Venous Chimney Procedure: A Novel Technical Solution to Prevent Iatrogenic Budd– Chiari Syndrome Following Retrohepatic Vena Cava Injury

2021 ◽  
Vol 4 (2) ◽  
Author(s):  
Eitan Heldenberg ◽  
Dan Hebron ◽  
Boris Kessel ◽  
Ofer Galili ◽  
Itay Zoarets ◽  
...  
Keyword(s):  
Mortality Rate ◽  
Damage Control ◽  
Vena Cava ◽  
Balloon Occlusion ◽  
Technical Solution ◽  
Trauma Patients ◽  
Endovascular Techniques ◽  
Vascular Surgeon ◽  
Posterior Aspect ◽  
Management Concepts

Traumatic inferior vena cava (IVC) lesions account for approximately 25% of abdominal vascular injuries and are among the most challenging and lethal lesions sustained by trauma patients. Whether caused by blunt or penetrating mechanisms of injury, the overall mortality rate is up to 92%; as many as 50% of  the patients with those injuries die before reaching medical care, and the mortality rate among patients who arrive to a trauma center, with signs of life and/or receive operative treatment, ranges between 20% and 57% (1). Retrohepatic Vena Cava (RHVC) injuries (RHVCI) are extremely rare and as such both the treating trauma surgeon, as well as the vascular surgeon, lacks the necessary experience to deal with such complicated injuries. The mortality rates secondary to these injuries are extremely high, even with damage control management concepts application. Improving the outcome of these injuries remains a significant challenge of modern trauma care (2, 3). The treatment of RHVCI confronts the treating surgeon, with major obstacles, which raises from the anatomic location of the RHVC at the posterior aspect of the liver and the abundancy of bridging veins between the RHVC and the liver. These anatomic obstacles creates a major technical challenge of gaining proximal and distal control, in proximity to the injured RHVC. This many times necessitates abdominal as well as thoracic exposure in order to gain proper control. The average trauma, as well as the vascular, surgeons are not familiar with handling such complex injuries. This is even truer as referred to the new generation of vascular surgeons, whose experience with open vascular surgery, mainly in such extreme situations, decreases with the increasing usage of endovascular techniques (4).     The advancements in endovascular techniques have introduced new alternatives to traditional open repair strategies. In many cases, RHVCI treatment requires exploration of a retro-hepatic hematoma, which might be the single thing that prevents free venous rupture and as such, it should be avoided.  Venous balloon occlusion is a novel endovascular strategy that may be particularly advantageous in those circumstances as a bridging maneuver, for proximal and distal control, during hybrid repair. Our case in unique since it highlights the option of total endovascular treatment, using arterial treatment concepts, to treat this extremely challenging injury.    

scholarly journals Venous Chimney Procedure: A Novel Technical Solution to Prevent Iatrogenic Budd– Chiari Syndrome Following Retrohepatic Vena Cava Injury

2021 ◽  
Vol 4 (2) ◽  
Author(s):  
Eitan Heldenberg ◽  
Dan Hebron ◽  
Boris Kessel ◽  
Ofer Galili ◽  
Itay Zoarets ◽  
...  
Keyword(s):  
Mortality Rate ◽  
Damage Control ◽  
Vena Cava ◽  
Balloon Occlusion ◽  
Technical Solution ◽  
Trauma Patients ◽  
Endovascular Techniques ◽  
Vascular Surgeon ◽  
Posterior Aspect ◽  
Management Concepts

