscitation given, and outcomes remains unknown. We sought to elucidate those effects. This was a multicenter retrospective review of severe pelvic fracture patients in shock between 2011 and 2016. Shock was defined as systolic blood pressure less than 90 mm Hg, heart rate greater than 120 beats per minute, or base deficit less than -5. Definitive bleeding control was defined as time to surgical control in the operating room or embolization by interventional radiology. Significance level was at p less than 0.05. A total of 279 severe pelvic fracture patients with shock on admission from 12 trauma centers were included. The cohort was primarily male (62%) with median (interquartile range) age of 40 years (28-54 years), Injury Severity Score of 38 (29-50), and Glasgow Coma Scale score of 13 (3-15). Overall mortality was 32%. The most common adjunct used was pelvic binder (50%) followed by no adjunct (30.5%); least common was resuscitative balloon occlusion of the aorta (REBOA) (2.5%). Preperitoneal packing alone and REBOA alone/with other adjunct(s) resulted in the fastest times to operating room/interventional radiology but also had the highest blood utilization and mortality rates. Resuscitative balloon occlusion of the aorta was most often used along with pelvic binder (6 of 13; 46%). Marked variation in management of severe pelvic fracture patients in shock indicates the need for a standardized approach to maximize outcomes and minimize transfusion requirements. The use of preperitoneal packing and/or REBOA yielded fastest times to definitive bleeding control. However, REBOA continues to be infrequently used. Future prospective analysis of this combination needs further validation in patients with severe pelvic hemorrhage. Therapeutic study, level IV.

Abstract 359: Use of Resuscitative Balloon Occlusion of the Aorta in a Swine Model of Prolonged Cardiac Arrest

Introduction: Despite advancements in CPR, survival to hospital discharge remains low for in- and out-of-hospital cardiac arrest (CA). Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is an evolving tool for temporary control of non-compressible truncal hemorrhage. In this investigation, we examined whether REBOA use during non-traumatic CA would produce favorable hemodynamic changes associated with return of spontaneous circulation (ROSC). Hypothesis: We hypothesized that REBOA use during CPR would result in higher coronary perfusion pressure (CPP) and common carotid artery blood flow (C-Flow) in a prolonged model of CA. Methods: Six male swine were anesthetized and instrumented to measure and monitor CPP, and C-Flow. A REBOA catheter (Prytime Medical Devices) was advanced into zone 1 of the aorta through the femoral artery. Ventricular fibrillation was electrically induced and untreated for 8 minutes. CPR was started manually at minute-8, then changed to mechanical CPR at minute-12 for the duration of the experiment. Continuous infusion of epinephrine (0.0024mg/kg/min) was simultaneously started with mechanical CPR. The REBOA balloon was inflated beginning at minute-16 for 3 minutes then deflated for 3 minutes for a total of 6 cycles. At the end of the final cycle (REBOA inflation), CPR was stopped (after 33 minutes of total arrest time) and animals were defibrillated using 200 J biphasic shocks, repeated up to 6 times. Animals achieving ROSC were monitored for an additional 25 minutes. Results: Analysis using repeated measure ANOVA showed significant differences between balloon deflation and inflation periods for CPP (p&lt;0.0001) with mean difference(SD) of 14(2.6) (Range: 17 to 42) mmHg and for C-Flow (p&lt;0.0001) with mean difference(SD) 16(23) (Range: 115 to 269) mL/min across all animals. Three animals achieved ROSC and had significantly higher CPP (48 vs. 24mmHg, p&lt;0.0001) and C-Flow (249 vs. 168mL/min) by t-test (p&lt;0.0001). Post-mortem aortic histology did not reveal any changes produced by balloon inflation. Conclusion: REBOA significantly increased CPP and C-Flow in this swine model of prolonged CA. These increases may have contributed to the ability to achieve ROSC after greater than 30 min of CA.

