Resuscitative Endovascular Balloon Occlusion Of The Aorta Procedure Research Articles

An assessment of nationwide trends in emergency department (ED) resuscitative endovascular balloon occlusion of the aorta (REBOA) use – A trauma quality improvement program registry analysis

BackgroundUse of resuscitative endovascular balloon occlusion of the aorta (REBOA) for temporary hemorrhage control in severe non-compressible torso trauma remains controversial, with limited data on patient selection and outcomes. This study aims to analyze the nationwide trends of its use in the emergency department (EDs). MethodsA retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) from 2017 to 2022 was performed, focusing on REBOA placements in EDs. ResultsThe analysis included 3398 REBOA procedures. Majority patients were male (76 ​%) with a median age of 40 years (27–58) and injury severity score of 20 (20–41). The most common mechanism was collision (64 ​%), with emergency surgeries most frequently performed for pelvic trauma (14 ​%). Level 1 trauma centers performed 82 ​% of these procedures, with consistent low annual utilization (<200 facilities). Survival rates were 85 ​% at 1-h post-placement, decreasing significantly to 42 ​% by discharge. ConclusionsREBOA usage in remains limited but steady, primarily occurring at level 1 trauma center EDs. While short-term survival rates are favorable, they drop significantly by the time of discharge.

Arterial Access Complications Following Percutaneous Femoral Access in 24-Hour Resuscitative Endovascular Balloon Occlusion of the Aorta Survivors

IntroductionWith the use of resuscitative endovascular balloon occlusion of the aorta (REBOA) comes the potential for vascular access site complications (VASCs) and limb ischemic sequelae. We aimed to determine the prevalence of VASC and associated clinical and technical factors. MethodsA retrospective cohort analysis of 24-h survivors undergoing percutaneous REBOA via the femoral artery in the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute care surgery registry between Oct 2013 and Sep 2021 was performed. The primary outcome was VASC, defined as at least one of the following: hematoma, pseudoaneurysm, arteriovenous fistula, arterial stenosis, or the use of patch angioplasty for arterial closure. Associated clinical and procedural variables were examined. Data were analyzed using Fisher exact test, Mann-Whitney-U tests, and linear regression. ResultsThere were 34 (7%) cases with VASC among 485 meeting inclusion criteria. Hematoma (40%) was the most common, followed by pseudoaneurysm (26%) and patch angioplasty (21%). No differences in demographics or injury/shock severity were noted between cases with and without VASC. The use of ultrasound (US) was protective (VASC, 35% versus no VASC, 51%; P = 0.05). The VASC rate in US cases was 12/242 (5%) versus 22/240 (9.2%) without US. Arterial sheath size >7 Fr was not associated with VASC. US use increased over time (R2 = 0.94, P < 0.001) with a stable rate of VASC (R2 = 0.78, P = 0.61). VASC were associated with limb ischemia (VASC, 15% versus no VASC, 4%; P = 0.006) and arterial bypass procedures (VASC 3% versus no VASC 0%; P < 0.001) but amputation was uncommon (VASC, 3% versus no VASC, 0.4%; P = 0.07). ConclusionsPercutaneous femoral REBOA had a 7% VASC rate which was stable over time. VASC are associated with limb ischemia but need for surgical intervention and/or amputation is rare. The use of US-guided access appears to be protective against VASC and is recommended for use in all percutaneous femoral REBOA procedures.

