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

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.

Resuscitative Endovascular Balloon Occlusion of the Aorta in the Management of a Gunshot Wound and Rupture of the Uterus

Trauma is the leading cause of non-obstetrical maternal death. A 19-year-old woman at 20 weeks’ gestation was brought to the emergency room after suffering a gunshot wound to the lower abdomen. Upon arrival, she was hemodynamically stable and imaging was obtained. CT revealed a rupture of the uterus with a partially extrauterine fetus, and the patient was immediately taken for an explorative laparotomy. Prior to the surgical start, the patient’s blood pressure declined and, subsequently, a resuscitative endovascular balloon occlusion of the aorta (REBOA) was placed. The fetus and placenta were delivered and both uterine arteries and the inferior epigastric artery were ligated. Following an unremarkable postoperative course, she was discharged on hospital day 17. The mainstay approach to trauma in pregnancy should be to utilize focused imaging techniques to assess extent of trauma and provide adequate circulation to vital organs. Aortic balloon occlusion may be considered as a viable strategy to enhance resuscitation.

MANAGING PLACENTA ACCRETA SPECTRUM IN LOW RESOURCE SETTING USING A NOVEL DISSECTION-FREE AORTA CLAMP: OPERATIVE TECHNIQUE

A novel over-the-peritoneum aorta clamp enabled a senior obstetrician, backed by a urologist, to manage 33 women with histopathology-confirmed Placenta Accreta spectrum, with no maternal mortality, relatively low incidence of blood transfusion and urological injuries in a limited resource setting. Easily applied by the obstetricians themselves, this clamp can be an effective and relatively safer alternative to intra-aortic balloon occlusion and aortic-cross clamping. We anticipate, obstetricians in low-resource settings can easily adapt our methods and contribute further prospective evidence.

Risk factor analysis of clinical outcomes of total aortic arch replacement and frozen elephant trunk with aortic balloon occlusion

Background Total aortic arch replacement (TAR) with frozen elephant trunk (FET) requires hypothermic circulatory arrest (HCA) for 20 min, which increases the surgical risk. We invented an aortic balloon occlusion (ABO) technique that requires 5 min of HCA on average to perform TAR with FET and investigated the possible merit of this new method in this study. Methods This retrospective study included consecutive patients who underwent TAR and FET (consisting of 130 cases of ABO group and 230 cases of conventional group) in Fuwai Hospital between August 2017 and February 2019. In addition to the postoperative complications, the alterations of blood routine tests, alanine transaminase (ALT) and aspartate transaminase (AST) during in-hospital stay were also recorded. Results The 30-day mortality rates were similar between ABO group (4.6%) and conventional group (7.8%, P = 0.241). Multivariate analysis showed ABO reduced postoperative acute kidney injury (23.1% vs. 35.7%, P = 0.013) and hepatic injury (12.3% vs. 27.8%, P = 0.001), and maintained similar cost to patients (25.5 vs. 24.9 kUSD, P = 0.298). We also found that AST was high during intensive care unit (ICU) stay and recovered to normal before discharge, while ALT was not as high as AST in ICU but showed a rising tendency before discharge. The platelet count showed a rising tendency on postoperative day 3 and may exceed the preoperative value before discharge. Conclusions The ABO achieved the surgical goal of TAR with FET with an improved recovery process during the in-hospital stay.

Damage Control Surgery for Thoracic Outlet Vascular Injuries: The New Resuscitative Median Sternotomy Plus Endovascular Aortic Balloon Occlusion of the Aorta Approach

Thoracic vascular trauma is associated with high mortality and is the second most common cause of death in patients with trauma following head injuries. Less than 25% of patients with a thoracic vascular injury arrive alive to the hospital and more than 50% of these die within the first 24 hours. Thoracic trauma with the involvement of the great vessels is a surgical challenge due to the complex and restricted anatomy of these structures and its association with adjacent organ damage. The aim of this article is to delineate the experience obtained in the surgical management of thoracic vascular injuries via the creation of a practical algorithm that includes basic principles of damage control surgery. We have been able to show that the early application of a resuscitative median sternotomy together with Zone I resuscitative endovascular balloon occlusion of the aorta (REBOA) in hemodynamically unstable patients with thoracic outlet vascular injuries improves survival by providing rapid stabilization of central aortic pressure and serving as a bridge to hemorrhage control. Damage control surgery principles should also be implemented when indicated followed by definitive repair once the correction of the lethal diamond has been achieved. To this end, we have developed a six-step management algorithm that illustrates the surgical care of patients with thoracic outlet vascular injuries according to the American Association of the Surgery of Trauma (AAST) classification.

