Potential benefit of early operative utilization of low profile, partial resuscitative endovascular balloon occlusion of the aorta (P-REBOA) in major traumatic hemorrhage

Davidson, Anders J.; Russo, Rachel M.; DuBose, Joseph J.; Roberts, J. E. H.; Jurkovich, Gregory J.; Galante, Joseph M.

doi:10.1136/tsaco-2016-000028

Cited by 35 publications

(28 citation statements)

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“…Clinical reports of volatile proximal hemodynamics during step-wise or partial balloon deflation support our finding that graded balloon deflation alone may be insufficient to support proximal MAP. (10, 17) Thus, partial reinflation of the balloon may be required to maintain or restore adequate proximal perfusion pressure to the heart and brain during this process.…”

Section: Discussionmentioning

confidence: 99%

“…Yet, anecdotal evidence suggests even graded balloon deflation may result in hemodynamic instability. (10) Given the lack of clarity from both a translational and clinical perspective, we sought to characterize the hemodynamic impact of incremental balloon deflation following sustained REBOA, particularly with respect to mean arterial pressure and aortic flow.…”

Section: Introductionmentioning

confidence: 99%

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Incremental balloon deflation following complete resuscitative endovascular balloon occlusion of the aorta results in steep inflection of flow and rapid reperfusion in a large animal model of hemorrhagic shock

Davidson

Russo

Ferencz

et al. 2017

Journal of Trauma and Acute Care Surgery

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Introduction To avoid potential cardiovascular collapse after Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), current guidelines recommend methodically deflating the balloon over 5 minutes to gradually reperfuse distal tissue beds. However, anecdotal evidence suggests that this approach may still result in unpredictable aortic flow rates and hemodynamic instability. We sought to characterize aortic flow dynamics following REBOA as the balloon is deflated in accordance with current practice guidelines. Methods Eight Yorkshire-cross swine were splenectomized, instrumented, and subjected to rapid 25% total blood volume hemorrhage. After 30 minutes of shock, animals received 60 minutes of zone 1 REBOA with a low-profile REBOA catheter. During subsequent resuscitation with shed blood, the aortic occlusion balloon was gradually deflated in stepwise fashion at the rate of 0.5 mL every 30 seconds until completely deflated. Aortic flow rate and proximal mean arterial pressure (MAP) were measured continuously over the period of balloon deflation. Results Graded balloon deflation resulted in variable initial return of aortic flow (median 78 seconds, IQR 68–105sec). A rapid increase in aortic flow during a single balloon deflation step was observed in all animals (Median 819 mL/min IQR 664-1241mL/min) and corresponded with an immediate decrease in proximal MAP (Median 30 mmHg IQR 14.5–37mmHg). Total balloon volume and time to return of flow demonstrated no correlation (r2=0.016). Conclusion This study is the first to characterize aortic flow during balloon deflation following REBOA. A steep inflection point occurs during balloon deflation that results in an abrupt increase in aortic flow and a concomitant decrease in MAP. Furthermore, the onset of distal aortic flow was inconsistent across study animals and did not correlate with initial balloon volume or relative deflation volume. Future studies to define the factors that impact aortic flow during balloon deflation are needed to facilitate controlled reperfusion following REBOA.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Incremental balloon deflation following complete resuscitative endovascular balloon occlusion of the aorta results in steep inflection of flow and rapid reperfusion in a large animal model of hemorrhagic shock

Davidson

Russo

Ferencz

et al. 2017

Journal of Trauma and Acute Care Surgery

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“…17 Furthermore, hemodynamic instability during attempts at partial flow restoration has been observed in early clinical experience. 20 While this approach to aortic flow reintroduction is rational in resource-rich environments with access to blood products and operating rooms, it will be limited in scenarios in which a prolonged time period exists between injury and hemorrhage control. In an effort to address these limitations, we have proposed an experimental technique to deliver tightly controlled, low-volume aortic blood flow, termed variable aortic control (VAC).…”

Section: Introductionmentioning

confidence: 99%

Automated variable aortic control versus complete aortic occlusion in a swine model of hemorrhage