Feasibility and Clinical Outcomes of Resuscitative Endovascular Balloon Occlusion of the Aorta in Patients with Traumatic Shock: A Single-Center 5-Year Experience.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has recently gained popularity as an adjunct to resuscitation of patients with traumatic shock. However, the effectiveness of REBOA is still debated because of inconsistent indications across centers and the lack of medical records. The purpose of this study was to investigate the effectiveness and feasibility of REBOA by analyzing clinical results from a single center. This study included 96 patients who underwent REBOA between August 2016 and September 2021 at a regional trauma center according to the center's treatment algorithm for traumatic shock. Medical records, including the time of the decision to conduct the REBOA procedure, time of operation, type of aortic occlusion, and clinical outcomes, were collected prospectively and analyzed retrospectively. Patients were classified by REBOA protocol (group 1, 2, or 3) and survival status (survivor or non-survivor) for analysis. The overall success rate of the procedure was 97.9%, and the survival rate was 32.6%. In survivors, blood pressure was higher than in non-survivors both before the REBOA procedure (p=0.002) and after aortic occlusion (p=0.03). The total aortic occlusion time was significantly shorter (p=0.001) and the proportion of partial aortic occlusion was significantly higher (p=0.014) among the survivors. The non-survivors had more acidosis (p<0.001) and higher lactate concentrations (p<0.001) than the survivors. REBOA may be a feasible bridge therapy for resuscitation of patients with traumatic shock. Prompt and accurate decision-making to perform REBOA followed by damage control surgery could improve survival rates and clinical outcomes.

87 A Low-Cost Simulator for Ultrasound-Guided Retrograde Endovascular Balloon Occlusion of the Aorta

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a technique used for obtaining emergent control of life-threatening, non-compressible thoracic, abdominal, or pelvic hemorrhage (1). This abstract will detail a low-cost, ultrasound-realistic simulator for performance of the REBOA procedure. A major hurdle to widespread implementation of the REBOA technique has been the difficulty in obtaining adequate training analogues for development of competency among physicians (2). Currently, there is a paucity of literature and few commercially available simulators for REBOA training. Commercial simulation models for REBOA include high-fidelity simulators developed by Keller et al. (2), Prytime Medical (3), and Medalus (4). A low-cost, low-fidelity simulator has been proposed by Walsh et al. (5), however it lacks ultrasound compatibility. Performance of the REBOA procedure involves several steps. First, the provider must prepare a sterile field and cannulate the femoral artery with an introducer sheath under ultrasound guidance. The REBOA device is then passed through the introducer sheath to one of three target zones. Once positioned, the REBOA balloon is inflated until occlusion is achieved (1). Our simulator is constructed from a gelatin thigh analog with silicon tubing vessels connected to a clear plastic reusable simulated aorta. To create the gelatin thigh analog, two 30-cm sections of 0.5-in diameter silicon tubing are secured within an aluminum mold and embedded into a gelatin mixture. To create the gelatin, 50g of commercially available psyllium husk powder and 120g of gelatin powder (Commercial Knox Gelatin Powder(R)) are mixed in 1L of water and refrigerated for 12 hours prior to use. One of the two 0.5-in silicon tubing segments is connected to a 40-cm length of 1-in diameter rigid clear plastic tubing, which constitutes the aortic segment of the model. The aortic segment is then connected to a length of latex tubing with an in-line unidirectional manual pressure bulb to simulate pulsatile arterial flow. The other 0.5-in tubing segment is connected to an unpressurized reservoir to simulate non-pulsatile venous flow. To test the simulator, a 30-minute simulation session was conducted among 24 current emergency medicine resident physicians. Participants were asked to describe their knowledge of and confidence performing the REBOA procedure on a 1-to-5 Likert Scale before and after the simulation session. Confidence improved after the training, with a median confidence score of 1.0 before the session and 4.0 after the session. The results were evaluated using a Mann-Whitney U test which yielded a p-value <0.0001. Regarding cost, our model can be constructed for a total cost of $24. It is ultrasound compatible, provides life-like aortic pulsatility, and maintains anatomic functional accuracy. This project details the construction of a low-cost, ultrasound-compatible simulator for training physicians in the REBOA procedure. Our simulation session and subsequent review of participant data demonstrate that such a simulation exercise yielded measurable benefits in procedural skills and medical knowledge for the participants.

Analysis of procedural performance after a pilot course on endovascular training for resuscitative endovascular balloon occlusion of the aorta.

