One discussion this week included the use of REBOA for trauma cases.

Reference: Brenner, M, et al. Use of resuscitative endovascular balloon occlusion of the aorta for proximal aortic control in patients with severe hemorrhage and arrest. JAMA Surgery. 2018 Feb;153(2):130-135. doi:10.1001/jamasurg.2017.3549.

Summary: Reporting on the largest single-institution study on REBOA in the US, Brenner et al (2018) state that the risks of clinician exposure and morbidity of opening the thorax to cross-clamp the aorta make REBOA a more attractive option than emergency department thoracotomy with aortic cross-clamp (EDTCC). This study observed outcomes of patients with  severe traumatic hemorrhage, traumatic arrest (AR), and nontraumatic hemorrhage (NTH) between 2013 and 2017.

For 79 patients with severe traumatic hemorrhage and AR, in-hospital mortality was 71%. Technical success, as defined by AO at the intended level (zone 1 or 3), occurred in 44 of the 53 patients (83%) who had radiographic, fluoroscopic, manual, or CT confirmation of the balloon. The remaining identified malpositioned catheters were repositioned immediately to a slightly more proximal location (proximal zone 2 to distal zone 1) without clinical sequelae. Seven patients underwent REBOA at zone 1, which was then purposefully repositioned to zone 3 after intra-abdominal hemorrhage was ruled out by imaging (n = 3) or surgical exploration (n = 4) (p.131-132).

In the patients with severe traumatic hemorrhage, the 30-day survival was 59% (p.132). Indications for REBOA were transient responders or nonresponders who remained severely hypotensive despite resuscitation efforts. A total of 18 patients (62%) received REBOA in zone 1, while 11 patients with severe hemorrhage from the pelvis or below (38%) received REBOA in zone 3. Twelve patients received REBOA in the OR; the indications included AR or impending AR, refractory hypotension, presence of expanding pelvic hematoma with abdominal hemostasis, and performance of REBOA prior to exploration of a large central hematoma including, in 1 patient, severe adhesions from a previous laparotomy.

Of the patients with AR, 50 received REBOA while in arrest. Spontaneous circulation occurred in 29 (58%), 20 of those survived to the OR. The 30-day survival was 10% (p.133). Access to the CFA was percutaneous in 13 patients and via surgical cutdown
in 37 patients, including 8 patients who had access attempted percutaneously but completed via cutdown. Patients received cardiopulmonary resuscitation throughout the REBOA procedure (p.133).

Benefits of REBOA are:

• the ability to provide continuous closed chest compressions during the procedure
• its ability to temporize hemorrhage and thus buy time to gather results of diagnostic imaging, especially when other injuries may alter treatment algorithms
• the consequences of extended occlusion, particularly in patient care settings without resources for definitive hemorrhage control

Brenner et al (2018) note that REBOA can also be used for more targeted AO in the distal aorta for pelvic, junctional, or extremity hemorrhage (p.135).

One discussion this week included the morbidity and mortality of TEVAR in the setting of ruptured thoracic aortic aneurysms.

Reference: Geisbusch, P, et al. Endovascular repair of ruptured thoracic aortic aneurysms is associated with high perioperative mortality and morbidity. Journal of Vascular Surgery. 2010 Feb;51(2):299-304. doi:10.1016/j.jvs.2009.08.049.

Summary: In a retrospective study, Geisbusch et al (2010) analyzed the outcomes of emergency endovascular treatment of thoracic aortic pathologies (TEVAR). Out of 236 patients, 23 received thoracic aortic repair due to a ruptured thoracic aortic aneurysm (rTAA). The overall hospital mortality was 48% (see table below, p.302). Overall technical success was 87%. Three patients showed relevant primary endoleaks, and thus were not considered technical successes.

The causes of death in the 11 patients were: cardiac complications (7), multiorgan failure (3), and pulmonary embolism (1) (p.301).

The authors admit: “Mortality rates after TEVAR for acute descending aortic rupture vary between 0% and 17% in the few available series, which seems relatively low compared with our in-hospital mortality rate of 48%” (p.303).

The patient population in this study had a median age of 75 years, and was highly comorbid (83% with coronary heart disease, 43% with renal insufficiency, and 30% with COPD), resulting in high cardio-pulmonary and renal complications with consecutive perioperative death. Three-year survival is estimated at 30%.

In conclusion, “the endovascular treatment of ruptured thoracic aortic aneurysms is associated with a high perioperative mortality and morbidity as well as poor midterm survival. Renal insufficiency proved as an independent risk factor for perioperative death” (p.303).