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Aortic balloon occlusion is effective in controlling pelvic hemorrhage

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Abstract

Background

The objective of this study was to evaluate the efficacy of resuscitative endovascular aortic balloon occlusion (REBOA) of the distal aorta in a porcine model of pelvic hemorrhage.

Methods

Swine were entered into three phases of study: injury (iliac artery), hemorrhage (45 s), and intervention (180 min). Three groups were studied: no intervention (NI, n = 7), a kaolin-impregnated gauze (Combat Gauze) (CG, n = 7), or REBOA (n = 7). The protocol was repeated with a dilutional coagulopathy (CG-C, n = 7, and REBOA-C, n = 7). Measures of physiology, rates of hemorrhage, and mortality were recorded.

Results

Rate of hemorrhage was greatest in the NI group, followed by the REBOA and CG groups (822 ± 415 mL/min versus 11 ± 13 and 0.2 ± 0.4 mL/min respectively; P < 0.001). MAP following intervention (at 15 min) was the same in the CG and REBOA groups and higher than in the NI group (70 ± 4 and 70 ± 11 mm Hg versus 5 ± 13 mm Hg respectively; P < 0.001). There was 100% mortality in the NI group, with no deaths in the CG or REBOA group. In the setting of coagulopathy, the rate of bleeding was higher in the CG-C versus the REBOA-C group (229 ± 295 mL/min versus 20 ± 7 mL/min, P = 0.085). MAP following intervention (15 min) was higher in the REBOA-C than the CG-C group (71 ± 12 mm Hg versus 28 ± 31 mm Hg; P = 0.005). There were 5 deaths (71.4%) in the CG-C group, but none in the REBOA-C group (P = 0.010).

Conclusion

Balloon occlusion of the aorta is an effective method to control pelvic arterial hemorrhage. This technique should be further developed as an adjunct to manage noncompressible 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.

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