As resuscitative endovascular balloon occlusion of the aorta (REBOA) is performed in an extremely emergent situation, achieving competent clinical practice is mandatory. Although there are several educational courses that teach the REBOA procedure, there have been no reports evaluating the impact of training on clinical practice. Therefore, this study is aimed to evaluate the effects of the course on procedural performance during resuscitation and on clinical outcomes. Patients who were managed at a regional trauma center in Dankook University Hospital from August 2016 to February 2018 were included and were grouped as precourse (August 2016-August 2017, n=9) and postcourse (September 2017-February 2018, n=9). Variables regarding injury, parameters regarding REBOA procedure, morbidity, and mortality were prospectively collected and reviewed for comparison between the groups. Demographics and REBOA variables did not differ between groups. The time required from arterial puncture to balloon inflation was significantly shortened from 9.0 to 5.0 minutes (P=0.003). There were no complications associated with REBOA after the course. Mortality did not show any statistical difference before and after the course. The endovascular training for REBOA pilot course, which uses a modified form of flipped learning, realistic simulation of ultrasound-guided catheter insertion and balloon manipulation, and competence assessment, significantly improved procedural performance during resuscitation of trauma patients.

A Guide to Femoral Arterial Access for Resuscitative Endovascular Balloon Occlusion of the Aorta

Arterial access is essential in the resuscitation of trauma and hemorrhagic shock patients and can be effectively used for rapid endovascular treatment such as resuscitative endovascular balloon occlusion of the aorta (REBOA) and interventional radiology (IVR), continuous invasive hemodynamic monitoring, and frequent blood tests. In the REBOA procedure, obtaining arterial access is the first and most critical step. Arterial access can be obtained in three ways: (1) blind/landmark technique, (2) ultrasound-guided technique or (3) surgical cutdown technique. Regardless of which technique is chosen, it is crucial to recognize external landmarks before implementing any technique. In ultrasound-guided puncture, there are two types of techniques: short-axis puncture and long-axis puncture. There are two methods for actual puncture: the single-wall puncture method and the double-wall puncture method. In cases of hemorrhagic shock, the double-wall puncture method is advantageous when it is necessary to obtain arterial access quickly and reliably. The cutdown technique is useful when the femoral artery cannot be identified through ultrasound guidance or cannot be punctured for a long time owing to puncture-induced hematoma or obesity. This technique should be used without hesitation if it is evaluated to be more rapid and reliable than an ultrasound-guided puncture.

Indication of Resuscitative Endovascular Balloon Occlusion of the Aorta in Trauma Patients

In trauma bays, resuscitation as a bridge to definitive hemorrhage control to avoid cardiac arrest is challenging.Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a resuscitation procedure for refractory hemorrhagicshock. The REBOA procedure itself is simple compared to other endovascular procedures, such as angioembolizationor stent graft placement. However, adequate REBOA implementation requires a complete understanding ofits potential risks and simulation training. We should be aware that REBOA is not a hemostatic device, but a bridge todefinitive hemorrhage control; furthermore, it is not a magical device that can improve the critical situation in traumaresuscitation. For appropriate use, we herein describe the indication of REBOA in trauma resuscitation based onexisting evidence.

Reliable and valid assessment of procedural skills in resuscitative endovascular balloon occlusion of the aorta.

