Resuscitative endovascular balloon occlusion of the aorta for major abdominal venous injury in a porcine hemorrhagic shock model

Lallemand, Michaël; Moe, Donald; McClellan, John M.; Smith, Joshua P.; Daab, Leo J.; Marko, Shannon T.; Tran, Nam; Starnes, Benjamin W.; Martin, Matthew J.

doi:10.1097/ta.0000000000001548

Cited by 41 publications

(19 citation statements)

References 14 publications

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“…Though bleeding was not arterial in this case, we feel that aortic occlusion did allow for controlled entry into the abdomen, safe dissection, and control of the iliac vessels, and provided time for anesthesia to 'catch up' with resuscitation. Control of venous bleeding with REBOA has been demonstrated previously [21]. After operative control of the iliac vessels, we were able to deflate the balloon without further hemodynamic compromise.…”

Section: Journal Of Endovascular Resuscitation and Trauma Managementsupporting

confidence: 56%

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as an Adjunct to Damage Control Surgery for Combat Trauma: A Case Report of the First REBOA Placed in Afghanistan

Glaser

Teeter²,

Gerlach³

et al. 2017

JEVTM

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Background: Non compressible torso hemorrhage continues to be the leading cause of preventable death in combat operations. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as an alternative hemorrhage control strategy, with morbidity advantages over resuscitative thoracotomy. We report the first ever use of REBOA in a combat casualty in Afghanistan. Case Report: An 18 year old Afghan male was injured by a single high velocity gunshot wound during partnered operations. He was treated with a damage control operation at the role 2 level, with significant presacral and pelvic bleeding controlled with combat gauze packing. The patient continued to be hemodynamically labile, with ongoing transfusion requirements and required emergent re-exploration. Upon transfer from the gurney to the operating table the patient was noted to be hypotensive with a blood pressure of 62/38. An ER-REBOA catheter was measured for Zone 1 occlusion and placed without difficulty. The patient’s hemodynamics normalized, which allowed for sterile entry into the abdomen and vascular control. After 10 minutes of occlusion the balloon was deflated. Surgical repair was completed and patient survived to discharge. Conclusions: REBOA is an adjunct to hemorrhagic shock that provides temporary proximal control bridge to definitive surgical hemostasis while avoiding the morbidity of a resuscitative thoracotomy. This case represents the first reported use of REBOA in the Afghanistan Theater. This case further supports increased consideration for use of REBOA in the forward setting.

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Section: Journal Of Endovascular Resuscitation and Trauma Managementsupporting

confidence: 56%

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as an Adjunct to Damage Control Surgery for Combat Trauma: A Case Report of the First REBOA Placed in Afghanistan

Glaser

Teeter²,

Gerlach³

et al. 2017

JEVTM

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“…For some applications, high-voltage, non-neural vasoconstriction has the advantage of constricting veins nearly as much as arteries. This could help control traumatic bleeding in highly perfused tissue, where the major arterial blood supply may be difficult to locate or reach, or in sacral and pelvic cavities where venous hemorrhage can be significant [ 47 – 49 ].…”

