Resuscitative endovascular balloon occlusion of the aorta or resuscitative thoracotomy with aortic clamping for noncompressible torso hemorrhage

Abstract Introduction This study aims to provide an updated review on in-hospital mortality rates in patients who underwent Resuscitative Endovascular Balloon Occlusion of Aorta (REBOA) versus Resuscitative thoracotomy (RT) or standard care without REBOA, to identify potential indicators of REBOA use and complications. Method Cochrane and PRISMA guidelines were used to perform the study. A literature search was done from 01 January 2005 to 30 June 2020 using EMBASE, MEDLINE and COCHRANE databases. Meta-analysis was conducted using a random effects model and the DerSimonian and Laird estimation method. Results 25 studies were included in this study. The odds of in-hospital mortality of patients who underwent REBOA compared to RT was 0.18 (p < 0.01). The odds of in-hospital survival of patients who underwent REBOA compared to non-REBOA was 1.28 (p = 0.62). There was a significant difference found between survivors and non-survivors in terms of their pre-REBOA systolic blood pressure (SBP) (19.26 mmHg, p < 0.01), post-REBOA SBP (20.73 mmHg, p < 0.01), duration of aortic occlusion (-40.57 mins, p < 0.01) and ISS (-8.50, p < 0.01). Common complications of REBOA included acute kidney injury, multi-organ dysfunction and thrombosis. Conclusions Our study demonstrated lower in-hospital mortality of REBOA versus RT. Prospective multi-centre studies are needed for further evaluation of the indications, feasibility, and complications of REBOA.

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Assessing the need for resuscitative endovascular balloon occlusion of the aorta (REBOA) for management of non-compressible hemorrhage at a Canadian urban trauma centre

10.21203/rs.3.rs-198760/v1 ◽

2021 ◽

Author(s):

Elizabeth Purssell ◽

Sean Patrick ◽

Joseph Haegert ◽

Vesna Ivkov ◽

John Taylor

Keyword(s):

Injury Severity ◽

Retrospective Chart Review ◽

Balloon Occlusion ◽

Trauma Centre ◽

Trauma Patients ◽

Potential Candidate ◽

Study Objective ◽

Resuscitative Thoracotomy ◽

Less Invasive ◽

Endovascular Balloon Occlusion

Abstract Introduction Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a less invasive alternative to resuscitative thoracotomy (RT) for life threatening, infra-diaphragmatic, non-compressible hemorrhage from trauma. Existing evidence surrounding the efficacy of REBOA is conflicting; nevertheless, expert consensus suggests that REBOA should be considered in select trauma patients. There has been a paucity of studies that evaluate the potential utility of REBOA in the Canadian setting. The study objective was to evaluate the percentage of trauma patients presenting to a Level 1 Canadian trauma centre that would have met criteria for REBOA. Methods We conducted a retrospective chart review of patients recorded in the British Columbia Trauma Registry who warranted a trauma team activation (TTA) at our institution. We identified REBOA candidates using pre-defined criteria based on published guidelines. Each TTA case was screened by a reviewer, and then each Potential Candidate was reviewed by a panel of trauma physicians for determination of final candidacy. Results Fourteen patients were classified as Likely REBOA Candidates (2.2% of TTAs, median age 46.1 years, 64.3% female). These patients had a median Injury Severity Score of 31.5 (IQR 26.8). The main sources of hemorrhage in these patients were from abdominal injuries (71.4%) and pelvic fractures (42.9%). Conclusion The percentage of patients who met criteria for REBOA is similar to that of RTs performed at our Canadian institution. While REBOA would be performed infrequently, it is a less-invasive alternative to RT, which could be a potentially life-saving procedure in a small group of the most severely injured trauma patients.

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Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as an adjunct to damage control surgery for combat trauma

Journal of Endovascular Resuscitation and Trauma Management ◽

10.26676/jevtm.v1i1.16 ◽

2017 ◽

Vol 1 (1) ◽

pp. 58-62

Author(s):

Jacob J Glaser ◽

William Teeter ◽

Travis Gerlach ◽

Nathanial Fernandez

Keyword(s):