Valid and reliable assessment of skills is essential for improved and evidence-based training concepts. In a recent study, we presented a novel tool to assess procedural skills in resuscitative endovascular balloon occlusion of the aorta (REBOA), REBOA-RATE, based on international expert consensus. Although expert consensus is a strong foundation, the performance of REBOA-RATE has not been explored. The study aimed to examine the reliability and validity of REBOA-RATE. This was an experimental simulation-based study. We enrolled doctors with three levels of expertise to perform two REBOA procedures in a simulated scenario of out-of-hospital cardiac arrest. Procedures were video-recorded, and videos were blinded and randomized. Three clinical experts independently rated all procedures using REBOA-RATE. Data were analyzed using Messick's framework for validity evidence, including generalizability analysis of reliability and determination of a pass/fail standard. Forty-two doctors were enrolled: 16 novices, 13 anesthesiologists, and 13 endovascular experts. They all performed two procedures, yielding 84 procedures and 252 ratings. The REBOA-RATE assessment tool showed high internal consistency (Cronbach's α = 0.95) and excellent interrater reliability (intraclass correlation coefficient, 0.97). Assessment using one rater and three procedures could ensure overall reliability suitable for high-stakes testing (G-coefficient >0.80). Mean scores (SD) for the three groups in the second procedure were as follows: novices, 32% (24%); anesthesiologists, 55% (29%); endovascular experts, 93% (4%) (p < 0.001). The pass/fail standard was set at 81%, which all experts but no novices passed. Data strongly support the reliability and validity of REBOA-RATE, which successfully discriminated between all experience levels. The REBOA-RATE assessment tool requires minimal instruction, and one rater is sufficient for reliable assessment. Together, these are strong arguments for the use of REBOA-RATE to assess REBOA skills, allowing for competency-based training and certification concepts. Diagnostic test, no or poor gold standard, level V.

Computed tomography imaging of resuscitative endovascular balloon occlusion of the aorta (REBOA): pearls and pitfalls

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is performed in patients with hemorrhagic shock who develop massive subdiaphragmatic bleeding. This procedure enables rapid and less invasive aortic blockade compared to resuscitative thoracotomy and aortic cross-clamp procedures. However, the REBOA procedure is often blindly performed in the emergency department without fluoroscopy, and the appropriateness of the procedure may be evaluated on computed tomography (CT) after REBOA. Therefore, radiologists should be familiar with the imaging features of REBOA. We present a pictorial review of the radiological findings of REBOA along with a description of the procedure, its complications, and pitfalls.

Resuscitative endovascular occlusion of the aorta (REBOA) for refractory out of hospital cardiac arrest. An Utstein-based case series

AimsOut of hospital cardiac arrest (OHCA) is still a leading cause of mortality worldwide. In recent years, resuscitative endovascular balloon occlusion of the aorta (REBOA) has been progressively studied as an adjunct to standard advanced life support (ALS) in both traumatic and non-traumatic refractory OHCA.Since January 2019, the REBOA procedure has been applied to all the patients experiencing both traumatic and non-traumatic refractory OHCA (≥15 min of cardiopulmonary resuscitation) not eligible for ECPR for clinical or logistic reasons.We aimed at describing the feasibility and effects of REBOA performed both in the Emergency Department and in the pre-hospital environment served by the local HEMS for refractory OHCA. MethodsTwenty consecutive patients experiencing refractory OHCA and in whom REBOA was attempted in 2019 and 2020 were included in the study, Utstein data and REBOA specific variables were recorded. ResultsSuccessful catheter placement was achieved in 18 out of 20 patients, 11 of these were non-traumatic OHCAs while 7 were traumatic OHCAs, the 2 failures were related to repeated arterial puncture failure.Median time between the EMS dispatch and REBOA catheter placing attempt was 46 min.An increase in etCO2 over 10 mmHg was observed after balloon inflation in 12 out of 18 patients (8/11 non-traumatic and 4/7 traumatic OHCAs), a sustained ROSC was observed in 5 patients (1 traumatic and 4 non-traumatic OHCA) that were subsequently admitted to the ICU. Four out of the 5 patients reached the criteria for brain death in the subsequent 24 h while one patient experienced another episode of refractory cardiac arrest in ICU and subsequently died. ConclusionOur data confirm the feasibility of REBOA technique as an adjunct to ALS in both the ED and prehospital phase and most of the treated patients experienced a transient ROSC after balloon inflation while 5 out of 18 experienced a sustained ROSC.However, while in the trauma setting increasing evidence suggests an improved survival when REBOA is applied to refractory OHCA, in non-traumatic OHCA this has yet to be demonstrated and large studies are needed.