Section: Discussionmentioning

confidence: 99%

Mechanisms of electrical vasoconstriction

Brinton

Mandel

Schachar

et al. 2018

J NeuroEngineering Rehabil

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BackgroundElectrical vasoconstriction is a promising approach to control blood pressure or restrict bleeding in non-compressible wounds. We explore the neural and non-neural pathways of electrical vasoconstriction in-vivo.MethodsCharge-balanced, asymmetric pulses were delivered through a pair of metal disc electrodes. Vasoconstriction was assessed by measuring the diameter of rat saphenous vessels stimulated with low-voltage (20 V, 1 ms) and high-voltage (150 V, 10 μs) stimuli at 10 Hz for 5 min. Activation pathways were explored by topical application of a specific neural agonist (phenylephrine, alpha-1 receptor), a non-specific agonist (KCl) and neural inhibitors (phenoxybenzamine, 25 mg/ml; guanethidine, 1 mg/ml). Acute tissue damage was assessed with a membrane permeability (live-dead) fluorescent assay. The Joule heating in tissue was estimated using COMSOL Multiphysics modeling.ResultsDuring stimulation, arteries constricted to 41 ± 8% and 37 ± 6% of their pre-stimulus diameter with low- and high-voltage stimuli, while veins constricted to 80 ± 18% and 40 ± 11%, respectively. In arteries, despite similar extent of constriction, the recovery time was very different: about 30 s for low-voltage and 10 min for high-voltage stimuli. Neural inhibitors significantly reduced low-voltage arterial constriction, but did not affect high-voltage arterial or venous constriction, indicating that high-voltage stimuli activate non-neural vasoconstriction pathways. Adrenergic pathways predominantly controlled low-voltage arterial but not venous constriction, which may involve a purinergic pathway. Viability staining confirmed that stimuli were below the electroporation threshold. Modeling indicates that heating of the blood vessels during stimulation (< 0.2 °C) is too low to cause vasoconstriction.ConclusionsWe demonstrate that low-voltage stimuli induce reversible vasoconstriction through neural pathways, while high-voltage stimuli activate non-neural pathways, likely in addition to neural stimulation. Different stimuli providing precise control over the extent of arterial and venous constriction as well as relaxation rate could be used to control bleeding, perfusion or blood pressure.

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“…Blood loss is similar between groups but the rate of bleeding is markedly decreased with REBOA. REBOA appears effective for central venous injuries and provides a sustained period of stabilization and an extended window for surgical intervention [ 7 ].…”

Section: Introductionmentioning

confidence: 99%

Three cases of resuscitative endovascular balloon occlusion of the aorta (REBOA) in austere pre-hospital environment—technical and methodological aspects

et al. 2018

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BackgroundThe present paper describes three cases where ER-REBOA® was used with partial aorta occlusion (AO), by performing a partial resuscitative endovascular balloon occlusion of the aorta or pREBOA, in an austere pre-hospital military environment.In addition, because no specific REBOA algorithm for pre-hospital environment exists yet, this paper seeks to fill this gap, proposing a new pragmatic REBOA algorithm.MethodsBelgian Special Operations Surgical Team applied REBOA in three patients according to a decisional algorithm, based on the MIST acronym used for trauma patients. Only 3 ml, in the first instance, was inflated in the balloon to get AO. The balloon was then progressively deflated, and reperfusion was tracked through changes of end-tidal carbon dioxide (EtCO2).ResultsSystolic blood pressure (SBP) before ER-REBOA® placement was not higher than 60 mmHg. However, within the first 5 min after AO, SBP improved in all three cases. Due to the aortic compliance, a self-made pREBOA was progressively achieved while proximal SBP was raising with intravenous fluid infusion. Afterwards, during deflation, a steep inflection point was observed in SBP and EtCO2.ConclusionsER-REBOA® is suitable for use in an austere pre-hospital environment. The MIST acronym can be helpful to select the patients for which it could be beneficial. REBOA can also be performed with pREBOA in a dynamic approach, inflating only 3 mL in the balloon and using the aortic compliance. Furthermore, while proximal SBP can be convenient to follow the occlusion, EtCO2 can be seen as an easy and interesting marker to follow the reperfusion.

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Resuscitative endovascular balloon occlusion of the aorta for major abdominal venous injury in a porcine hemorrhagic shock model

Cited by 41 publications

References 14 publications

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as an Adjunct to Damage Control Surgery for Combat Trauma: A Case Report of the First REBOA Placed in Afghanistan

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as an Adjunct to Damage Control Surgery for Combat Trauma: A Case Report of the First REBOA Placed in Afghanistan

Mechanisms of electrical vasoconstriction

Three cases of resuscitative endovascular balloon occlusion of the aorta (REBOA) in austere pre-hospital environment—technical and methodological aspects

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