Association for Academic SurgeryAortic balloon occlusion is effective in controlling pelvic hemorrhage
Introduction
Vascular disruption with concomitant hemorrhage is the leading cause of potentially preventable death following military and civilian trauma [1], [2], [3]. Vascular injury within the pelvis and proximal femoral region is particularly challenging as it exists within a junctional zone between the torso and the extremities [4], [5]. In this anatomic location, pelvic and proximal femoral vascular injury is not readily amenable to direct pressure or tourniquet application and generally requires control to be obtained within the abdomen.
The issue of vascular control in the setting of pelvic and junctional femoral hemorrhage has become particularly relevant to surgeons treating patients injured by improvised explosive devices (IEDs) [6]. Frequently these patients have sustained bilateral high lower extremity amputations with pelvic disruption and present in extremis requiring significant resuscitation and immediate operation [7]. Often, the first surgical maneuver required is occlusion of the terminal aorta through a laparotomy in order to reduce bleeding and enhance central aortic pressure.
An alternative method of aortic control is the use of endovascular aortic balloon occlusion, a technique that has been used in the setting of elective and emergent aneurysm repair for many years [8], [9]. When used in the trauma context, this technique has been termed resuscitative endovascular balloon occlusion of the aorta, or REBOA [10]. The technique of REBOA does not require an operating room and has been used to salvage patients with pelvic trauma who are too unstable to move from the emergency room [11]. Recently, three aortic zones have been proposed for consideration with the use of REBOA: zone I, an occlusion zone of the descending thoracic aorta; zone II, a nonocclusion zone consisting of the paravisceral aorta; and zone III, an occlusion zone of the infrarenal aorta [10]. The aim of this study is to evaluate the effectiveness of zone III REBOA in a porcine model of pelvic arterial hemorrhage.
Section snippets
Study overview
This study protocol was approved by the Institutional Animal Care and Use Committee (IACUC) and was undertaken at an accredited facility (Lackland Air Force Base, San Antonio, TX) under the supervision of licensed veterinary staff. Female Yorkshire swine (Sus scrofa), aged between 5 and 6 mo and weighing between 75 and 100 kg, were studied. Animals were physically fit and free of pathogens, having undergone a quarantine and acclimatization phase in the facility 7 d prior to the protocol.
The
Results
Thirty-eight consecutive animals were entered into the investigation: 3 model development and 35 study animals. All animals had similar pre-injury physiologic and laboratory indices (Table 1) except for weight. The animals in the NI group were heaviest, with animals in the CG group the lightest. There was no difference among groups when comparing blood volume of blood loss during the 45-s hemorrhage phase (P = 0.366).
In phase I (normal coagulation profile) the rate of hemorrhage (mL/min) during
Discussion
This study describes a novel translatable model of pelvic vascular injury resulting in a consistent rate of hemorrhage and mortality. Findings from this study demonstrate that in the setting of normal coagulation, zone III REBOA is equally as effective at controlling hemorrhage as manual pressure with a known topical hemostatic agent (Combat Gauze) but results in greater resuscitative fluid requirements. In the setting of dilutional coagulopathy, zone III REBOA provides better hemorrhage
Conclusion
In the setting of normal coagulation, zone III REBOA is equally effective at controlling hemorrhage as manual pressure with a known topical hemostatic agent but results in greater resuscitative fluid requirements. In the setting of coagulopathy, zone III REBOA provides better hemorrhage control, improved central aortic pressure, and lower mortality than the established topical hemostatic agent. In the current model, zone III REBOA had high rates of technical success and resulted in no adverse
Acknowledgments
We are grateful for the expertise of Dr. Bijan Kheirabadi and the Damage Control Resuscitation Task Area at the US Army Institute of Surgical Research, whose advice and discussion assisted in the planning of the model used in this study.
References (21)
- et al.
Endovascular balloon occlusion of the aorta is superior to resuscitative thoracotomy with aortic clamping in a porcine model of hemorrhagic shock
Surgery
(2011) - et al.
Evaluation of balloon tamponade of the abdominal aorta
J Surg Res
(1971) - et al.
Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003–2004 versus 2006
J Trauma
(2008) - et al.
Died of wounds on the battlefield: Causation and implications for improving combat casualty care
J Trauma
(2011) - et al.
Impact of hemorrhage on trauma outcome: An overview of epidemiology, clinical presentations, and therapeutic considerations
J Trauma
(2006) - et al.
Epidemiology and outcome of complex pelvic injury
Acta Orthop Belg
(2005) - et al.
Early predictors of mortality in hemodynamically unstable pelvis fractures
J Orthop Trauma
(2007) - et al.
Associated injuries in casualties with traumatic lower extremity amputations caused by improvised explosive devices
Br J Surg
(2012) - Jansen JO, Thomas GOR, Adams SA, et al. Early management of proximal traumatic lower extremity amputation and pelvic...
- et al.
Clamp before you cut: Proximal control of ruptured abdominal aortic aneurysms using endovascular balloon occlusion: Case reports
Vasc Endovasc Surg
(2006)
Cited by (117)
Open versus endovascular REBOA control of blood loss during cesarean delivery in the placenta accreta spectrum: A single-center retrospective case control study
2021, European Journal of Obstetrics and Gynecology and Reproductive BiologyWho Would Have Benefited from the Prehospital Use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)? An Autopsy Study
2019, Journal of the American College of SurgeonsResuscitative Endovascular Balloon Occlusion of the Aorta: A Review for Emergency Clinicians
2019, Journal of Emergency MedicineRevisiting the promise, practice and progress of resuscitative endovascular balloon occlusion of the aorta
2023, Current Opinion in Critical Care