Needs assessment of resuscitative endovascular balloon occlusion of the aorta (REBOA) in patients with major haemorrhage: a cross-sectional study

BackgroundResuscitative endovascular balloon occlusion of the aorta (REBOA) can be used as an adjunct treatment in traumatic abdominopelvic haemorrhage, ruptured abdominal aortic aneurysms, postpartum haemorrhage (PPH), gastrointestinal bleeding and iatrogenic...

Safe balloon inflation parameters for resuscitative endovascular balloon occlusion of the aorta.

Noncompressible hemorrhage is a leading cause of preventable death in civilian and military trauma populations. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a promising method for controlling noncompressible hemorrhage, but safe balloon inflation parameters are not well defined. Our goal was to determine the balloon inflation parameters associated with benchtop flow occlusion and aortic/balloon rupture in ex vivo human aortas and test the hypothesis that optimal balloon inflation characteristics depend on systolic pressure and subject demographics. Aortic occlusion parameters in human thoracic aortas (TAs) and abdominal aortas (AAs) from 79 tissue donors (median ± SD age, 52 ± 18 years [range, 13-75 years]; male, 52; female, 27) were recorded under 100/40, 150/40, and 200/40 mm Hg flow pressures for ER-REBOA and Coda balloons. Rupture tests were done with Coda balloons only without flow. In the TA, the average balloon inflation volumes and pressures resulting in 100/40 mm Hg flow occlusion were 11.7 ± 3.8 mL and 174 ± 65 mm Hg for the ER-REBOA, and 10.6 ± 4.3 mL and 94 ± 57 mm Hg for the Coda balloons. In the AA, these values were 6.2 ± 2.6 mL and 110 ± 47 mm Hg for the ER-REBOA, and 5.9 ± 2.2 mL and 71 ± 30 mm Hg for the Coda. The average balloon inflation parameters associated with aortic/Coda balloon rupture were 39.1 ± 6.5 mL and 1,284 ± 385 mm Hg in the TA, and 27.7 ± 7.7 mL and 1,410 ± 483 mm Hg in the AA. Age, sex, and systolic pressure all had significant effects on balloon occlusion and rupture parameters. Optimal balloon inflation parameters depend on anatomical, physiological, and demographic characteristics. Pressure-guided rather than volume-guided balloon inflation may reduce the risk of aortic rupture. These results can be used to help improve the safety of REBOA procedures and devices.

Strategies for successful implementation of resuscitative endovascular balloon occlusion of the aorta in an urban Level I trauma center.

The rationale for resuscitative endovascular balloon occlusion of the aorta (REBOA) is to control life-threatening subdiaphragmatic bleeding and facilitate resuscitation; however, incorporating this into the resuscitative practices of a trauma service remains challenging. The objective of this study is to describe the process of successful implementation of REBOA use in an academic urban Level I trauma center. All REBOA procedures from April 2014 through December 2019 were evaluated; REBOA was implemented after surgical faculty attended a required and internally developed Advanced Endovascular Strategies for Trauma Surgeons course. Success was defined by sustained early adoption rates. An institutional protocol was published, and a REBOA supply cart was placed in the emergency department with posters attached to depict technical and procedural details. A focused professional practice evaluation was utilized for the first three REBOA procedures performed by each faculty member, leading to internal privileging. Resuscitative endovascular balloon occlusion of the aorta was performed in 97 patients by nine trauma surgeons, which is 1% of the total trauma admissions during this time. Each surgeon performed a median of 12 REBOAs (interquartile range, 5-14). Blunt (77/97, 81%) or penetrating abdominopelvic injuries (15/97, 15%) comprised the main injury mechanisms; 4% were placed for other reasons (4/97), including ruptured abdominal aortic aneurysms (n = 3) and preoperatively for a surgical oncologic resection (n = 1). Overall survival was 65% (63/97) with a steady early adoption trend that resulted in participation in a Department of Defense multicenter trial. Strategies for how departments adopt new procedures require clinical guidelines, a training program focused on competence, and a hospital education and privileging process for those acquiring new skills. Therapeutic, level V.

