Megan Brenner

A Clinical Series of Resuscitative Endovascular Balloon Occlusion of the Aorta for Hemorrhage Control and Resuscitation

BACKGROUND A requirement for improved methods of hemorrhage control and resuscitation along with the translation of endovascular specialty skills has resulted in reappraisal of resuscitative endovascular balloon occlusion of the aorta (REBOA) for end-stage shock. The objective of this report was to describe implementation of REBOA in civilian trauma centers. METHODS Descriptive case series of REBOA (December 2012 to March 2013) used in scenarios of end-stage hemorrhagic shock at the University of Maryland, R. Adams Cowley Shock Trauma Center, Baltimore, Maryland, and Herman Memorial Hospital, The Texas Trauma Institute, Houston, Texas. RESULTS REBOA was performed by trauma and acute care surgeons for blunt (n = 4) and penetrating (n = 2) mechanisms. Three cases were REBOA in the descending thoracic aorta (Zone I) and three in the infrarenal aorta (Zone III). Mean (SD) systolic blood pressure at the time of REBOA was 59 (27) mm Hg, and mean (SD) base deficit was 13 (5). Arterial access was accomplished using both direct cutdown (n = 3) and percutaneous (n = 3) access to the common femoral artery. REBOA resulted in a mean (SD) increase in blood pressure of 55 (20) mm Hg, and the mean (SD) aortic occlusion time was 18 (34) minutes. There were no REBOA-related complications, and there was no hemorrhage-related mortality. CONCLUSION REBOA is a feasible and effective means of proactive aortic control for patients in end-stage shock from blunt and penetrating mechanisms. With available technology, this method of resuscitation can be performed by trauma and acute care surgeons who have benefited from instruction on a limited endovascular skill set. Future work should be aimed at devices that allow easy, fluoroscopy-free access and studies to define patients most likely to benefit from this procedure. LEVEL OF EVIDENCE Therapeutic study, level V.

The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: Data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA)

INTRODUCTION Aortic occlusion (AO) for resuscitation in traumatic shock remains controversial. Resuscitative endovascular balloon occlusion of the aorta (REBOA) offers an emerging alternative. METHODS The American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery registry prospectively identified trauma patients requiring AO from eight ACS Level 1 centers. Presentation, intervention, and outcome variables were collected and analyzed to compare REBOA and open AO. RESULTS From November 2013 to February 2015, 114 AO patients were captured (REBOA, 46; open AO, 68); 80.7% were male, and 62.3% were blunt injured. Aortic occlusion occurred in the emergency department (73.7%) or the operating room (26.3%). Hemodynamic improvement after AO was observed in 62.3% [REBOA, 67.4%; open OA, 61.8%); 36.0% achieving stability (systolic blood pressure consistently >90 mm Hg, >5 minutes); REBOA, 22 of 46 (47.8%); open OA, 19 of 68 (27.9%); p =0.014]. Resuscitative endovascular balloon occlusion of the aorta (REBOA) access was femoral cut-down (50%); US guided (10.9%) and percutaneous without imaging (28.3%). Deployment was achieved in Zones I (78.6%), II (2.4%), and III (19.0%). A second AO attempt was required in 9.6% [REBOA, 2 of 46 (4.3%); open OA, 9 of 68 (13.2%)]. Complications of REBOA were uncommon (pseudoaneurysm, 2.1%; embolism, 4.3%; limb ischemia, 0%). There was no difference in time to successful AO between REBOA and open procedures (REBOA, 6.6 ± 5.6 minutes; open OA, 7.2 ± 15.1; p = 0.842). Overall survival was 21.1% (24 of 114), with no significant difference between REBOA and open AO with regard to mortality [REBOA, 28.2% (13 of 46); open OA, 16.1% (11 of 68); p = 0.120]. CONCLUSION Resuscitative endovascular balloon occlusion of the aorta has emerged as a viable alternative to open AO in centers that have developed this capability. Further maturation of the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database is required to better elucidate optimal indications and outcomes. LEVEL OF EVIDENCE Therapeutic/care management study, level IV.

Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage

BACKGROUND Hemorrhage remains the leading cause of death in trauma patients. Proximal aortic occlusion, usually performed by direct aortic cross-clamping via thoracotomy, can provide temporary hemodynamic stability, permitting definitive injury repair. Resuscitative endovascular balloon occlusion of the aorta (REBOA) uses a minimally invasive, transfemoral balloon catheter, which is rapidly inserted retrograde and inflated for aortic occlusion, and may control inflow and allow time for hemostasis. We compared resuscitative thoracotomy with aortic cross-clamping (RT) with REBOA in trauma patients in profound hemorrhagic shock. METHODS Trauma registry data was used to compare all patients undergoing RT or REBOA during an 18-month period from two Level 1 trauma centers. RESULTS There was no difference between RT (n = 72) and REBOA groups (n = 24) in terms of demographics, mechanism of injury, or Injury Severity Scores (ISSs). There was no difference in chest and abdominal Abbreviated Injury Scale (AIS) scores between the groups. However, the RT patients had lower extremity AIS score as compared with REBOA patients (1.5 [0–3] vs. 4 [3–4], p < 0.001). Of the 72 RT patients, 45 (62.5%) died in the emergency department, 6 (8.3%) died in the operating room, and 14 (19.4%) died in the intensive care unit. Of the 24 REBOA patients, 4 (16.6%) died in the emergency department, 3 (12.5%) died in the operating room, and 8 (33.3%) died in the intensive care unit. In comparing location of death between the RT and REBOA groups, there were a significantly higher number of deaths in the emergency department among the RT patients as compared with the REBOA patients (62.5% vs. 16.7%, p < 0.001). REBOA had fewer early deaths and improved overall survival as compared with RT (37.5% vs. 9.7%, p = 0.003). CONCLUSION REBOA is feasible and controls noncompressible truncal hemorrhage in trauma patients in profound shock. Patients undergoing REBOA have improved overall survival and fewer early deaths as compared with patients undergoing RT. LEVEL OF EVIDENCE Therapeutic study, level IV.

Brief episodes of intracranial hypertension and cerebral hypoperfusion are associated with poor functional outcome after severe traumatic brain injury.

BACKGROUND Management strategies after severe traumatic brain injury (TBI) target prevention and treatment of intracranial hypertension (ICH) and cerebral hypoperfusion (CH). We have previously established that continuous automated recordings of vital signs (VS) are more highly correlated with outcome than manual end-hour recordings. One potential benefit of automated vital sign data capture is the ability to detect brief episodes of ICH and CH. The purpose of this study was to establish whether a relationship exists between brief episodes of ICH and CH and outcome after severe TBI. MATERIALS Patients at the R Adams Cowley Shock Trauma Center were prospectively enrolled over a 2-year period. Inclusion criteria were as follows: age >14 years, admission within the first 6 hours after injury, Glasgow Coma Scale score <9 on admission, and placement of a clinically indicated ICP monitor. From high-resolution automated VS data recording system, we calculated the 5-minute means of intracranial pressure (ICP), cerebral perfusion pressure (CPP), and Brain Trauma Index (BTI = CPP/ICP). Patients were stratified by mortality and 6-month Extended Glasgow Outcome Score (GOSE). RESULTS Sixty subjects were enrolled with a mean admission Glasgow Coma Scale score of 6.4 ± 3.1, a mean Head Abbreviated Injury Severity Scale score of 4.2 ± 0.7, and a mean Marshall CT score of 2.5 ± 0.9. Significant differences in the mean number of brief episodes of CPP <50 and BTI <2 in patients with a GOSE 1-4 versus GOSE 5-8 (9.4 vs. 4.7, p = 0.02 and 9.3 vs. 4.9, p = 0.03) were found. There were significantly more mean brief episodes per day of ICP >30 (0.52 vs. 0.29, p = 0.02), CPP <50 (0.65 vs. 0.28, p < 0.001), CPP <60 (1.09 vs. 0.7, p = 0.03), BTI <2 (0.66 vs. 0.31, p = 0.002), and BTI <3 (1.1 vs. 0.64, p = 0.01) in those patients with GOSE 1-4. Number of brief episodes of CPP <50, CPP <60, BTI <2, and BTI <3 all demonstrated high predictive power for unfavorable functional outcome (area under the curve = 0.65-0.75, p < 0.05). CONCLUSIONS This study demonstrates that the number of brief 5-minute episodes of ICH and CH is predictive of poor outcome after severe TBI. This finding has important implications for management paradigms which are currently targeted to treatment rather than prevention of ICH and CH. This study demonstrates that these brief episodes may play a significant role in outcome after severe TBI.

