A comparison of Selective Aortic Arch Perfusion and Resuscitative Endovascular Balloon Occlusion of the Aorta for the management of hemorrhage-induced traumatic cardiac arrest: A translational model in large swine

Abstract

BackgroundSurvival rates remain low after hemorrhage-induced traumatic cardiac arrest (TCA). Noncompressible torso hemorrhage (NCTH) is a major cause of potentially survivable trauma death. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) at the thoracic aorta (Zone 1) can limit subdiaphragmatic blood loss and allow for IV fluid resuscitation when intrinsic cardiac activity is still present. Selective Aortic Arch Perfusion (SAAP) combines thoracic aortic balloon hemorrhage control with intra-aortic oxygenated perfusion to achieve return of spontaneous circulation (ROSC) when cardiac arrest has occurred.Methods and findingsMale Yorkshire Landrace cross swine (80.0 ± 6.0 kg) underwent anesthesia, instrumentation for monitoring, and splenectomy. TCA was induced by laparoscopic liver lobe resection combined with arterial catheter blood withdrawal to achieve a sustained systolic blood pressure <10 mmHg, cardiac arrest. After 3 min of arrest, swine were allocated to one of three interventions: (1) REBOA plus 4 units of IV fresh whole blood (FWB), (2) SAAP with oxygenated lactated Ringer’s (LR), 1,600 mL/2 min, or (3) SAAP with oxygenated FWB 1,600 mL/2 min. Primary endpoint was survival to the end of 60 min of resuscitation, a simulated prehospital phase. Thirty animals were allocated to 3 groups (10 per group)—5 protocol exclusions resulted in a total of 35 animals being used. Baseline measurements and time to cardiac arrest were not different amongst groups. ROSC was achieved in 0/10 (0%, 95% CI 0.00–30.9) REBOA, 6/10 (60%, 95% CI 26.2–87.8) SAAP-LR and 10/10 (100%, 95% CI 69.2–100.0) SAAP-FWB animals, p < 0.001. Survival to end of simulated 60-minute prehospital resuscitation was 0/10 (0%, 95% CI 0.00–30.9) for REBOA, 1/10 (10%, 95% CI 0.25–44.5) for SAAP-LR and 9/10 (90%, 95% CI 55.5–99.7) for SAAP-FWB, p < 0.001. Total FWB infusion volume was similar for REBOA (2,452 ± 0 mL) and SAAP-FWB (2,250 ± 594 mL). This study was undertaken in laboratory conditions, and as such may have practical limitations when applied clinically. Cardiac arrest in this study was defined by intra-aortic pressure monitoring that is not feasible in clinical practice, and as such limits the generalizability of findings. Clinical trials are needed to determine if the beneficial effects of SAAP-FWB observed in this laboratory study will translate into improved survival in clinical practice.ConclusionsSAAP conferred a superior short-term survival over REBOA in this large animal model of hemorrhage-induced traumatic cardiac arrest with NCTH. SAAP using an oxygen-carrying perfusate was more effective in this study than non-oxygen carrying solutions in TCA. SAAP can effect ROSC from hemorrhage-induced electrocardiographic asystole in large swine.

Epidemiology and aetiology of paediatric traumatic cardiac arrest in England and Wales

“…In our study 50.0% of these procedures were performed in the pre-hospital environment with 13 (72.2%) following penetrating trauma, revealing severe thoracic and abdominal injuries in 17 patients (94.4%). While we acknowledge the survival rate is poor, it should be recognised that for the management of haemorrhagic TCA, pre-hospital interventions other than RT, for example, Resuscitative Emergency Balloon Occlusion of the Aorta or Selective Aortic Arch Perfusion are still experimental and are unlikely to be widely available in the near future 15 16…”

The outcome of patients in traumatic cardiac arrest presenting to deployed military medical treatment facilities: data from the UK Joint Theatre Trauma Registry

“…The challenges of palpating a central pulse in the military environment (for example, in a tactically flying helicopter) have not been well described, but it is possible that some patients we describe as ‘TCA survivors’ might have had a palpable pulse in a more permissive environment—potentially producing a higher survival rate. At the other end of the spectrum, there is a no-output state in trauma (NOST), where there is no cardiac output, and either a brady-agonal or asystolic cardiac rhythm—haemorrhage control and resuscitation with fluid filling alone is unlikely to be successful in this group 19. There are no clinical guidelines to differentiate LOST and NOST, but organised electrical activity and cardiac motion on ultrasound may help to prognosticate 20…”

“…There were 69 TCA patients with an AIS >3 abdominal or lower limb injury (in the absence of a severe head or thoracic injury) who died, with over 80% of these patients likely to have had a primary haemorrhagic aetiology for their TCA. This group may represent an opportunity to advance military TCA outcomes by improved haemorrhage control; for example, with the use of aortic balloon occlusion,21 selective aortic arch perfusion,19 the aortic abdominal tourniquet22 and abdominal foam 23. However, this technology may need to be used in the prehospital setting to have maximum benefit.…”

The use of resuscitative endovascular balloon occlusion of the aorta (REBOA) for non‐traumatic cardiac arrest: A review

“…SAAP utilizes a large-lumen balloon catheter to occlude the thoracic aorta and provide heart and brain perfusion during cardiac arrest. 53,54…”

“…REBOA is being investigated to treat NTCA along with other advanced technologies, including selective aortic arch perfusion (SAAP) and ECMO. SAAP utilizes a large‐lumen balloon catheter to occlude the thoracic aorta and provide heart and brain perfusion during cardiac arrest 53,54 . Although the SAAP catheter, like REBOA catheter, is inserted via a femoral artery to the thoracic aorta, SAAP is primarily an extracorporeal perfusion intervention.…”