Abstract No. 134 Placenta accreta spectrum: multidisciplinary team approach and endovascular management

To investigate the role of endovascular treatment in the management of placenta accreta spectrum (PAS) and to review the intraoperative planning and multidisciplinary team workflow This retrospective study was performed at our institution from September 2018 to July 2020 and involved a total of thirteen women prenatally diagnosed with abnormal placentation. The patients were placed in dorsal lithotomy position for urology team to insert ureteric stents. Arterial sheath was then inserted into either the radial or common femoral artery (CFA) by vascular interventional radiology (VIR) team. The neonate was then delivered immediately via hysterotomy (CS) followed by clamping of umbilical cord. In resuscitative endovascular balloon occlusion of the aorta (REBOA) cases, the catheter was inserted by the trauma team into zone III and the balloon was inflated in order to achieve bleeding control prior to embolization (UAE) and hysterectomy. Patients were transferred afterward to the intensive care unit (ICU). The radiation dose and fluoroscopy time were recorded. The estimated blood loss (EBL), operative time, hysterectomy, postoperative complications, VIR data, maternal and fetal death, and postoperative hospitalization were recorded. Hysterectomy was required in all patients with PAS. The mean operating time, radiation dose and fluoroscopy time were 328.2 min, 4374.1 mGy and 27.7 min, respectively. The median (EBL) was 3000 mL. REBOA was placed prophylactically in 3 cases. 11 cases required embolization. Gelfoam was used as the only embolization material in 5 cases. Additional embolization material was required in 6 patients. Right radial (2 cases), left radial (6) and right common femoral (5) arteries were used as an access without any reported complications. No maternal mortality was reported. Massive blood transfusion was required in 5 cases. One woman developed respiratory distress after massive transfusion and required extracorporeal membrane oxygenation (ECMO). Hysterectomy was complicated by urinary bladder injury in 10 patients. Average hospital stays postoperatively including ICU stay was 7 days. A total of 3 fetal demise were reported. This case series delineates the important role of UAE in controlling PAS related bleeding. We believe that best results can be achieved with a multidisciplinary planning with early radiological consultation. This preliminary result should stimulate other studies to demonstrate the efficacy and safety of UAE and REBOA procedures and to best identify patients who will benefit from this approach.

Practical tips for performing resuscitative endovascular balloon occlusion of the aorta

Background: Hemorrhage is the leading cause of death in trauma settings. Non-compressible torso hemorrhage, which is caused by abdominopelvic and thoracic injuries, is an important cause of subsequent organ dysfunction and poor outcomes in multiple trauma patients. The management of hemodynamically unstable patients with non-compressible torso hemorrhage has changed, and the concept of damage control resuscitation has been developed in the last decades. Currently, resuscitative endovascular balloon occlusion of the aorta (REBOA) as a method of temporary stabilization is the modern evolution of bleeding control, and it is in the middle of a paradigm shift as a treatment for non-compressible torso hemorrhage. Despite its effectiveness in patients with hemorrhagic shock, the application of REBOA remains limited because of lack of experience and troubleshooting guidelines. Objectives: The aim of study was to provide useful tips for the implementing a step-by-step procedure for REBOA in various hospital settings and capabilities. Methods: We introduced REBOA procedures using a REBOA-customized 7 Fr balloon catheter through the animation models or radiography from preparation to access, catheter management, and device removal after procedure completed. Results: We have described REBOA procedures as follows: identification of the common femoral artery, arterial access for placement of a guidewire, precautions during a sheath insertion, guidewire and balloon positioning in the aorta, occlusion zones and adjustment of balloon location, REBOA strategy for extending the occlusion time, balloon deflation and removal, sheath removal, and medical records. Conclusion: We believe that the practical tips mentioned in this article will help in performing the REBOA procedure systematically and developing an effective REBOA framework.

