Gastroesophageal resuscitative occlusion of the aorta prolongs survival in a lethal liver laceration model

Abstract

BACKGROUND: Noncompressible torso hemorrhage management remains a challenge especially in the prehospital setting. We evaluated a device designed to occlude the aorta from the stomach (gastroesophageal resuscitative occlusion of the aorta [GROA]) for its ability to stop hemorrhage and improve survival in a swine model of lethal liver laceration and compared its performance to resuscitative endovascular balloon occlusion of the aorta (REBOA) and controls. METHODS:Swine (n = 24) were surgically instrumented and a 30% controlled arterial hemorrhage over 20 minutes was followed by liver laceration. Animals received either GROA, REBOA, or control (no treatment) for 60 minutes. Following intervention, devices were deactivated, and animals received whole blood and crystalloid resuscitation. Animals were monitored for an additional 4 hours. RESULTS:The liver laceration resulted in the onset of class IV shock. Mean arterial blood pressure (MAP) (standard deviation) decreased from 84.5 mm Hg (11.69 mm Hg) to 27.1 mm Hg (5.65 mm Hg) at the start of the intervention. Seven of eight control animals died from injury prior to the end of the intervention period with a median survival (interquartile) time of 10.5 minutes (12 minutes). All GROA and REBOA animals survived the duration of the intervention period (60 minutes) with median survival times of 86 minutes (232 minutes) and 79 minutes (199 minutes) after resuscitation, respectively. The GROA and REBOA animals experienced a significant improvement in survival compared with controls ( p = 0.01). Resuscitative endovascular balloon occlusion of the aorta resulted in higher MAP at the end of intervention 114.6 mm Hg (22.9 mm Hg) compared with GROA 88.2 mm Hg (18.72 mm Hg) ( p = 0.024), as well as increased lactate compared with GROA 13.2 meq•L −1 (1.56 meq•L −1 ) versus 10.5 meq•L −1 (1.89 meq•L −1 ) ( p = 0.028). Histological examination of the gastric mucosa in surviving animals revealed mild ischemic injury from both GROA and REBOA. CONCLUSION: The GROA and REBOA devices were both effective at temporarily stanching lethal noncompressible torso hemorrhage of the abdomen and prolonging survival.

A contemporary assessment of resuscitative endovascular balloon occlusion of the aorta

“…Finally, and as an "out of the box" approach to resuscitative aortic occlusion, Ward and colleagues from the University of Michigan Center for Integrative Research in Critical Care report in this month's issue a technique and device referred to as gastroesophageal resuscitative occlusion of the aorta. 33…”

A review of two emerging technologies for pre‐hospital treatment of non‐compressible abdominal hemorrhage

“…In a follow-up study, GROA's ability to stanch NCTH was evaluated using a highly lethal grade V liver laceration model comparing GROA to REBOA and controls. 27 Occlusion time in this study was limited to 60-min based on the previous tolerance testing. 26 The model was rapidly lethal for the control group resulting in a median survival time of only 10.5 min from the onset of the injury.…”

“…In a pilot study, the IPHD was evaluated for its ability to temporarily control hemorrhage and subsequently improve survival in a model of rapidly lethal, multi-organ hemorrhage including a grade-V liver laceration (the same method as used in the aforementioned GROA study) combined with a severe spleen and kidney laceration. 27,28 The group of animals treated with IPHD was compared to controls (no IPHD) for survival, hemodynamics, and other metrics of shock. All control animals (3/3) died within 15-43 min from injury while all IPHDtreated animals (5/5) survived the duration of the 60-min intervention period.…”

“…This application time is likely largely due to difficulties in cannulating the femoral artery. 27 While we envision military medics and civilian first responders being able to effectively apply the GROA device, future feasibility studies will need to be performed.…”

“…To further address the unmet need for temporary prehospital stabilization of the victim of non-compressible abdominal hemorrhage, our team has developed two technologies known as Gastroesophageal Resuscitative Occlusion of the Aorta (GROA), 26,27 and the Intra-Peritoneal Hemostasis Device (IPHD). 28 The main motivation for the development of these technologies is to allow for the rapid treatment of NCTH in austere combat environments, civilian pre-hospital, and higher echelons of care including emergency department and trauma center settings when surgical expertise and/or resources may be delayed.…”