Damage Control ◽

Damage Control Surgery ◽

Balloon Occlusion ◽

Combat Trauma ◽

Operating Table ◽

Vascular Control ◽

Resuscitative Thoracotomy ◽

Combat Casualty ◽

Transfusion Requirements ◽

Endovascular Balloon Occlusion

Background: Non compressible torso hemorrhage continues to be the leading cause of preventable death in combat operations. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as an alternative hemorrhage control strategy, with morbidity advantages over resuscitative thoracotomy. We report the first ever use of REBOA in a combat casualty in Afghanistan. Case Report: An 18 year old Afghan male was injured by a single high velocity gunshot wound during partnered operations. He was treated with a damage control operation at the role 2 level, with significant presacral and pelvic bleeding controlled with combat gauze packing. The patient continued to be hemodynamically labile, with ongoing transfusion requirements and required emergent re-exploration. Upon transfer from the gurney to the operating table the patient was noted to be hypotensive with a blood pressure of 62/38. An ER-REBOA catheter was measured for Zone 1 occlusion and placed without difficulty. The patient’s hemodynamics normalized, which allowed for sterile entry into the abdomen and vascular control. After 10 minutes of occlusion the balloon was deflated. Surgical repair was completed and patient survived to discharge. Conclusions: REBOA is an adjunct to hemorrhagic shock that provides temporary proximal control bridge to definitive surgical hemostasis while avoiding the morbidity of a resuscitative thoracotomy. This case represents the first reported use of REBOA in the Afghanistan Theater. This case further supports increased consideration for use of REBOA in the forward setting.

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A meta-analysis of resuscitative endovascular balloon occlusion of the aorta (REBOA) or open aortic cross-clamping by resuscitative thoracotomy in non-compressible torso hemorrhage patients

World Journal of Emergency Surgery ◽

10.1186/s13017-017-0142-5 ◽

2017 ◽

Vol 12 (1) ◽

Cited By ~ 46

Author(s):

Ramiro Manzano Nunez ◽

Maria Paula Naranjo ◽

Esteban Foianini ◽

Paula Ferrada ◽

Erika Rincon ◽

...

Keyword(s):

Meta Analysis ◽

Balloon Occlusion ◽

Resuscitative Thoracotomy ◽

Endovascular Balloon Occlusion

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Implementation of Resuscitative Endovascular Balloon Occlusion of the Aorta as an Alternative to Resuscitative Thoracotomy for Non-compressible Truncal Hemorrhage

Journal of Emergency Medicine ◽

10.1016/j.jemermed.2015.11.029 ◽

2016 ◽

Vol 50 (1) ◽

pp. 213

Author(s):

Jacob Nacht

Keyword(s):

Balloon Occlusion ◽

Resuscitative Thoracotomy ◽

Endovascular Balloon Occlusion

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

Japanese Journal of Radiology ◽

10.1007/s11604-021-01166-w ◽

2021 ◽

Author(s):

Ryo Aoki ◽

Yusuke Kobayashi ◽

Shintaro Nawata ◽

Hiroyuki Kamide ◽

Toh Yamamoto ◽

...

Keyword(s):

Computed Tomography ◽

Balloon Occlusion ◽

Imaging Features ◽

Radiological Findings ◽

Computed Tomography Imaging ◽

Aortic Cross Clamp ◽

Tomography Imaging ◽

Resuscitative Thoracotomy ◽

Pictorial Review ◽

Endovascular Balloon Occlusion

AbstractResuscitative 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.

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A Practical Approach to Introducing Pre-Hospital Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), the Problems Encountered and Lessons Learned

Journal of Endovascular Resuscitation and Trauma Management ◽

10.26676/jevtm.v5i2.207 ◽

2021 ◽

Vol 5 (2) ◽

Author(s):

Manik Chana ◽

Zane Perkins ◽

Robbie Lendrum ◽

Samy Sadek

Keyword(s):

Hospital Care ◽

Significant Proportion ◽

Hospital Management ◽

Balloon Occlusion ◽

Lessons Learned ◽

Blunt Injury ◽

Relative Reduction ◽

Resuscitative Thoracotomy ◽

Endovascular Balloon Occlusion ◽

Resuscitative Measure

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is an endovascular procedure which utilises a catheter based balloon device to achieve aortic occlusion. The aim of this resuscitative measure is to improve blood pressure proximal to the occlusion site and therefore preserve cardiac and cerebral perfusion in order to prevent cardiac arrest; additionally there is a relative reduction in arterial inflow to the site of injury. Endovascular techniques are gaining acceptance for the in-hospital management of haemorrhage, however their use in pre-hospital care is still limited. This is due to a number of factors including the technical challenges, training and skill sets of pre-hospital care teams and the potential for harm of REBOA, particularly with extended balloon occlusion times. However, non compressible torso haemorrhage is associated with a mortality of approximately 50% and a significant proportion of these deaths occur in the pre-hospital phase of care. In the exsanguinating patient, resuscitative thoracotomy (RT) with direct aortic compression is often the only means to control haemorrhage. This resuscitative measure is now an established pre-hospital intervention which has significantly improved outcomes in the context of penetrating trauma, particularly thoracic injury. In the context of blunt injury and subdiaphragmatic haemorrhage, however, the outcomes from pre-hospital resuscitative thoracotomy remain poor. We present our initial technique for successfully introducing REBOA for the pre-hospital management of exsanguinating pelvic or groin heamorrhage following trauma, our indications for REBOA and comment on the problems and limitations encountered as well the lessons learned.