Positioning of Resuscitative Endovascular Balloon Occlusion of the Aorta Catheter: A Case of an Elderly Patient with Concomitant Chest and Pelvic Injury after Blunt Trauma

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been increasingly used in recent years as a resuscitative adjunct for trauma patients with life-threatening non-compressible torso hemorrhage. By blocking the aorta temporarily with an inflated balloon, REBOA preserves cerebral and coronary perfusion while diminishing exsanguination below the balloon, thereby providing time for resuscitation and definitive bleeding control. When determining the occlusion zone during the REBOA procedure, factors such tortuosity of the aorta, co-occurring minor chest injuries, and the severity of shock must be considered, as well as the main injury site. This paper describes a case of high Zone I REBOA in an elderly patient with a tortuous aorta who had concomitant injuries of the chest and pelvis.

Ultrasound-guided versus blind vascular access followed by REBOA on board of a medical helicopter in a hemorrhagic ovine model

BackgroundThe aim of this study is to evaluate the feasibility of en-route resuscitative endovascular balloon occlusion of the aorta (REBOA) on board of a helicopter. MethodsSix sedated male sheep (weighing 42–54 kg) underwent a controlled hemorrhage until the systolic blood pressure (BP) dropped to <90 mmHg, and were placed into a low capacity Eurocopter AS-350 (France). During the 30-minutes normal flight, every animal underwent blind (left side) and ultrasound-guided (US) (right side) vascular access (VA) to the femoral artery followed by REBOA: the first catheter (Rescue balloon, Japan) – into Zone I, the second one (MIT, Russia) – Zone III. In case of blind VA failure, an alternate US-puncture was attempted. Six experienced flight anesthetists were enrolled into the study. Vascular access and REBOA catheter placement (confirmed by X-Ray later) success rate and timing were recorded. ResultsAmong six blind punctures one was successful, 2/6 – were into the vein, 3/6 – completely failed and switched to US-punctures (making total number of US-punctures nine). Eight out of nine US-punctures were successful. However, correct wire insertion and sheath placement was performed in 1/6 animal in the ‘blind’ group and only in 6/9 animals in the ‘US’ group. It took a median of 65 seconds (range 5–260) for US-puncture and a median of 4 minutes to get the sheath in. Among the 9 VAs, there were 2 REBOA failures (1 ruptured balloon [MIT] and 1 mistaken vena cava placement primarily recognized by a sudden drop of BP and later confirmed by X-Ray). Five out of seven balloons were placed in a desired intra-aortic position: 4/5 in Zone I and 1/2 – in Zone III. A median time for a successful REBOA procedure was 5.0 (range 2.5–10.0) minutes (1 min after sheath placement). ConclusionOur study demonstrates the potential feasibility of the en-route REBOA which can be performed within 5 minutes. Ultrasound-guidance is critically important to achieve en-route VA.

A Low-Cost Insertion Trainer for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA).

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emergency procedure designed to treat non-compressible torso hemorrhage. Because this is a high-acuity low-occurrence event, it is difficult to train providers on the procedure and difficult for trained providers to stay proficient. Our primary objective was to develop a low-cost, high-fidelity teaching model to increase emergency medicine (EM) resident knowledge, confidence, and proficiency in performing REBOA. We utilized readily available materials to allow for ease of replication and cost-effectiveness. The aorta was simulated by a bicycle tire inner tube, and the femoral artery was simulated by natural rubber tubing. Once connected, these simulated vascular structures were threaded through a plastic torso mold and filled with simulated blood. Participants then performed the REBOA procedure with very little time required for reset between participants. After completing the training using our model, participants completed a survey rating aspects of the session on a five-point Likert scale. Participants included 21 EM residents from all levels of training. Participants rated the fidelity of the REBOA insertion trainer very highly (mean = 4.05, SD 0.67) and felt that the training was overall very useful (mean = 4.29, SD 0.56). Comments regarding the model were universally positive. We present a novel low-cost REBOA task trainer that is easy to build, reusable, and portable, and can be utilized either in a hospital or austere training environment.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) : Current aspects of material, indications and limits: an overview