Traditional systolic blood pressure targets underestimate hypotension-induced secondary brain injury.

BACKGROUND: Vital signs, particularly blood pressure, are often manipulated to maximize perfusion and optimize recovery from severe traumatic brain injury (sTBI). We investigated the utility of automated continuously recorded vital signs to predict outcomes after sTBI. METHODS: Sixty patients with head Abbreviated Injury Scale score ≥3, age >14 years, “isolated” TBI, and need for intracranial pressure monitoring were prospectively enrolled at a single, large urban tertiary care facility. Outcome was measured by mortality and extended Glasgow Outcome Scale (GOSE) at 12 months. Continuous, automated, digital data were collected every 6 seconds for 72 hours after admission, and 5-minute means of systolic blood pressure (SBP) were recorded. We calculated SBP as pressure × time dose (PTD) to describe the cumulative amplitude and duration of episodes above and below clinical thresholds. The extent and duration of the insults were calculated as percent time (%time), PTD, and PTD per day (PTD/D) of defined thresholds (SBP: <90 mm Hg, <100 mm Hg, <110 mm Hg, and <120 mm Hg; mean arterial pressure: <60 mm Hg and <70 mm Hg; heart rate: >100 bpm and >120 bpm; and SpO2: <88% and <92%) for the first 12 hours, 24 hours, and 48 hours of intensive care unit admission. We analyzed their ability to predict mortality and GOSE by receiver operator characteristics. RESULTS: Mean age was 33.9 (range, 16–83) years, mean admission Glasgow Coma Scale score 6.4 ± 3, and mean head Abbreviated Injury Scale score 4.2 ± 0.72. The 30-day mortality rate was 13.3%. Of the 45 patients in whom GOSE at 12 months was available, 28 (62%) had good neurologic outcomes (GOSE score >4). Traditional markers of poor outcome (admission SBP, admission Glasgow Coma Scale, and Marshall score) were not different between groups with good or poor outcome. PTD, PTD/D, and %time SBP <110 mm Hg and SBP <120 mm Hg predicted mortality at 12 hours, 24 hours, and 48 hours (p < 0.04). Percent time SBP <110 mm Hg in the first 24 hours was predictive of 12-month GOSE (p = 0.02). PTD/D SBP <120 mm Hg in the first 24 hours and PTD and PTD/D in the first 48 hours were also predictive of 12-month GOSE (p < 0.05). CONCLUSIONS: Within the first 48 hours of intensive care unit admission, hypotension was found to be predictive of mortality and functional outcomes at higher thresholds than traditionally defined. Systemic blood pressure targets closer to 120 mm Hg may be more efficacious in minimizing secondary insults and particularly useful in settings without invasive intracranial monitoring capabilities. LEVEL OF EVIDENCE: III, prognostic study.

Basic endovascular skills for trauma course: bridging the gap between endovascular techniques and the acute care surgeon.