Traumatic inferior vena cava (IVC) lesions account for approximately 25% of abdominal vascular injuries and are among the most challenging and lethal lesions sustained by trauma patients. Whether caused by blunt or penetrating mechanisms of injury, the overall mortality rate is up to 92%; as many as 50% of  the patients with those injuries die before reaching medical care, and the mortality rate among patients who arrive to a trauma center, with signs of life and/or receive operative treatment, ranges between 20% and 57% (1). Retrohepatic Vena Cava (RHVC) injuries (RHVCI) are extremely rare and as such both the treating trauma surgeon, as well as the vascular surgeon, lacks the necessary experience to deal with such complicated injuries. The mortality rates secondary to these injuries are extremely high, even with damage control management concepts application. Improving the outcome of these injuries remains a significant challenge of modern trauma care (2, 3). The treatment of RHVCI confronts the treating surgeon, with major obstacles, which raises from the anatomic location of the RHVC at the posterior aspect of the liver and the abundancy of bridging veins between the RHVC and the liver. These anatomic obstacles creates a major technical challenge of gaining proximal and distal control, in proximity to the injured RHVC. This many times necessitates abdominal as well as thoracic exposure in order to gain proper control. The average trauma, as well as the vascular, surgeons are not familiar with handling such complex injuries. This is even truer as referred to the new generation of vascular surgeons, whose experience with open vascular surgery, mainly in such extreme situations, decreases with the increasing usage of endovascular techniques (4).     The advancements in endovascular techniques have introduced new alternatives to traditional open repair strategies. In many cases, RHVCI treatment requires exploration of a retro-hepatic hematoma, which might be the single thing that prevents free venous rupture and as such, it should be avoided.  Venous balloon occlusion is a novel endovascular strategy that may be particularly advantageous in those circumstances as a bridging maneuver, for proximal and distal control, during hybrid repair. Our case in unique since it highlights the option of total endovascular treatment, using arterial treatment concepts, to treat this extremely challenging injury.    

Use of endovascular balloons may simplify the proximal and distal control in complicated vascular trauma.

2017 ◽  
Vol 1 (1) ◽  
pp. 39-41
Author(s):  
Offer Galili
Keyword(s):  
Damage Control ◽  
Vascular Trauma ◽  
Balloon Occlusion ◽  
Control Measures ◽  
Case Presentation ◽  
Simplified Approach ◽  
Management Concepts ◽  
Novel Strategy ◽  
Anatomic Locations ◽  
Control Management

The treatment of vascular injuries remains a significant challenge of modern trauma care. This is particularly true of injuries at challenging anatomic locations or that are complex in nature. The mortality rates from these injuries can be high, despite recent progress in application of damage control management concepts. Developments of endovascular techniques have introduced new alternatives to traditional open repair strategies that may prove useful in the setting of complex vascular injury. The concept of endovascular and hybrid trauma management (EVTM) gains experience which allows replacing traditional principles of open vascular management in selected cases. Endovascular modalities, specifically intra-vascular balloon occlusion, offer a novel strategy that may be of particular use in these situations. Our present case presentation outlines an example of successful utilization of this approach and affords an opportunity to review a simplified approach using endovascular balloons as proximal and distal control measures, in order to limit the challenges represented by more extensive anatomic exposures in a victim of trauma.

scholarly journals Mortality in hypotensive trauma patients requiring laparotomy is related to degree of hypotension and provides evidence for focused interventions

2021 ◽  
Vol 6 (1) ◽  
pp. e000723
Author(s):  
James W Davis ◽  
Rachel C Dirks ◽  
David R Jeffcoach ◽  
Krista L Kaups ◽  
Lawrence P Sue ◽  
...  
Keyword(s):  
Mortality Rate ◽  
Patient Group ◽  
Injury Severity ◽  
Balloon Occlusion ◽  
Physiological Data ◽  
Trauma Patients ◽  
Level Of Evidence ◽  
Management Level ◽  
Level I ◽  
Emergent Laparotomy

