Southwestern Surgical Congress
Resuscitative endovascular balloon occlusion of the aorta for control of noncompressible truncal hemorrhage in the abdomen and pelvis

https://doi.org/10.1016/j.amjsurg.2016.09.027Get rights and content

Abstract

Background

Noncompressible truncal hemorrhage is a leading cause of potentially preventable death in trauma and acute care surgery patients. These patients are at high risk of exsanguination before potentially life-saving surgical intervention may be performed. Temporary aortic occlusion is an effective means of augmenting systolic blood pressure and perfusion of the heart and brain in these patients. Aortic occlusion temporarily controls distal bleeding until permanent hemostasis can be achieved. The traditional method for temporary aortic occlusion is via resuscitative thoracotomy with cross clamping of the descending aorta. While effective, resuscitative thoracotomy is highly invasive and may worsen blood loss, hypothermia, and coagulopathy by opening an otherwise uninjured body cavity. Resuscitative endovascular balloon occlusion of the aorta (REBOA) achieves temporary aortic occlusion using an occlusive balloon catheter that is introduced into the aorta via endovascular access of the common femoral artery. For this reason it is thought that REBOA could provide a less-invasive method for temporary aortic occlusion. Our purpose is to describe our experience with the implementation of REBOA at our Level 1 trauma center.

Methods

A retrospective case series describing all cases of REBOA performed at a prominent level 1 trauma center between October 2011 and September 2015. The study inclusion criteria were any patient that received a REBOA procedure in the acute phases after injury. There were no exclusion criteria. Data were collected from electronic medical records and the hospital's trauma registry.

Results

A total of 31 patients underwent REBOA during the study period. The median age of REBOA patients was 47 (interquartile range [IQR] = 27 to 63) and 77% were male. A majority (87%) of patients sustained blunt trauma. The median injury severity score was 34 (IQR = 22 to 42). The overall survival rate was 32% but varied greatly between subgroups. Balloon inflation resulted in a median increase in systolic blood pressure of 55-mm Hg (IQR 33 to 60), in cases where the data were available (n = 20). A return to spontaneous circulation was noted in 60% of patients who had arrested before REBOA (n = 10). Overall, early death by hemorrhage was 28% with only 2 deaths in the emergency department before reaching the operating room.

Conclusions

REBOA is an effective method for achieving temporary aortic occlusion in trauma patients with noncompressible truncal hemorrhage. Balloon inflation correlated with increased blood pressure and temporary hemorrhage control in a vast majority of patients.

Section snippets

Patients and Methods

We retrospectively identified all patients that underwent REBOA at The Texas Trauma Institute, an American College of Surgeons–verified Level 1 Trauma Center in Houston, Texas between October 2011 and September 2015. Inclusion criteria were all patients that underwent REBOA during the study period. No patients that underwent REBOA were excluded from the study. Demographic data, mechanism of injury, injury severity score (ISS), Abbreviated Injury Scale, admission vital signs/laboratory values,

Results

Over the course of the 48-month study period, a total of 31 patients underwent REBOA. The median age of REBOA patients was 47 years of age (IQR 27 to 63). Seventy-seven percent of the patients were male and 87% had a blunt mechanism of injury. The median ISS was 34 (IQR = 22 to 42) and the overall survival rate was 32%. Of the 31 patients, 10 patients had cardiopulmonary resuscitation (CPR) in progress at the time of REBOA insertion.

Of the 21 deaths, 2 (9.5%) occurred in the ER, 7 (33%)

Comments

This clinical series represents the largest single center series from the United States on the contemporary use of REBOA as an adjunct for patients with hemorrhagic shock arising below the diaphragm. Although there has been a recent resurgence in the use of REBOA, the concept of aortic balloon occlusion is not new. In a 1954 case series, Lieutenant Colonel Carl Hughes first described the use of aortic balloon occlusion in 3 soldiers with intra-abdominal hemorrhage during the Korean War.16 With

Conclusions

Resuscitative endovascular balloon occlusion of the Aorta is an effective method for achieving temporary aortic occlusion in trauma patients with noncompressible torso hemorrhage arising from below the diaphragm. Balloon inflation in both zone 1 and zone 3 occlusions results in an increase in SBP. In addition, REBOA inflation during CPR resulted in return of spontaneous circulation in 60% of the patients. Despite the high-injury severity seen in this population, the overall survival rate was

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    There were no relevant financial relationships or any sources of support in the form of grants, equipment, or drugs.

    The authors declare no conflicts of interest.

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