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Challenges in trauma and acute care surgery
Use of REBOA to stabilize in-hospital iatrogenic intra-abdominal hemorrhage
  1. Christopher J Goodenough,
  2. Tyler A Cobb,
  3. John B Holcomb
  1. Department of Surgery, University of Texas Health Science Center at Houston, Memorial Hermann Hospital Red Duke Trauma Institute, Houston, Texas, USA
  1. Correspondence to Dr Christopher J Goodenough, Department of Surgery, University of Texas Health Science Center at Houston, Memorial Hermann Hospital Red Duke Trauma Institute, Houston, TX 77030, USA; christopher.j.goodenough{at}uth.tmc.edu

Abstract

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has become an increasingly popular alternative to emergency thoracotomy and aortic cross-clamping in patients with exsanguinating hemorrhage.1 This new capability is increasingly being used in non-trauma situations.2 3 This report demonstrates another novel use of REBOA for iatrogenic intra-abdominal hemorrhage.

An 83-year-old man with multiple medical comorbidities and a history of chronic mesenteric ischemia was admitted to our institution for an elective mesenteric revascularization. Revascularization was unsuccessful, despite attempts to cross the lesion. Postprocedure, the patient developed a right groin hematoma, and CT on postprocedure day 0 demonstrated a femoral artery pseudoaneurysm and subintimal contrast at the level of the celiac artery, representing an iatrogenic dissection.

The following day, he complained of dizziness. Physical examination revealed a blood pressure of 68/35 mm Hg, heart rate of 100 beats per minute, and a distended abdomen. Because the surgical intensive care unit (SICU) was full, he was transferred to the neurotrauma intesive care unit (NTICU) and intubated for hemodynamic instability. A chest X-ray revealed a prior thoracic endovascular aortic repair (figure 1), but no intrathoracic hemorrhage or pathology. Bedside ultrasonography revealed intra-abdominal fluid. Laboratory workup showed hemoglobin of 6.1 g/dL, from 10.9 the previous day. The patient was given two units of packed red blood cells, without response. The intensive care unit (ICU) team initiated norepinephrine, with minimal improvement despite increasing doses.

Figure 1
Figure 1

Chest X-ray with catheter in zone 1. Arrows mark the proximal and distal markers of the resuscitative endovascular balloon occlusion of the aorta.

What would you do?

  1. Transfuse two units of packed red blood cells and observe.

  2. Proceed to the operating room (OR) for exploratory laparotomy.

  3. Endovascular balloon occlusion of the aorta (zone 1).

  • endovascular therapy
  • intraabdominal hemorrhage

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/tsaco-2018-000165

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    Footnotes

    • Contributors TAC: table and figure preparation. CJG and JBH: literature review and article preparation.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests JBH: Chief Medical Officer of Prytime Medical, Founder and Board of Directors of Decisio Health, Consultant for Terumo BCT, Medical Advisory Board of Arsenal Medical, and coinventor of the junctional emergency treatment tool.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement There are no relevant unpublished data.