BackgroundMortality in hypotensive patients requiring laparotomy is reported to be 46% and essentially unchanged in 20 years. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been incorporated into resuscitation protocols in an attempt to decrease mortality, but REBOA can have significant complications and its use in this patient group has not been validated. This study sought to determine the mortality rate for hypotensive patients requiring laparotomy and to evaluate the mortality risk related to the degree of hypotension. Additionally, this study sought to determine if there was a presenting systolic blood pressure (SBP) that was associated with a sharp increase in mortality to target the appropriate patient group most likely to benefit from focused interventions such as REBOA.MethodsThe trauma registry at a level I trauma center was reviewed for patients undergoing emergent laparotomy from January 2007 to June 2020. Data included demographics, mechanism of injury, physiological data, Injury Severity Score, blood products transfused, and outcomes. Group comparisons were based on initial SBP (0 to 50 mm Hg, 60 to 69 mm Hg, 70 to 79 mm Hg, 80 to 89 mm Hg, and ≥90 mm Hg).ResultsDuring the study period, 52 016 trauma patients were treated and 1174 required laparotomy within 90 min of arrival; 424 had an initial SBP of <90 mm Hg. The overall mortality rate was 18%, but mortality increased as SBP decreased (≥90=9%, 80 to 89=20%, 70 to 79=21%, 60 to 69=48%, 0 to 59=66%). Mortality increased sharply with SBP of <70 mm Hg.DiscussionMortality rate increases with worsening hypotension and increases sharply with an SBP of <70 mm Hg. Further study on focused interventions such as REBOA should target this patient group.Level of evidenceTherapeutic/care management, level III.

scholarly journals Practical tips for performing resuscitative endovascular balloon occlusion of the aorta

2021 ◽  
pp. 102490792199442
Author(s):  
Sung Wook Chang ◽  
Dae Sung Ma ◽  
Ye Rim Chang ◽  
Dong Hun Kim
Keyword(s):  
Damage Control ◽  
Balloon Catheter ◽  
Common Femoral Artery ◽  
Balloon Occlusion ◽  
Trauma Patients ◽  
Arterial Access ◽  
Occlusion Time ◽  
Sheath Insertion ◽  
Multiple Trauma Patients ◽  
Endovascular Balloon Occlusion

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.

scholarly journals Damage control approach to refractory neurogenic shock: a new proposal to a well-established algorithm

2021 ◽  
Vol 52 (2) ◽  
pp. e4164800
Author(s):  
Michael W Parra ◽  
Carlos Alberto Ordoñez ◽  
David Mejia ◽  
Yaset Caicedo ◽  
Javier Mauricio Lobato ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Damage Control ◽  
Aortic Pressure ◽  
Balloon Occlusion ◽  
Trauma Patients ◽  
Algorithmic Approach ◽  
Control Approach ◽  
Neurogenic Shock ◽  
Cord Injury ◽  
Prolonged Hypotension

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is commonly used as an adjunct to resuscitation and bridge to definitive control of non-compressible torso hemorrhage in patients with hemorrhagic shock. It has also been performed for patients with neurogenic shock to support the central aortic pressure necessary for cerebral, coronary and spinal cord perfusion. Although volume replacement and vasopressors are the cornerstones of the management of neurogenic shock, we believe that a REBOA can be used as an adjunct in carefully selected cases to prevent prolonged hypotension and the risk of further anoxic spinal cord injury. This manuscript aims to propose a new damage control algorithmic approach to refractory neurogenic shock that includes the use of a REBOA in Zone 3. There are still unanswered questions on spinal cord perfusion and functional outcomes using a REBOA in Zone 3 in trauma patients with refractory neurogenic shock. However, we believe that its use in these case scenarios can be beneficial to the overall outcome of these patients.

scholarly journals The fat embolism syndrome as a cause of paraplegia

2018 ◽  
Vol 6 ◽  
pp. 2050313X1878931 ◽  
Author(s):  
Siert TA Peters ◽  
Marieke J Witvliet ◽  
Anke Vennegoor ◽  
Birkitt ten Tusscher ◽  
Bauke Boden ◽  
...  
Keyword(s):  
Damage Control ◽  
Vena Cava ◽  
Damage Control Surgery ◽  
Fat Embolism ◽  
Trauma Patients ◽  
Optimal Care ◽  
Fat Embolism Syndrome ◽  
Femur Fractures ◽  
Embolism Syndrome ◽  
Accident Victim

