Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is controversial as a hemorrhage control adjunct due to lack of data with a suitable control group. We aimed to determine outcomes of ...trauma patients in shock undergoing REBOA versus no-REBOA.
This single-center, retrospective, matched cohort study analyzed patients ≥16 years in hemorrhagic shock without cardiac arrest (2000-2019). REBOA (R; 2015-2019) patients were propensity matched 2:1 to historic (H; 2000-2012) and contemporary (C; 2013-2019) groups. In-hospital mortality and 30-day survival were analyzed using chi-squared and log rank testing, respectively.
A total of 102,481 patients were included (R = 57, C = 88,545, H = 13,879). Propensity scores were assigned using age, race, mechanism, lowest systolic blood pressure, lowest Glasgow Coma Score (GCS), and body region Abbreviated Injury Scale scores to generate matched groups (R = 57, C = 114, H = 114). In-hospital mortality was significantly lower in the REBOA group (19.3%) compared to the contemporary (35.1%; p = 0.024) and historic (44.7%; p = 0.001) groups. 30-day survival was significantly higher in the REBOA versus no-REBOA groups.
In a high-volume center where its use is part of a coordinated hemorrhage control strategy, REBOA is associated with improved survival in patients with noncompressible torso hemorrhage.
Purpose
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used to temporize patients with infradiaphragmatic hemorrhage. Current guidelines advise < 30 min, to avoid ischemia/ ...reperfusion injury, whenever possible. The technique of partial REBOA (P-REBOA) has been developed to minimize the effects of distal ischemia. This study presents our clinical experience with P-REBOA, comparing outcomes to complete occlusion (C-REBOA).
Patients and methods
Retrospective analysis of patients’ electronic data and local REBOA registry between January 2016 and May 2019. Inclusion criteria: adult trauma patients who received Zone I C-REBOA or P-REBOA for infradiaphragmatic hemorrhage, who underwent attempted exploration in the operating room. Comparison of outcomes based on REBOA technique (P-REBOA vs C-REBOA) and occlusion time (> 30 min, vs ≤ 30 min)
Results
46 patients were included, with 14 treated with P-REBOA. There were no demographic differences between P-REBOA and C-REBOA. Prolonged (> 30 min) REBOA (regardless of type of occlusion) was associated with increased mortality (32% vs 0%,
p
= 0.044) and organ failure. When comparing prolonged P-REBOA with C-REBOA, there was a trend toward lower ventilator days 19 (11) vs 6 (9);
p
= 0.483 and dialysis (36.4% vs 16.7%;
p
= 0.228) with significantly less vasopressor requirement (72.7% vs 33.3%;
p
= 0.026).
Conclusion
P-REBOA can be delivered in a clinical setting, but is not currently associated with improved survival in prolonged occlusion. In survivors, there is a trend toward lower organ support needs, suggesting that the technique might help to mitigate ischemic organ injury. More clinical data are needed to clarify the benefit of partial occlusion REBOA.
Patient selection for resuscitative endovascular balloon occlusion of the aorta (REBOA) has evolved during the last decade. A recent multicenter collaboration to implement the newest generation REBOA ...balloon catheter identified variability in patient selection criteria. The aims of this systematic review were to compare recent REBOA patient selection guidelines and to identify current areas of consensus and variability.
In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic review of clinical practice guidelines for REBOA patient selection in trauma. Published algorithms from 2015 to 2022 and institutional guidelines from a seven-center REBOA collaboration were compiled and synthesized.
Ten published algorithms and seven institutional guidelines on REBOA patient selection were included. Broad consensus exists on REBOA deployment for blunt and penetrating trauma patients with non-compressible torso hemorrhage refractory to blood product resuscitation. Algorithms diverge on precise systolic blood pressure triggers for early common femoral artery access and REBOA deployment, as well as the use of REBOA for traumatic arrest and chest or extremity hemorrhage control.
