REBOA: Who, What and Why - Deborah Stein

REBOA: WHO, WHAT AND WHY? (AND HOW)

Deborah M. Stein, MD, MPHChief of Trauma, R Adams Cowley Shock Trauma Center

The “why”

Leading Causes of Death Following Injury?

#2 Hemorrhage

#3 Sepsis/MODS

#1 Traumatic

Brain Injury

…is the leading cause of potentially preventable death

Hemorrhage

“The only weapon with which the unconscious

patient can immediately retaliate upon the

incompetent surgeon is hemorrhage.”

- Halstead

Direct Manual Pressure

Topical Hemostatic Agents QuikClot®

Modified Rapid Deployment Hemostatic Dressing

WoundStat™

HemCon

Etc…

Tourniquets

• Non-compressible bleeding accounts for approximately 85% of preventable deaths on the battlefield, 80% of which include acute hemorrhage within the abdomen/torso.

Noncompressible hemorrhage

Guiding Principle - Proximal Aortic Control

Ledgerwood AM, et al. J Trauma. 1976

Advantages to aortic occlusion prior to laparotomy:1. Continued cerebral/coronary

perfusion2. Avoid catastrophic CV collapse

with laparotomy3. Proximal aortic control decreases

blood loss

Examine role of laparotomy in ED for abdominal hemorrhage

51 patients All had EDT prior to laparotomy

Survival 0%

It is all about exposure!

Is there a better way?

Pubmed “REBOA” 2 years ago….

The “what”

REBOA – Resuscitative Endovascular Balloon Occlusion of the Aorta

Not a New Concept

Hughes CW. Surgery, 1954

Pre-Endovascular Era

Low RB et al. Preliminary report on the use of the Percluder occluding aortic balloon in human beings.

Annals of emergency medicine. 1986 Dec;15(12):1466–9. 13% survival in 15 trauma patients after REBOA

Gupta BK et al. The Role of Intra-aortic Balloon Occlusion in Penetrating Abdominal Trauma.

The Journal of Trauma. 1989;29(6):861–5. 35% survival in 20 trauma patients after REBOA

Endovascular Era Greenberg RK et al. An endoluminal

method of hemorrhage control and repair of ruptured AAA. J Endovasc Ther 2000

Malina M, Veith F. Balloon occlusion of the aorta during endovascular repair of ruptured abdominal aortic aneurysm. J Endovasc Ther. 2005 Oct;12(5):556–9.

Translational Research Endovascular balloon occlusion of the aorta is

superior to resuscitative thoracotomy with aortic clamping in a porcine model of hemorrhagic shock. White et al. Surgery 2011;150:400-9.

REBOA vs EDT + clamping REBOA group:

Less acidotic Lower serum lactate Lower pCO2 level Required less fluid and pressor during resuscitation

Translational Research Forty-minute Endovascular Aortic Occlusion Increases

Survival in an Experimental Model of Uncontrolled Hemorrhagic Shock caused by Abdominal Trauma. Avaro et al. J Trauma. 2011;71:720-5

REBOA vs fluid resuscitation REBOA group:

More survivors Higher MAP Lower lactate levels

No difference in bowel/renal ischemia between no REBOA and REBOA groups at 40 or 60 minutes

Morrison JJ, et al. J Sur Research. 2012

Translational research Same group has looked at

Effect on inflammatory cascades Survivability up to 90 minutes of occlusion Functional outcomes and paraplegia rates Continuous vs. intermittent use

Novel systems without fluoroscopy and smaller sheaths

Morrison JJ, et al. J Surg Research. 2014Markov NP, et al. Surgery 2013

Long KN, et al. Ann Vasc Surg. 2015Morrison JJ, et al. Shock. 2014Scott DJ, et al. J Trauma. 2013

Case Series - Trauma

13 patients with pelvic fracture, refractory hypotension

Aortic occlusion performed by IR – in-house 46% survival

Martinelli T, et al. J Trauma 2010 Apr;68(4):942-8

Brenner ML, et al. J Trauma Acute Care Surg. 2013

Overall (N = 96) 

Resuscitative Thoracotomy (n=72)