Abstract 357: Resuscitative Balloon Occlusion of the Aorta in Non-Traumatic out of Hospital Cardiac Arrest - Evaluation of an Educational Program

Background: Out of hospital cardiac arrest (OHCA) is a critical incident with a high mortality rate. Augmentation of the circulation and hence oxygen delivery to vital organs such as the brain and heart during cardio-pulmonal resuscitation (CPR) might be beneficial. Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) redistribute cardiac output to the organs proximal to the occlusion. Preclinical data supports that patients in non-traumatic CA might benefit from REBOA placed in the thoracic level during CPR. Methods: We developed a REBOA team-based training program involving the physicians and prehospital emergency medical service (P-EMS) operators working on the National Air Ambulance helicopter base in Trondheim, Norway. The program consists of a four-step approach to educate, train and implement the REBOA procedure in a simulated prehospital setting. An objective structured assessment of prehospital REBOA application (OSAPRA) scoring chart and a special designed training dummy was made for this study. Results: 7 physicians and 3 P-EMS operators participated. The time needed to perform the REBOA procedure was 8,5 min (range; 6,3 - 12,7). The corresponding time from arrival at scene to balloon inflation was 12,0 min (range; 8,8 - 15). The total objective assessment scores of the candidates’ competency was 41,8 points out of 48 (range; 39 - 43,5). The advanced cardiovascular life support (ACLS) remained at standard quality, regardless of the simultaneous REBOA procedure. Conclusions: This four-step approach to educate, train and implement the REBOA technique to a prehospital working team is feasible and provides adequate competence. In a simulated setting the procedure does not add significant time to the prehospital resuscitation time nor does the procedure interfere with the quality of the ACLS.

Abstract 310: Retrograde Hemorrhage and Ischemic Injury after REBOA in a Porcine Model of Uncontrolled Aortic Injury

Introduction: Resuscitative Balloon Occlusion of the Aorta (REBOA) has gained popularity as a less invasive approach to temporize traumatic noncompressible hemorrhage, yet mortality remains over 70%. Although associated injuries may account for some deaths, contributions from ischemia and ongoing retrograde bleeding are also likely, with REBOA occlusion frequently in Zone 1 (descending thoracic aorta) and often greater than 20 minutes. This study examined retrograde blood loss and ischemic injury after REBOA in a porcine model of aortic injury. Methods: Six anesthetized swine with invasive hemodynamic and neurophysiologic monitoring (Muscle Evoked Potentials and Somatosensory Evoked Potentials) underwent 8 Fr femoral access and Zone 1 positioning of a REBOA balloon prior to aortic injury. The thoracic aorta was injured with a 22 Fr dilator, followed by aortography and immediate REBOA inflation proximal to the injury. Profound deterioration of the first three animals with one hour of REBOA prompted the next three animals to undergo only 30 minutes of REBOA. Blood loss was recovered with a cellsaver. Animals underwent permanent stent repair of the aortic injury and resuscitation with the intent to recover. Results: Despite proximal hemorrhage control documented angiographically, blood loss from retrograde bleeding was substantial averaging 3.7 L and 3.5 L for the 30- and 60-minute groups, respectively. After balloon inflation, mean pressure fell an average of 62 mmHg within 20 minutes (p &lt; 0.001), while cardiac output decreased 20-40%. In the lower extremities, Neuromonitoring revealed ischemic loss of motor signals at a mean of 27 minutes. Even after resuscitation with blood, bicarbonate, saline and pressors, all six animals arrested shortly after balloon deflation, amidst falling bicarbonate (p less than 0.001), and rising lactate (p less than 0.01) relative to baseline. Conclusions: Retrograde hemorrhage is an underappreciated event during REBOA control of aortic injuries, that may contribute to spinal cord ischemia, tissue ischemia and death. This study suggests that improved outcomes for noncompressible hemorrhage will require balance of competing goals of hemorrhage control and distal perfusion.

Feasibility and Proposed Training Pathway for Austere Application of Resuscitative Balloon Occlusion of the Aorta

