Use of bilobed partial resuscitative endovascular balloon occlusion of the aorta is logistically superior in prolonged management of a highly lethal aortic injury

Complications associated with the use of resuscitative endovascular balloon occlusion of the aorta (REBOA): an updated review

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has become part of the arsenal to temporize patients in shock from severe hemorrhage. REBOA is used in trauma to prevent cardiovascular collapse by preserving heart and brain perfusion and minimizing distal hemorrhage until definitive hemorrhage control can be achieved. Significant side effects, including death, ischemia and reperfusion injuries, severe renal and lung damage, limb ischemia and amputations have all been reported. The aim of this article is to provide an update on complications related to REBOA. REBOA has emerged as a critical intervention for managing severe hemorrhagic shock, aiming to temporize patients and prevent cardiovascular collapse until definitive hemorrhage control can be achieved. However, this life-saving procedure is not without its challenges, with significant reported side effects. This review provides an updated overview of complications associated with REBOA. The most prevalent procedure-related complication is distal embolization and lower limb ischemia, with an incidence of 16% (range: 4-52.6%). Vascular and access site complications are also noteworthy, documented in studies with incidence rates varying from 1.2% to 11.1%. Conversely, bleeding-related complications exhibit lower documentation, with incidence rates ranging from 1.4% to 28.6%. Pseudoaneurysms are less likely, with rates ranging from 2% to 14%. A notable incidence of complications arises from lower limb compartment syndrome and lower limb amputation associated with the REBOA procedure. Systemic complications include acute kidney failure, consistently reported across various studies, with incidence rates ranging from 5.6% to 46%, representing one of the most frequently documented systemic complications. Infection and sepsis are also described, with rates ranging from 2% to 36%. Pulmonary-related complications, including acute respiratory distress syndrome and multisystem organ failure, occur in this population at rates ranging from 7.1% to 17.5%. This comprehensive overview underscores the diverse spectrum of complications associated with REBOA.

Prolonging the zone 1 aortic occlusion time to 4 hours using a partial resuscitative endovascular balloon in a swine model

BACKGROUND

The clinical usage of the resuscitative endovascular balloon occlusion of the aorta (REBOA) is limited by distal ischemia resulting from complete aortic occlusion. We hypothesized that animals would physiologically tolerate the prolonged partial occlusion using the novel partially occluding REBOA (pREBOA) with survivable downstream injuries.

METHODS

This study used the pREBOA-PRO catheter in a previously established swine model. Female Yorkshire swine (n = 10) underwent a volume-controlled hemorrhage (40% estimated blood). After 1 hour of shock (mean arterial pressure, 28-32 mm Hg), animals were randomized to partial occlusion for either 2 hours or 4 hours. The pREBOA was inflated in zone 1 to achieve partial occlusion defined as a distal systolic blood pressure (SBP) of 20 ± 2 mm Hg. The balloon was deflated at the end of the occlusion period, and animals were resuscitated for 2 hours. Tissues were examined for gross and histologic injury. The primary endpoint was histologic organ injury, and secondary end points were hemodynamic variables and degree of distal organ ischemia.

RESULTS

All animals survived to the endpoint. Both groups had similar proximal and distal SBP at baseline, with a divergence of pressures ranging from 55 mm Hg to 90 mm Hg on inflation. The lactate levels increased throughout the occlusion and decreased approximately 40% during the observation period. More animals required norepinephrine and fluid in the 4-hour group compared with the 2-hour group. There was no gross small bowel ischemia noted in the 2-hour animals. The 4-hour group had surgically resectable patchy short segment ischemia. Neither group showed nonsurvivable organ ischemia on pathology or laboratory values.

CONCLUSION

This is the first study showing that the zone 1 aorta can be occluded for over 4 hours using a new pREBOA device without need for balloon titration. In conclusion, simple changes in balloon design offer reliable partial aortic occlusion, with potentially survivable and surgically manageable downstream injuries.