BACKGROUND The use of catheter-based skills is increasing in the field of vascular trauma. Virtual reality simulation (VRS) is a well-established means of endovascular skills training, and potentially lifesaving skills such as resuscitative endovascular balloon occlusion of the aorta (REBOA) may be obtained through VRS. METHODS Thirteen faculty members in the Division of Trauma and Critical Care performed REBOA six times on the Vascular Intervention System Training Simulator–C after a didactic and instructional session. Subjects were excluded if they had taken a similar endovascular training course, had additional training in endovascular surgery, or had performed this procedure in the clinical setting. Performance metrics included procedural time; accurate placement of guide wire, sheath, and balloon; correct sequence of steps; economy of motion; and safe use of endovascular tools. A precourse and postcourse test and questionnaire were performed by each subject. RESULTS Significant improvements in knowledge (p = 0.0013) and procedural task times (p < 0.0001) were observed at the completion of the course. No correlation was observed with endovascular experience in residency, number of central and arterial catheters placed weekly, or other parameters. All trainees strongly agreed that the course was beneficial, and the majority would recommend this training to other acute care surgeons. CONCLUSION Damage control endovascular procedures can be effectively taught using VRS. Significant improvements in procedural time and knowledge can be achieved regardless of endovascular experience in residency, years since residency, or other parameters. Novice interventionalists (acute care surgeons) can add a specific skill set (REBOA) to their existing core competencies, which has the potential to improve the survival and/or outcomes of severely injured patients.

Smaller introducer sheaths for REBOA may be associated with fewer complications.

Introduction Large arterial sheaths currently used for resuscitative endovascular balloon occlusion of the aorta (REBOA) may be associated with severe complications. Smaller diameter catheters compatible with 7Fr sheaths may improve the safety profile. Methods A retrospective review of patients receiving REBOA through a 7Fr sheath for refractory traumatic hemorrhagic shock was performed from January 2014 to June 2015 at five tertiary-care hospitals in Japan. Demographics were collected including method of arterial access; outcomes included mortality and REBOA-related access complications. Results Thirty-three patients underwent REBOA at Zone 1 (level of the diaphragm). Most patients were male (70%), with a mean age (+SD) 50 ± 18 years, mean BMI 23 ± 4, and a median [IQR] ISS of 38 [34, 52]. Ninety-four percent of patients presented after sustaining injuries from blunt mechanisms. Twenty-four percent underwent CPR before arrival, and an additional 15% received CPR after admission. Percutaneous arterial access without ultrasound or fluoroscopy was achieved in all patients. Systolic blood pressure increased significantly following balloon occlusion (mean 62 ± 36 to 106 ± 40 mm Hg, p < 0.001). Median total duration of complete initial occlusion was 26 [range 10–35] minutes. Sixteen patients (49%) survived beyond 24 hours, and 14 patients (42%) survived beyond 30 days. Twenty-four-hour and 30-day survival were 48% and 42%, respectively. Of the patients surviving 24 hours (n = 16), median duration of sheath placement was 28 [range 18–45] hours with all removed using manual pressure to achieve hemostasis. Of 33 REBOAs, 20 were performed by Emergency Medicine practitioners, 10 by Emergency Medicine practitioners with endovascular training, and 3 by Interventional Radiologists. No complication related to sheath insertion or removal was identified during the follow-up period, including dissection, pseudoaneurysm, retroperitoneal hematoma, leg ischemia, or distal embolism. Conclusions 7Fr REBOA catheters can significantly elevate systolic blood pressure with no access-related complications. Our results suggest that a 7Fr introducer device for REBOA may be a safe and effective alternative to large-bore sheaths, and may remain in place during the post-procedure resuscitative phase without sequelae. LEVEL OF EVIDENCE Therapeutic/care management, level V.