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Combined, Converted, and Prophylactic Use of Resuscitative Endovascular Balloon Occlusion of the Aorta for Severe Torso Trauma: A Retrospective Study

10.21203/rs.3.rs-1196024/v1 ◽

2021 ◽

Author(s):

Takayuki Irahara ◽

Dai Oishi ◽

Masanobu Tsuda ◽

Yuka Kajita ◽

Hisatake Mori ◽

...

Keyword(s):

Cardiopulmonary Arrest ◽

Survival Rates ◽

Balloon Occlusion ◽

Shock Group ◽

Total Occlusion ◽

Occlusion Time ◽

Resuscitative Thoracotomy ◽

Aortic Balloon Occlusion ◽

Torso Trauma ◽

Endovascular Balloon Occlusion

Abstract Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used as an intra-aortic balloon occlusion method in Japan; however, the protocols for its effective use in different pathological conditions remain unclear. This study aimed to summarise the strategies of REBOA use in severe torso trauma.Methods: Twenty-nine cases of REBOA for torso trauma treated at our hospital over 5 years were divided into the shock (n=12), cardiopulmonary arrest (CPA) (n=13), and non-shock (n=4) groups. We retrospectively examined patient characteristics, trauma mechanism, injury site, severity score, intervention, survival rates at 24 hours, and intervention details in each group.Results: In the shock group, 9 and 3 patients survived and died within 24 hours, respectively; time to intervention (56.6 vs 130.7 min, p=0.346) and total occlusion time (40.2 vs 337.7 min, p=0.009) were both shorter in surviving patients than in the casualties. In the CPA group, 10 patients were converted from resuscitative thoracotomy with aortic cross-clamp (RTACC); a single patient survived. Four patients in the non-shock group survived, having received prophylactic REBOA.Conclusions: The efficacy of REBOA for severe torso trauma depends on patient condition. In the shock group, time to intervention and total occlusion time correlated with survival. The use of REBOA with definitive haemostasis and minimum delays to intervention may improve outcomes. Patients with CPA are at a high risk of mortality; however, conversion from RTACC may be effective in some cases. Prophylactic intervention in the non-shock group may help achieve immediate definitive haemostasis.

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Improving the safety of resuscitative endovascular balloon occlusion of the aorta – Compliant versus semi-compliant balloon systems

Vascular ◽

10.1177/1708538120922106 ◽

2020 ◽

Vol 28 (5) ◽

pp. 612-618

Author(s):

Marta J Madurska ◽

Curtis Franklin ◽

Michael Richmond ◽

Sakib M Adnan ◽

Gerard P Stansby ◽

...

Keyword(s):

Safety Valve ◽

Balloon Catheter ◽

Balloon Occlusion ◽

Quadratic Model ◽

Second Phase ◽

Relief Valve ◽

Pressure Relief ◽

Resuscitative Thoracotomy ◽

Working Length ◽

Endovascular Balloon Occlusion

Objectives Resuscitative endovascular balloon occlusion of the aorta is an alternative to resuscitative thoracotomy in non-compressible torso haemorrhage. Low-profile, compliant balloon catheter systems have been developed, which can be deployed without the need for fluoroscopy. However, concern exists for over inflation and aortic injury, especially as compliant balloon material can stretch reducing syringe feedback and limiting the effectiveness of a safety valve. An alternative material would be a semi-compliant balloon material, but its performance is unknown. The aim of this study was to compare the inflation characteristics of compliant versus semi-compliant balloon systems and to determine whether a pressure relief safety valve can be practically applied to a semi-compliant balloon catheter as a safety device. Methods This was an ex vivo study using porcine segments of thoracic aorta. The study consisted of two phases. The first phase involved intermittent inflation of six compliant balloon and six semi-compliant balloon balloons until balloon or aortic rupture. In the second phase, six semi-compliant balloons with the pressure-relief valve set at 0.45 atmospheres were inflated in the aortas until the valve release, followed by injection with additional 30 mL. Data including pressure, volume, balloon working length, diameter and circumferential stretch ratio were collected. Results At failure, mean balloon volume was almost double in compliant balloon group vs semi-compliant balloon group – 49.83 mL (±23.25) and 25.16 mL (±8.93), respectively ( p = 0.004), with 36% increase in working length in the compliant balloon group – 81.17 mm (±19.11) vs 59.49 (±4.86) for semi-compliant balloon ( p = 0.023). When plotted, the relationship pattern between volume and pressure fit a linear model for the compliant balloon, and a quadratic model for the semi-compliant balloon. Following attempted over inflation with the pressure valve, there was no change in parameters before and after attempted over inflation. Conclusions The inflation profile differs between balloon designs. In contrast to semi-compliant balloons, compliant balloons will accommodate more volume to mitigate increase in pressure. This does not completely eliminate the risk of over inflation. The inflation characteristics of the semi-compliant balloon permit pairing it with a safety valve, which could lead to a development of a safer balloon technology in the future.

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