Williams

Neff

Johnson

et al. 2017

Journal of Trauma and Acute Care Surgery

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Background Future endovascular hemorrhage control devices will require features that mitigate the adverse effects of vessel occlusion. Permissive regional hypoperfusion (PRH) with variable aortic control (VAC) is a novel strategy to minimize hemorrhage and reduce the ischemic burden of complete aortic occlusion (AO). The objective of this study was to compare PRH with VAC to AO in a lethal model of hemorrhage. Methods Twenty-five swine underwent cannulation of the supraceliac aorta, with diversion of aortic flow through an automated extracorporeal circuit. After creation of uncontrolled liver hemorrhage, animals were randomized to 90 minutes of treatment: Control (full, unregulated flow; n=5) AO (no flow; n=10), and PRH with VAC (dynamic distal flow initiated after 20 minutes of AO; n=10). In the PRH group, distal flow rates were regulated between 100–300mL/min based on a desired, preset range of proximal mean arterial pressure (MAP). At 90 minutes, damage control surgery, resuscitation, and restoration of full flow ensued. Critical care continued for 4.5 hours or until death. Hemodynamic parameters and markers of ischemia were recorded. Results Study survival was 0%, 50%, and 90% for control, AO, and VAC respectively (p<0.01) (Figure). During intervention, VAC resulted in more physiologic proximal MAP (84mmHg±18 vs. 105±9mmHg, p<0.01) and higher renal blood flow than AO animals (p=0.02). During critical care, VAC resulted in higher proximal MAP (73 mmHg±8 vs. 50 mmHg±6, p<0.01), carotid and renal blood flow (p<0.01), lactate clearance (p<0.01), and urine output (p<0.01) than AO despite requiring half the volume of crystalloids to maintain proximal MAP ≥50 mmHg (p<0.01). Conclusion Permissive regional hypoperfusion with variable aortic control minimizes the adverse effects of distal ischemia, optimizes proximal pressure to the brain and heart, and prevents exsanguination in this model of lethal hemorrhage. These findings provide foundational knowledge for the continued development of this novel paradigm and inform next generation endovascular designs.

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“…Clear contraindications have yet to be established, but expert opinion suggests REBOA may be harmful in the setting of both blunt and penetrating thoracic injury, particularly when a thoracic aortic injury is suspected (24). It has been hypothesized that in the setting of thoracic trauma Zone I occlusion could lead to increased bleeding and rapid hemodynamic collapse, although recent clinical experience in a single patient with both thoraco-abdominal penetrating trauma has demonstrated that REBOA can lead to successful resuscitations even in the setting of thoracic trauma as long as major vessel injury is not suspected (25). Patient selection may ultimately require consideration of the anatomic distribution of injuries and the mechanism of injury, as patients with penetrating injury tend to have higher survival following REBOA therapy than do patients with a similar degree of hemorrhagic shock from blunt injury (22).…”

Section: Endovascular Methods For Achieving Aortic Occlusionmentioning

confidence: 99%

“…In a case report out of Sweden, an aortic occlusion balloon was partially inflated in an effort to augment proximal blood pressure, slow pelvic hemorrhage distally, and avoid exacerbation of a TBI in a multi-trauma patient with hemorrhagic shock (35). A recent second case not yet published has also demonstrated success of P-REBOA during the resuscitation of a multiply injured patient without a TBI, but together these individual case reports are only anecdotal (25). To address this knowledge gap, our group sought to explore the utility of P-REBOA in a simulated pre-hospital scenario of uncontrolled truncal hemorrhage.…”

Section: Endovascular Methods For Achieving Aortic Occlusionmentioning

confidence: 99%

Emerging Endovascular Therapies for Non-Compressible Torso Hemorrhage

Russo

Neff

Johnson

et al. 2016

Shock

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Management of non-compressible torso hemorrhage (NCTH) remains a challenge despite continued advancements in trauma resuscitation. Resuscitative thoracotomy with aortic cross-clamping and recent advances in endovascular aortic occlusion, including resuscitative endovascular occlusion of the aorta (REBOA), have finite durations of therapy due to the inherent physiologic stressors that accompany complete occlusion. Here we attempt to illuminate the current state of aortic occlusion for trauma resuscitation including: 1) explanation of the deleterious consequences of complete occlusion, 2) potential methods and limitations of existing technology to overcome these consequences, 3) a description of innovative methods to improve the resuscitation of NCTH. By explaining the complexity and potential deleterious effects of resuscitation augmented with aortic occlusion, our goal is to provide practitioners with a real-world perspective on current endovascular technology and to encourage the continued innovation required to overcome existing obstacles.

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Potential benefit of early operative utilization of low profile, partial resuscitative endovascular balloon occlusion of the aorta (P-REBOA) in major traumatic hemorrhage

Cited by 35 publications

References 0 publications

Incremental balloon deflation following complete resuscitative endovascular balloon occlusion of the aorta results in steep inflection of flow and rapid reperfusion in a large animal model of hemorrhagic shock

Incremental balloon deflation following complete resuscitative endovascular balloon occlusion of the aorta results in steep inflection of flow and rapid reperfusion in a large animal model of hemorrhagic shock

Automated variable aortic control versus complete aortic occlusion in a swine model of hemorrhage

Emerging Endovascular Therapies for Non-Compressible Torso Hemorrhage

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