Noncompressible junctional and truncal hemorrhage remains a significant cause of combat casualty death. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an effective treatment for many junctional and noncompressible hemorrhages. The current hospital standard for time of placement of REBOA is approximately 6 minutes. This study examined the training process and the ability of nonsurgical physicians to apply REBOA therapy in an austere field environment.This was a skill acquisition and feasibility study. The participants for this experiment were two board-certified military emergency medicine physicians with no prior endovascular surgery exposure. Both providers attended two nationally recognized REBOA courses for training. A perfused cadaver model was developed for the study. Each provider then performed REBOA during different phases of prehospital care. Time points were recorded for each procedure.There were 28 REBOA catheter placement attempts in 14 perfused cadaver models in the nonhospital setting: eight placements in a field setting, eight placements in a static ambulance, four placements in a moving ambulance, and eight placements inflight on a UH-60 aircraft. No statistically significant differences with regard to balloon inflation time were found between the two providers, the side where the catheter was placed, or individual cadaver models. Successful placement was accomplished in 85.7% of the models. Percutaneous access was successful 53.6% of the time. The overall average time for REBOA placement was 543 seconds (i.e., approximately 9 minutes; median, 439 seconds; 95% confidence interval [CI], 429-657) and the average placement time for percutaneous catheters was 376 seconds (i.e., 6.3 minutes; 95% CI, 311-44 seconds) versus those requiring vascular cutdown (821 seconds; 95% CI, 655-986). Importantly, the time from the decision to convert to open cutdown until REBOA placement was 455 seconds (95% CI, 285-625).This study demonstrated that, with proper training, nonsurgical providers can properly place REBOA catheters in austere prehospital settings at speeds.

Anatomical landmarks for safely implementing resuscitative balloon occlusion of the aorta (REBOA) in zone 1 without fluoroscopy

BackgroundResuscitative balloon occlusion of the aorta (REBOA) can maintain hemodynamic stability during hemorrhagic shock after a following torso injury, although inappropriate balloon placement may induce brain or visceral organ ischemia. External anatomical landmarks [the suprasternal notch (SSN) and xiphoid process (Xi)] are empirically used to implement REBOA in zone 1. We aimed to confirm if these landmarks were useful for determining a balloon catheter length for safe implementation of REBOA in zone 1 without using fluoroscopy.MethodWe selected 25 successive adult blunt trauma cases requiring contrast-enhanced chest/abdominal computed tomography (CT) treated at our emergency department (in an urban area of Kyoto city, Japan) between October 1, 2016 and January 31, 2017. We retrospectively evaluated anonymized CT images. We used three-dimensional multiplanar reconstructions to measure the length along the aorta’s central axis, from the bilateral common femoral arteries (FA) to the celiac trunk (CeT) (FA–CeT) and to the origin of the left subclavian artery (LSCA) (FA–LSCA). Volume-rendering reconstruction images were used to measure the external distance from common FAs to SSN (FA–SSN) and to Xi (FA–Xi).ResultFA–LSCA was significantly longer than FA–SSN. FA–CeT was significantly shorter than FA–Xi.DiscussionBased on these results, the REBOA balloon catheter should be shorter than FA–SSN, and longer than FA–Xi to avoid placement outside zone 1. The advantages of this method are that it can rapidly and easily predict a safe balloon catheter length, and it reflects each patient’s individual torso height.ConclusionTo safely implement REBOA, the balloon catheter length should be shorter than FA–SSN and longer than FA–Xi. We believe that these anatomical landmarks are good references for safe implementation of REBOA in zone 1 without radiographic guidance.

Pelvic fracture pattern predicts the need for hemorrhage control intervention-Results of an AAST multi-institutional study.

Early identification of patients with pelvic fractures at risk of severe bleeding requiring intervention is critical. We performed a multi-institutional study to test our hypothesis that pelvic fracture patterns predict the need for a pelvic hemorrhage control intervention. This prospective, observational, multicenter study enrolled patients with pelvic fracture due to blunt trauma. Inclusion criteria included shock on admission (systolic blood pressure <90 mm Hg or heart rate >120 beats/min and base deficit >5, and the ability to review pelvic imaging). Demographic data, open pelvic fracture, blood transfusion, pelvic hemorrhage control intervention (angioembolization, external fixator, pelvic packing, and/or REBOA [resuscitative balloon occlusion of the aorta]), and mortality were recorded. Pelvic fracture pattern was classified according to Young-Burgess in a blinded fashion. Predictors of pelvic hemorrhage control intervention and mortality were analyzed by univariate and multivariate regression analyses. A total of 163 patients presenting in shock were enrolled from 11 Level I trauma centers. The most common pelvic fracture pattern was lateral compression I, followed by lateral compression I, and vertical shear. Of the 12 patients with an anterior-posterior compression III fracture, 10 (83%) required a pelvic hemorrhage control intervention. Factors associated with the need for pelvic fracture hemorrhage control intervention on univariate analysis included vertical shear pelvic fracture pattern, increasing age, and transfusion of blood products. Anterior-posterior compression III fracture patterns and open pelvic fracture predicted the need for pelvic hemorrhage control intervention on multivariate analysis. Overall in-hospital mortality for patients admitted in shock with pelvic fracture was 30% and did not differ based on pelvic fracture pattern on multivariate analysis. Blunt trauma patients admitted in shock with anterior-posterior compression III fracture patterns or patients with open pelvic fracture are at greatest risk of bleeding requiring pelvic hemorrhage control intervention. Prognostic/epidemiologic study, level III.

