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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%
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”
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