Improvement of Clinical Outcomes of Total Aortic Arch Replacement and Frozen Elephant Trunk Surgery With Aortic Balloon Occlusion

Background: Total aortic arch replacement (TAR) with frozen elephant trunk (FET) surgery provides improved long-term results, but the surgery itself is associated with higher risks compared with isolated proximal reconstructions. We applied an aortic balloon occlusion (ABO) technique to reduce the circulatory arrest (CA) time and improve other clinical outcomes.Methods: All patients who underwent TAR with FET surgery (130 with ABO technique, 230 with the conventional approach) in Fuwai Hospital from August 2017 to February 2019 were reviewed in this retrospective observational cohort study. Intra- and early-postoperative results and clinical characteristics were analyzed.Results: After 1:1 propensity score matching (130 cases in each group), the 30-day mortality of the ABO group and the conventional group were 4.6% and 10.8% (p = 0.063), respectively. Although the reduction in complications was not statistically significant, the complication rate in the ABO group was relatively low, having fewer cases of postoperative renal (23.1 vs. 38.5%, p = 0.007) and hepatic (12.3 vs. 30.0%, p < 0.001) injury, lower postoperative wake-up time (15.2 ± 23.6 h vs. 20.1 ± 26.5 h, respectively, p < 0.001), reduced chest tube output (176.03 ± 143.73 ml vs. 213.29 ± 130.12 ml, respectively, p = 0.003), lower red blood cell transfusion volume (4.98 ± 6.53 u vs. 7.28 ± 10.41 u, respectively, p = 0.008), and no fatal events.Conclusions: The ABO technique is a simple method that can reduce the CA time and improve the recovery stage following TAR with FET surgery. The technique represents a practical strategy to treat patients with high operative risks due to its lower complication rate compared with the conventional approach.

Risk Factor Analysis of Clinical Outcomes of Total Aortic Arch Replacement and Frozen Elephant Trunk With Aortic Balloon Occlusion

Background: Total aortic arch replacement (TAR) with frozen elephant trunk (FET) requires hypothermic circulatory arrest (HCA) for 20 minutes, which increases the surgical risk. We invented an aortic balloon occlusion technique that requires 5 minutes of HCA on average to perform TAR with FET and investigated the possible merit of this new method in this study. Methods: This retrospective study included consecutive patients who underwent TAR and FET (consisting of 130 cases of aortic balloon occlusion group and 230 cases of conventional group) in Fuwai Hospital between August 2017 and February 2019. In addition to the postoperative complications, the alterations of blood routine tests, alanine transaminase (ALT) and aspartate transaminase (AST) during the in-hospital stay were also recorded. Results: The 30-day mortality rates were similar between the aortic balloon occlusion group (4.6%) and the conventional group (7.8%, P = 0.241). Multivariate analysis showed aortic balloon occlusion reduced postoperative acute kidney injury (23.1% vs 35.7%, P = 0.013) and hepatic injury (12.3% vs 27.8%, P = 0.001), and maintained similar cost to patients (25.5 vs 24.9 kUSD, P = 0.298). We also found that AST was high during intensive care unit (ICU) stay and recovered to normal before discharge, while ALT was not as high as AST in ICU but showed a rising tendency before discharge. The platelet count showed a rising tendency on postoperative day 3 and may exceed the preoperative value before discharge. Conclusions: The aortic balloon occlusion achieved the surgical goal of TAR with FET with an improved recovery process during the in-hospital stay.