Contemporary management and outcomes of blunt thoracic aortic injury: A multicenter retrospective study

BACKGROUND Blunt thoracic aortic injuries (BTAIs) are composed of a spectrum of lesions ranging from intimal tear to rupture, yet optimal management and ultimate outcome have not been clearly established. METHODS This is a retrospective multicenter study of BTAIs from January 2008 to December 2013. Demographics, diagnosis, treatment, and in-hospital outcomes were analyzed. RESULTS Nine American College of Surgeons–verified Level I trauma centers contributed data from 453 patients with BTAIs. After exclusion of patients expiring before imaging (58) and transfers (13), 382 patients with imaging diagnosis were available for analysis (Grade 1, 94; Grade 2, 68; Grade 3, 192; Grade 4, 28). Hypotension was present on admission in 56 (14.7%). Computed tomographic angiography was used for diagnosis in 94.5%. Nonoperative management (NOM) was selected in 32%, with two in-hospital failures (Grade 1, Grade 4) requiring endovascular salvage (thoracic endovascular aortic repair [TEVAR]). Open repair (OR) was completed in 61 (16%). TEVAR was conducted in 198 (52%), with 41% of these requiring left subclavian artery coverage. Complications of TEVAR included endograft malposition (6, 3.0%), endoleak (5, 2.5%), paralysis (1, 0.5%), and stroke (2, 1.0%). Six TEVAR failures were treated by repeat TEVAR (2) or OR (4). Overall in-hospital mortality was 18.8%, and aortic-related mortality was 6.5% (NOM, 9.8%; OR, 13.1%; TEVAR, 2.5%) (Grade 1, 0%; Grade 2, 2.9%; Grade 3, 5.2%; Grade 4, 46.4%). The majority of aortic-related deaths (18 of 25) occurred before the opportunity for repair. Independent predictors of aortic-related mortality among BTAI patients were higher chest Abbreviated Injury Scale (AIS) score, grade, and Injury Severity Score (ISS); TEVAR was protective (p = 0.03; odds ratio, 0.21; confidence interval, 0.05–0.88). CONCLUSION Failures and aortic-related mortality of NOM following BTAI Society of Vascular Surgery Grade 1 to 3 injuries are rare. TEVAR seems independently protective against aortic-related mortality. Early complications of TEVAR have decreased relative to previous reports. Prospective long-term follow-up data are required to better refine indications for intervention. LEVEL OF EVIDENCE Level IV.

Resuscitative endovascular balloon occlusion of the aorta

The management of non-compressible torso hemorrhage can be problematic. Current therapy requires either open or interventional radiologic control of bleeding vessels and/or organs. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a new tool to stabilize patients in shock by achieving temporary inflow occlusion of non-compressible torso hemorrhage. This proactive technique represents a paradigm shift in achieving hemodynamic stability in patients as a bridge to definitive hemostasis. REBOA is applicable by trauma professionals, including emergency physicians, at the bedside in the emergency department, but its use needs to be considered within the context of available evidence and a robust system encompassing training, accreditation, multidisciplinary involvement and quality assurance. We review the evolving role of REBOA and discuss unanswered questions and future applications.

Current Opinion on Catheter-based Hemorrhage Control in Trauma Patients

Abstract : Surgery has undergone several fundamental paradigm changes during the last 25 years. Laparoscopic and catheter-based interventions have become common, ultrasound is ubiquitous, and robotics and damage-control surgery are commonplace. When combined with ever-advancing imaging technology, all these tools will continue to change the face of trauma surgery. Accordingly, the University of Texas Health Science at Houston, the Memorial Hermann Texas Trauma Institute, and the Methodist Institute for Technology, Innovation, and Education held a 2-day meeting on February 26 to 27, 2013, to discuss developing new techniques and potential paradigm shifts for catheter-based hemorrhage control including the trauma hybrid operating room (THOR) concept. At this meeting, 60 North American physicians from more than 25 institutions including leaders from the American College of Surgeons and representatives from six specialties (trauma, vascular surgery, orthopedic surgery, critical care, general surgery) involved in caring for traumatically injured patients met and discussed relevant clinical problems, the technology needed to improve patient care, patient-centric flow patterns, new treatments, training, credentialing, and competency issues and participated in a catheter-based hemorrhage control skills laboratory for acute care surgeons. The following is a summary of the proceedings.