The fat embolism syndrome is a well-known complication in trauma patients. We describe a rare case of traumatic fat embolism that leads to paraplegia. A 19-year-old male motorcycle accident victim was presented to our hospital. After stabilization and trauma survey, he was diagnosed with bilateral femur fractures, a spleen laceration and a tear in the inferior vena cava, for which damage control surgery was performed. Post-operatively, the patient became paraplegic and developed a fluctuating consciousness, respiratory distress and petechiae. Fat embolism syndrome was considered as the most plausible cause of the paraplegia. The fat embolism syndrome is seen in approximately 1% of trauma patients, mostly those with bilateral fractures of the femur. Prevention of the syndrome depends on early stabilization of fractures. However, even with optimal care, this syndrome can still occur and may have dramatic consequences, as we demonstrate in this case.

Introduction to the Sixth Edition of the JEVTM

2019 ◽  
Vol 3 (2) ◽  
Author(s):  
Igor M. Samokhvalov
Keyword(s):  
Post Partum ◽  
Damage Control ◽  
Interdisciplinary Approach ◽  
Simulation Models ◽  
Balloon Occlusion ◽  
Aortic Aneurysms ◽  
Sixth Edition ◽  
Bleeding Management ◽  
Aortic Balloon Occlusion ◽  
Poster Presentations

Dear Readers, Welcome to the sixth edition of the JEVTM! In 1866, the Great Russian surgeon and scientist Nikolai Pirogov wrote: “A new era for surgery will begin, if we can quickly and surely control the flow in a major artery without exploration and ligation”. This era has now arrived and it is called EVTM! Our mission has been to maximize the benefits of endovascular technologies for trauma and bleeding patients: from the first attempts of REBOA by Carl Hughes in the 1950s with hand-made aortic balloon occlusion catheters used in our department since the early 1990s to modern successful cases of out-of-hospital REBOA use in combat and civilian casualties for ruptured aneurysms, post-partum hemorrhage and trauma. In this edition, you will find articles related to a new strategy of damage control interventional radiology (DCIR), partial REBOA in elderly patients and in ruptured aortic aneurysms, thrombolysis for trauma-associated IVC thrombosis, simulation models for training of REBOA, contemporary utilization of Zone III REBOA and more. As a continuation of EVTM development, Russian surgeons, emergency physicians, anesthetists, and others will be involved in the world of EVTM, participating in expanding the horizons of trauma care and cultivating the endovascular mindset. Also published in this edition are some of the abstracts that will be presented at the EVTM conference in Russia, St. Petersburg (7/06/2019). More than 35 oral and 30 poster presentations will make this conference a scientific feast for our audience! By adopting these new techniques for bleeding management, we are following Pirogov’s motto – to achieve fast endovascular hemorrhage control – which can only be done as part of an interdisciplinary approach.   We look forward to seeing you in Saint Petersburg at the EVTM-Russia meeting! www.evtm.org

Use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as a bridge to endovascular aortic repair (EVAR) in blunt abdominal aortic injury (BAAI).

2019 ◽  
Vol 3 (1) ◽  
Author(s):  
Valentina Chiarini
Keyword(s):  
Trauma Center ◽  
Aortic Rupture ◽  
Damage Control ◽  
Aortic Injury ◽  
Balloon Occlusion ◽  
Traumatic Lesion ◽  
Abdominal Aortic ◽  
Aortic Injuries ◽  
Accepted Practice ◽  
Endovascular Balloon Occlusion

BAAI is a rare but challenging traumatic lesion. Since BAAI is difficult to suspect and diagnose, frequently lethal and associated to multiorgan injuries, its management is objective of research and discussion. REBOA is an accepted practice in ruptured abdominal aortic aneurysm. Conversely, blunt aortic injuries are the currently most cited contraindications for the use of REBOA in trauma, together with thoracic lesions. We reported a case of BAAI safely managed in our Trauma Center at Maggiore Hospital in Bologna (Italy) utilizing REBOA as a bridge to endovascular repair, since there were no imminent indications for laparotomy. Despite formal contraindication to placing REBOA in aortic rupture, we hypothesized that this approach could be feasible and relatively safe when introduced in a resuscitative damage control protocol.

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