Resuscitative endovascular balloon occlusion of the aorta in combat casualties: The past, present, and future

Stokes, Sarah C.; Theodorou, Christina M.; Zakaluzny, Scott; DuBose, Joseph J.; Russo, Rachel M.

doi:10.1097/ta.0000000000003166

Cited by 21 publications

(32 citation statements)

References 98 publications

(196 reference statements)

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“…The technique described uses 'off-the-shelf' equipment which is familiar to many clinicians with endovascular practice. The relative availability and lower cost of this technique offers some versatility and could be applied in the management of bleeding in other areas such as high-risk labour or postpartum haemorrhage [13,36], as well as use in austere healthcare settings [37] and in those with more limited budgets/resources, or in the management of out-of-hospital cardiac arrest [14].…”

Section: Governance and Trainingmentioning

confidence: 99%

A Practical Approach to Introducing Pre-Hospital Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), the Problems Encountered and Lessons Learned

Chana

Perkins²,

Lendrum

et al. 2021

JEVTM

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Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is an endovascular procedure which utilises a catheter based balloon device to achieve aortic occlusion. The aim of this resuscitative measure is to improve blood pressure proximal to the occlusion site and therefore preserve cardiac and cerebral perfusion in order to prevent cardiac arrest; additionally there is a relative reduction in arterial inflow to the site of injury. Endovascular techniques are gaining acceptance for the in-hospital management of haemorrhage, however their use in pre-hospital care is still limited. This is due to a number of factors including the technical challenges, training and skill sets of pre-hospital care teams and the potential for harm of REBOA, particularly with extended balloon occlusion times. However, non compressible torso haemorrhage is associated with a mortality of approximately 50% and a significant proportion of these deaths occur in the pre-hospital phase of care. In the exsanguinating patient, resuscitative thoracotomy (RT) with direct aortic compression is often the only means to control haemorrhage. This resuscitative measure is now an established pre-hospital intervention which has significantly improved outcomes in the context of penetrating trauma, particularly thoracic injury. In the context of blunt injury and subdiaphragmatic haemorrhage, however, the outcomes from pre-hospital resuscitative thoracotomy remain poor. We present our initial technique for successfully introducing REBOA for the pre-hospital management of exsanguinating pelvic or groin heamorrhage following trauma, our indications for REBOA and comment on the problems and limitations encountered as well the lessons learned.

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Section: Governance and Trainingmentioning

confidence: 99%

A Practical Approach to Introducing Pre-Hospital Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), the Problems Encountered and Lessons Learned

Chana

Perkins²,

Lendrum

et al. 2021

JEVTM

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“…The partial Resuscitative Endovascular Balloon Occlusion of Aorta (pREBOA)-PRO system is utilized to temporize non-compressible truncal hemorrhage in the setting of trauma. Since the first reported instance of the use of aortic balloon occlusion in the 1950s in a battlefield setting, much progress has been made in development of this minimally invasive portable technology with the goal of reducing loss of life due to hemorrhage [1]. In practice, immense variation exists in the range of specific locations and occlusion times of the pREBOA-PRO system.…”

Section: Introductionmentioning

confidence: 99%

Reduction of Distal Ischemia with pREBOA-PRO in a Trauma Laparotomy Requiring Extended Occlusion Time

Foley

Hunt²,

Marr³

et al. 2023

JEVTM

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“…However, this heroic procedure has poor outcomes and is highly invasive. A minimally invasive endovascular alternative, resuscitative endovascular balloon occlusion of the aorta (REBOA) ( Stannard et al, 2011 ; Morrison et al, 2012 ; Morrison et al, 2014 ; Borger van der Burg et al, 2018 ; Brenner et al, 2018 ; Glaser et al, 2020 ; Stokes et al, 2021 ), which was initially used for management of ruptured aortic aneurysms ( Hughes, 1954 ; Malina et al, 2005 ; White et al, 2011 ; Berland et al, 2013 ), has proved useful for NCTH following trauma. To occlude the aorta, the balloon-bearing catheter is placed through a femoral arterial sheath and inserted into the aorta where it is used to provide endovascular aortic occlusion.…”

Section: Introductionmentioning

confidence: 99%

The Underlying Cardiovascular Mechanisms of Resuscitation and Injury of REBOA and Partial REBOA

et al. 2022

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Introduction: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is used for aortic control in hemorrhagic shock despite little quantification of its mechanism of resuscitation or cardiac injury. The goal of this study was to use pressure-volume (PV) loop analysis and direct coronary blood flow measurements to describe the physiologic changes associated with the clinical use of REBOA.Methods: Swine underwent surgical and vascular access to measure left ventricular PV loops and left coronary flow in hemorrhagic shock and subsequent placement of occlusive REBOA, partial REBOA, and no REBOA. PV loop characteristics and coronary flow are compared graphically with PV loops and coronary waveforms, and quantitatively with measures of the end systolic and end pressure volume relationship, and coronary flow parameters, with accounting for multiple comparisons.Results: Hemorrhagic shock was induced in five male swine (mean 53.6 ± 3.6 kg) as demonstrated by reduction of stroke work (baseline: 3.1 vs. shock: 1.2 L*mmHg, p < 0.01) and end systolic pressure (ESP; 109.8 vs. 59.6 mmHg, p < 0.01). ESP increased with full REBOA (178.4 mmHg; p < 0.01), but only moderately with partial REBOA (103.0 mmHg, p < 0.01 compared to shock). End systolic elastance was augmented from baseline to shock (1.01 vs. 0.39 ml/mmHg, p < 0.01) as well as shock compared to REBOA (4.50 ml/mmHg, p < 0.01) and partial REBOA (3.22 ml/mmHg, p = 0.01). Percent time in antegrade coronary flow decreased in shock (94%–71.8%, p < 0.01) but was rescued with REBOA. Peak flow increased with REBOA (271 vs. shock: 93 ml/min, p < 0.01) as did total flow (peak: 2136, baseline: 424 ml/min, p < 0.01). REBOA did not augment the end diastolic pressure volume relationship.Conclusion: REBOA increases afterload to facilitate resuscitation, but the penalty is supraphysiologic coronary flows and imposed increase in LV contractility to maintain cardiac output. Partial REBOA balances the increased afterload with improved aortic system compliance to prevent injury.

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Resuscitative endovascular balloon occlusion of the aorta in combat casualties: The past, present, and future

Cited by 21 publications

References 98 publications

A Practical Approach to Introducing Pre-Hospital Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), the Problems Encountered and Lessons Learned

A Practical Approach to Introducing Pre-Hospital Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), the Problems Encountered and Lessons Learned

Reduction of Distal Ischemia with pREBOA-PRO in a Trauma Laparotomy Requiring Extended Occlusion Time

The Underlying Cardiovascular Mechanisms of Resuscitation and Injury of REBOA and Partial REBOA

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