Partial resuscitative balloon occlusion of the aorta (P-REBOA): Clinical technique and rationale.

Partial resuscitative balloon occlusion of the aorta (P-REBOA): Clinical technique and rationale.

Small Adjustments, Big Effects: Physiologic Considerations for the Clinical Implementation of Next Generation Resuscitative Balloon Occlusion of the Aorta (REBOA)

Small Adjustments, Big Effects: Physiologic Considerations for the Clinical Implementation of Next Generation Resuscitative Balloon Occlusion of the Aorta (REBOA)

The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: Data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA).

Aortic occlusion (AO) for resuscitation in traumatic shock remains controversial. Resuscitative endovascular balloon occlusion of the aorta (REBOA) offers an emerging alternative. The American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery registry prospectively identified trauma patients requiring AO from eight ACS Level 1 centers. Presentation, intervention, and outcome variables were collected and analyzed to compare REBOA and open AO. From November 2013 to February 2015, 114 AO patients were captured (REBOA, 46; open AO, 68); 80.7% were male, and 62.3% were blunt injured. Aortic occlusion occurred in the emergency department (73.7%) or the operating room (26.3%). Hemodynamic improvement after AO was observed in 62.3% [REBOA, 67.4%; open OA, 61.8%); 36.0% achieving stability (systolic blood pressure consistently >90 mm Hg, >5 minutes); REBOA, 22 of 46 (47.8%); open OA, 19 of 68 (27.9%); p =0.014]. Resuscitative endovascular balloon occlusion of the aorta (REBOA) access was femoral cut-down (50%); US guided (10.9%) and percutaneous without imaging (28.3%). Deployment was achieved in Zones I (78.6%), II (2.4%), and III (19.0%). A second AO attempt was required in 9.6% [REBOA, 2 of 46 (4.3%); open OA, 9 of 68 (13.2%)]. Complications of REBOA were uncommon (pseudoaneurysm, 2.1%; embolism, 4.3%; limb ischemia, 0%). There was no difference in time to successful AO between REBOA and open procedures (REBOA, 6.6 ± 5.6 minutes; open OA, 7.2 ± 15.1; p = 0.842). Overall survival was 21.1% (24 of 114), with no significant difference between REBOA and open AO with regard to mortality [REBOA, 28.2% (13 of 46); open OA, 16.1% (11 of 68); p = 0.120]. Resuscitative endovascular balloon occlusion of the aorta has emerged as a viable alternative to open AO in centers that have developed this capability. Further maturation of the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database is required to better elucidate optimal indications and outcomes. Therapeutic/care management study, level IV.

Resuscitative Endovascular Balloon Occlusion of the Aorta in a Trauma Patient with Hypovolemic Shock

Hemorrhagic shock is one of the most common causes of death in patients with multiple trauma and therefore rapid control of bleeding is the main strategy to save these patients. Resuscitative balloon occlusion of the aorta (REBOA) has been applied in several trauma cases and because of the effectiveness of this procedure it has been adopted in the trauma field. Herein, we report the first successful case of REBOA in Korea performed on a 46-year-old man with hemorrhagic shock after a fall from a height of 14-stories. The patient visited our hospital emergency room with hypovolemic shock, we performed Resuscitative Endovascular Balloon Occlusion of the Aorta under bed side blind technique. His vital sign was stabilized after procedure, then we could performed endovascular bleeding control. The patient was discharged on his 33rd in-hospital day without invasive procedure and major scar.