Although our convenience sample of institutional guidelines likely underestimates patient selection variability, broad consensus exists in the published literature regarding REBOA deployment for blunt and penetrating trauma patients with hypotension not responsive to resuscitation. Several areas of patient selection variability reflect individual practice environments.
Level 5, systematic review.
Transcarotid artery revascularization (TCAR) with flow reversal has substantially changed the management of carotid artery stenosis, enabling an endovascular approach with a periprocedural stroke ...rate as low as or lower than that of open carotid surgery. The use of TCAR for blunt carotid artery injury has not yet been described.
A review of the use of TCAR for blunt carotid artery injury was performed at a single center from October 2020 to August 2021. The patient demographics, mechanism of injury, and outcomes were collected and compared.
Ten carotid stents were placed via TCAR in eight patients for hemodynamically significant blunt carotid artery injuries. No periprocedural neurologic events occurred, and all stents remained patent during short-term follow-up.
TCAR is feasible and safe in the management of significant blunt carotid artery injuries. More data are needed regarding the long-term outcomes and ideal surveillance intervals.
We describe a 28-year-old man who sustained an open IIIB left ankle fracture dislocation with heel pad avulsion. The patient underwent formal angiography of the left lower extremity, followed by free ...tissue transfer of a rectus abdominis flap several days later. Intraoperatively, a thrombus was identified in the deep inferior epigastric artery above the femoral artery access site requiring thrombectomy. Histologic analysis estimated the thrombus age at 12 to 72 hours, raising concern that the thrombus was induced during angiogram instrumentation. Donor and recipient site-specific risks of arterial instrumentation (including invasive diagnostics) should be considered when planning free tissue transfer.
BackgroundThoracic endovascular aortic repair (TEVAR) has become the standard of care for thoracic aortic aneurysms and increasingly for blunt thoracic aortic injury (BTAI). Postoperative ...complications, including spinal cord ischemia and paraplegia, have been shown to be less common with elective TEVAR than with open thoracic or thoracoabdominal repair. Although small cohort studies exist, the postoperative complications of endovascular repair of traumatic aortic injury have not been described through large data set analysis.MethodsA retrospective cohort analysis was performed of the American College of Surgeons Trauma Quality Improvement Program registry spanning from 2007 to 2017. All patients with BTAI who underwent TEVAR, as indicated by the Abbreviated Injury Scale or the International Classification of Diseases (ICD-9 or ICD-10), were included. Categorical data were presented as proportions and continuous data as mean and SD. OR was calculated for each postoperative complication.Results2990 patients were identified as having undergone TEVAR for BTAI. The postoperative incidence of stroke was 2.8% (83), and 4.7% (140) of patients suffered acute kidney injury or renal failure. The incidence of spinal cord ischemia was 1.9% (58), whereas 0.2% (7) of patients suffered complete paraplegia. Renal events and stroke were found to occur significantly more frequently in those undergoing TEVAR (OR 1.758, 1.449–2.134 and OR 2.489, 1.917–3.232, respectively). Notably, there was no difference between TEVAR and non-operative BTAI incidences of spinal cord ischemia or paraplegia (OR 1.061, 0.799–1.409 and OR 1.698, 0.728–3.961, respectively).DiscussionPostoperative intensive care unit care of patients after BTAI has historically focused on awareness of spinal cord ischemia. Our analysis suggests that after endovascular repair of blunt aortic trauma, care should involve vigilance primarily against postoperative cerebrovascular and renal events. Further study is warranted to develop guidelines for the intensivist managing patients after TEVAR for BTAI.Level of evidenceLevel III.
Acute portal vein thrombosis complicated by mesenteric ischemia requires emergent treatment to address the compromised bowel as well as the portal vein thrombus. We report a novel hybrid approach to ...managing this disease process. The procedure we discuss entails exploratory laparotomy and small bowel resection by the acute care emergency surgery team. Following this, the vascular surgery team performs a portal venogram through a branch mesenteric vein accessed through the laparotomy incision and then places a thrombolysis catheter. This technique and approach allows us to provide initial management efficiently and effectively under one operation.
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