REBOA (n=24)

p value

Age, Median (P25,P75) 30.5(23.5, 48) 41 (24,62) 0.33Male %(n) 87.5% (63) 79.2%(19) 0.33Blunt %(n) 44.4% (32) 66.7% (16) 0.10ISS, Median (P25,P75) 34 (22,59) 29 (19,41) 0.17AIS Head, Median (P25,P75) 3 (0,5) 4 (3,5) 0.29AIS Chest, Median (P25,P75) 3 (3,4) 3.5 (3,4) 0.91AIS Abdomen, Median (P25,P75) 2 (0,4) 3 (2,4) 0.26AIS Extremity, Median (P25,P75) 1.5 (0,3) 4 (3,4) <0.001Survival Rate % (n) 9.7% (7) 37.5% (9) 0.003

Moore LJ, et al. AAST, 2014

Norii T, et al. J Trauma and Acute Care Surg, 2015

The “how”

Proximal Aortic Control – Aortic Occlusion Balloon (REBOA)

Stannard A, et al. J Trauma. 2011

The “who”

REBOA

Case

26 year old male with GSW to abdomen and SBP of 60

Resus lines and R femoral A line placed + FAST To OR

Case In OR, has cardiac arrest REBOA placed through R femoral access SBP to 95 At ex lap:

Shattered right kidney Grade IV liver injury Multiple mesenteric and bowel injuries Rapid hemorrhage control/nephrectomy/packed

Angio through R femoral sheath AE of R hepatic artery

Repair of R CFA Left open and packed

Case Taken back to OR on POD #2 Unpacked, closed Extubated POD #5/7

D/Ced home POD #11/13

Hybrid ORs

Biffl WL, et al. J Trauma Acute Care Surg. 2015

Unanswered Questions Who should be performing REBOA? What

should be the standards for training, credentialing, and competency?

What about open cardiac massage?

Is the technology appropriate?

Brenner ML, et al. J Trauma Acute Care Surg. 2014

Brenner ML, et al. J Trauma Acute Care Surg. 2014

What about open cardiac massage?Table. EtCO2 Values for CCC and OCCM periods

 CCC Only*

(n=18)

 OCCM after CCC

(n=17)

  CCC vs. OCCM

  First Min Total p CCC† OCCM p pInitial

6.1±9.4 8.2±10.6 0.53 3.4±3.4 8.5±5.7 0.007

0.92

Final 6.4±6.9 16.2±12.1

0.01 7.2±6.9 14.8±12.1

0.03 0.73

Peak 9±9.7 27.4±16.5

0.003

10.4±10.4

28.8±22.2

0.004

0.83

Mean 6.8±7.4 12.4±6.1 0.02 6.8±6.4 13.1±8.7 0.02 0.78*CCC-only data separated into first minute and the remainder of CCC period for comparison to OCCM†Mean CCC period duration prior to OCCM = 66.3 ± 33.1 seconds

Adjunct for Nonoperative Mangement?

Case Reports - Nontrauma Paull JD et al. Balloon occlusion of the abdominal aorta during

caesarean hysterectomy for placenta percreta. Anaes int care. 1995 Dec;23(6):731–4.

Bell-Thomas, SM et al. Emergency use of a transfemoral aortic occlusion catheter to control massive haemorrhage at caesarean hysterectomy. BJOG 2003 Dec;110(12):1120–2.

Tang X et al. Use of aortic balloon occlusion to decrease blood loss during sacral tumor resection. J Bone Joint Surg 2010 Jul 21;92(8):1747–53.

Søvik E et al. The use of aortic occlusion balloon catheter without fluoroscopy for life-threatening post-partum haemorrhage. Acta Anaes Scand. 2012 Mar;56(3):388–93.

Elective orthopedics? Elective urological procedures?

Nothing is for free!

Biffl WL, et al. J Trauma Acute Care Surg. 2015

Nothing is for free!

“Pre-hospital REBOA would appear to be well suited to the geography of Scotland, which includes a spectrum of topography ranging from major urban lowland regions to rural Northern and island territories. The use of this technique in patients with haemorrhagic shock, who are injured in remote areas, would facilitate an extension of the window for salvage, and in turn permit transfer to definitive care.”

Morrison JJ. The Surgeon. 2014

REBOA in the field?How London Air Ambulance saved life of cyclist who lost leg in skip

lorry crash

A young cyclist who was miraculously saved by Air Ambulance medics and

hospital surgeons after being run over by a skip lorry today told how she felt

“lucky to be alive”.

Victoria Lebrec, 24, only survived because a London’s Air Ambulance

doctor performed a life-saving procedure successfully at the

roadside for only the second time in the world to stop her bleeding to

death.

05 January 2015

Still to be answered

Many questions…

Work to be done…

Thank you