Alexandros N. Flaris

Fixed-Distance Model for Balloon Placement During Fluoroscopy-Free Resuscitative Endovascular Balloon Occlusion of the Aorta in a Civilian Population

Importance Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an innovative procedure in the treatment of noncompressible truncal hemorrhage. However, readily available fluoroscopy remains a limiting factor in its widespread implementation. Several methods have been proposed to perform REBOA without fluoroscopic guidance, and these methods were adapted predominantly from the military theater. Objective To develop a method for performing REBOA in a civilian population using a standardized distance from a set point of entry. Design, Setting, and Participants A retrospective study of whole-body computed tomographic (CT) scans from a cohort of 280 consecutive civilian trauma patients from University Hospitals of Lyon, France, was used to calculate the endovascular distances from both femoral arteries at the level of the upper border of the symphysis pubis to aortic zone I (descending thoracic aorta) and zone III (infrarenal aorta). These whole-body CT scans were performed between 2013 and 2015. Data were analyzed from July 16 to December 7, 2015. Main Outcomes and Measures Two segments (1 per zone) common to all CT scans were isolated, and their location, length, prevalence in the cohort, and predicted prevalence in the general population were calculated by inverting 99% certainty tolerance limits. Results Among the 280 trauma patients (140 men and 140 women) in this study, the mean (SD) height was 170.7 (8.7) cm, and the mean (SD) age was 38.8 (16.5) years. The common segment in zone I (414-474 mm) existed in all CT scans. The common segment in zone III (236-256 mm) existed in 99.6% and 97.9% of CT scans from the right and left femoral arteries, respectively. These segments are expected to exist in 98.7% (zone I) and 94.9% (zone III) of the general population. Conclusions and Relevance Target distances for blind placement of REBOA exist with more than 94% prevalence in a civilian population. These findings support the expanded use of REBOA in emergency department and prehospital settings. Validation for safety and efficacy on cadaveric and clinical models is necessary.

What Kind of Incision Should Be Used in Thoracic Trauma Patients in Emergent Cases? Reply

We would like to thank Dr. Gökalp and his colleagues for their interesting comments on our study, ‘‘Clamshell incision versus left anterolateral thoracotomy. Which one is faster when performing a resuscitative thoracotomy? The tortoise and the hare revisited’’ [1]. The question asked is which incision provides superior access to an underlying thoracic lesion. The authors propose a comparison between median sternotomy, left anterolateral thoracotomy, and the clamshell incision when performed on patients with cardiac or pulmonary lesions that do not necessitate a resuscitative approach. To answer the question from an anatomical point of view, our group in a previous study created anatomic accessibility maps of intrathoracic structures for the following incisions: left and right anterolateral thoracotomies, median sternotomy, and the clamshell incision [2]. We found that the clamshell incision provides total exposure to almost all intrathoracic structures. To answer the question from a functional point of view, thoracic incisions have to be further classified into different groups according to patient status. As Dr. Gökalp and colleagues suggested in their letter, thoracic incisions can be divided into two groups: those performed on patients in extremis (resuscitative thoracotomy) and those performed on patients in a less critical albeit emergent condition. Despite recent controversy [3, 4], and especially when the non-specialist has to perform a resuscitative thoracotomy, the clamshell incision is the right call, for four reasons: (1) the uncertainty about the location of the underlying lesions, which necessitates a wide incision that will cover all possibilities, (2) the clamshell’s superb exposure [2], (3) the ease with which it can be performed by non-specialists [5– 7], and (4) the simple instruments needed to perform it [8] (as opposed notably to median sternotomy). On the other hand, when the patient is not in extremis, there is time to choose the most appropriate incision depending on the most probable lesion. If a cardiac lesion necessitating an operation is found, median sternotomy is an excellent incision offering direct access to the heart [2]. Beşir et al. observed that when compared to the left anterolateral thoracotomy, median sternotomy resulted in a shorter duration of operation and hospital stay [9], important results indicating that median sternotomy is the right call for cardiac lesions in an emergent but not in an extremis situation. Since the indications for these two incisions, clamshell versus median sternotomy, are completely different, they cannot be functionally compared. It cannot be said that one is superior to the other, since they are generally not employed in the same setting. In summary, when a patient with thoracic lesions is in extremis, the clamshell incision should be preferred & Alexandros N. Flaris alexander.flaris@gmail.com