Hintergrund„Resuscitative endovascular balloon occlusion of the aorta“ (REBOA) stellt ein endovaskuläres Verfahren dar, bei dem ein Blockballon in die Aorta eingeführt wird, um eine distal des Ballons gelegene Blutung zu verringern und gleichzeitig die kardiale und zerebrale Oxygenierung zu verbessern.Ziel der ArbeitVorstellung der REBOA-Technik, der möglichen Indikationen, der benötigen Materialien und der möglichen Komplikationen des Verfahrens.Material und MethodenNichtsystematischer Übersichtsartikel über die aktuelle Literatur.ErgebnisseREBOA stellt gerade bei traumatisch bedingten Blutungen und rupturierten Aortenaneurysmen ein mögliches additives Verfahren zur hämodynamischen Stabilisierung dar. Die Komplikationsrate des Verfahrens liegt bei ungefähr 5 %, wobei Zugangskomplikationen im Vordergrund stehen, jedoch auch letale Komplikationen möglich sind.DiskussionEine aortale Ballonblockade wird bei der Versorgung rupturierter Aortenaneurysmen standardmäßig eingesetzt. Es gibt wachsende Evidenz, dass REBOA bei der Versorgung polytraumatisierter Patienten mit einem hämorrhagischen Schock aufgrund einer abdominellen oder viszeralen Blutung eine vergleichsweise minimal-invasive Alternative zur offen chirurgischen Aortenklemmung mittels Thorakotomie darstellt. Mit der Entwicklung neuer Ballonkatheter, die ohne Führungsdraht und mit geringeren Schleusendurchmessern auskommen, wird auch ein Einsatz bei anderen Krankheitsbildern wie postoperativen abdominellen Nachblutungen, gynäkologischen Blutungen oder als additives Verfahren bei der kardiopulmonalen Reanimation diskutiert.

Abstract 28: Feasibility and Safety of Pre-Hospital Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in Non-Traumatic Out-Of-Hospital Cardiac Arrest

Introduction: The proportion of patients surviving to hospital discharge after out of hospital cardiac arrest (OHCA) is low and any measure that may improve circulation to vital organs during cardiopulmonary resuscitation (CPR) is beneficial. The use of resuscitative endovascular balloon occlusion of the aorta (REBOA) will redistribute cardiac output to the organs proximal to the occlusion. Animal studies supports that aortic occlusion during CPR might benefit patients suffering from OHCA, but human data are scarce. Methods: We performed an observational study at the helicopter emergency medical service in Trondheim (Norway) to assess the feasibility and safety of establishing REBOA in OHCA patients. The femoral artery was identified by ultrasound and a REBOA catheter was placed in the thoracic aorta. All patients received advanced cardiac life support (ACLS) during the procedure. REBOA eligibility, procedural success and time intervals were registered. A safety monitoring program was conducted to ensure that the procedure did not interfere with the quality of ACLS. Results: REBOA was initiated in ten of 98 OHCA patients. The mean age was 63 years (55-71) and 7 were male. The REBOA procedure was successful in all cases (100%), with 80% success rate on first cannulation attempt. Mean REBOA procedural time was 11,7 minutes (8-16, SD 3,2). End-tidal CO2 (EtCO2) increased by a mean of 1.9 kPa at 60 seconds after inflation compared to baseline (p &lt; 0.001). Six of 10 patients (60%) achieved return of spontaneous circulation, 3 (30%) was admitted to hospital. 30-day survival was 10%. The mean width of the femoral artery and vein during CPR was 5,9 mm (3,6 - 7,4, SD 1,2) and 9,4 mm (5,0 - 12,9, SD 2,9), respectively. The safety monitoring group identified no negative influence on the ACLS quality. Conclusions: This is the first study to assess the pre-hospital use of REBOA in patients with non-traumatic cardiac arrest. The REBOA procedure does not interfere with the quality of the ACLS. REBOA is a feasible adjunct treatment in OHCA. The significant increase in EtCO2 after occlusion suggests improved organ circulation during CPR.