A randomized porcine study of hemorrhagic shock comparing end-tidal carbon dioxide targeted and proximal systolic blood pressure targeted partial resuscitative endovascular balloon occlusion of the aorta in the mitigation of metabolic injury

BACKGROUND

The definition of partial resuscitative endovascular balloon occlusion of the aorta (pREBOA) is not yet determined and clinical markers of the degree of occlusion, metabolic effects and end-organ injury that are clinically monitored in real time are lacking. The aim of the study was to test the hypothesis that end-tidal carbon dioxide (ETCO₂) targeted pREBOA causes less metabolic disturbance compared to proximal systolic blood pressure (SBP) targeted pREBOA in a porcine model of hemorrhagic shock.

MATERIALS AND METHODS

Twenty anesthetized pigs (26-35 kg) were randomized to 45 min of either ETCO₂ targeted pREBOA (pREBOA_ETCO2, ETCO₂ 90-110% of values before start of occlusion, n = 10) or proximal SBP targeted pREBOA (pREBOA_SBP, SBP 80-100 mmHg, n = 10), during controlled grade IV hemorrhagic shock. Autotransfusion and reperfusion over 3 h followed. Hemodynamic and respiratory parameters, blood samples and jejunal specimens were analyzed.

RESULTS

ETCO₂ was significantly higher in the pREBOA_ETCO2 group during the occlusion compared to the pREBOA_SBP group, whereas SBP, femoral arterial mean pressure and abdominal aortic blood flow were similar. During reperfusion, arterial and mesenteric lactate, plasma creatinine and plasma troponin concentrations were higher in the pREBOA_SBP group.

CONCLUSIONS

In a porcine model of hemorrhagic shock, ETCO₂ targeted pREBOA caused less metabolic disturbance and end-organ damage compared to proximal SBP targeted pREBOA, with no disadvantageous hemodynamic impact. End-tidal CO₂ should be investigated in clinical studies as a complementary clinical tool for mitigating ischemic-reperfusion injury when using pREBOA.

Partial Resuscitative Endovascular Balloon Occlusion of the Aorta Limits Ischemia-Reperfusion Injury After Simulated Aeromedical Evacuation

INTRODUCTION

One of the advantages of partial Resuscitative Endovascular Balloon Occlusion of the Aorta (pREBOA) compared to the original model is the mitigation of reperfusion injury. The safety and efficacy of pREBOA have not been demonstrated in the setting of aeromedical evacuation. We hypothesized that the pREBOA would result in less ischemia-reperfusion injury after altitude exposure.

METHODS

Twenty-four swine underwent femur fracture with hemorrhage for 20 min, followed by resuscitative endovascular balloon occlusion of the aorta (REBOA) deployment to Zone 1 and were randomized to pREBOA-PRO (Prytime Medical Devices Inc) full inflation, partial inflation, or sham inflation and then an altitude exposure of ground level or 8000 ft for 15 min. The primary endpoint was to examine if the balloon functioned at altitude. Our secondary endpoint was investigating evidence of ischemia-reperfusion by hemodynamic instability, electrolyte derangements, and acidosis. Comparisons were made by ANOVA.

RESULTS

After deflation, the partially inflated group maintained a higher mean arterial pressure (MAP) compared to fully inflated group (P = 0.026). Full REBOA pigs were more tachycardic compared to sham pREBOA at ground (P < 0.001) and this was exacerbated at altitude (P < 0.001). Full REBOA pigs were more acidotic than sham and pREBOA at ground pigs (P = 0.0006 and P = 0.0002, respectively). Altitude increased the acidosis in full REBOA pigs, resulting in a greater base deficit (P < 0.0001), lactate (P < 0.0001), and IL-6 (P = 0.006).

CONCLUSIONS

PREBOA resulted in less severe ischemia-reperfusion injury at both altitude and ground, while full balloon inflation at altitude exacerbated acidosis and ischemia-reperfusion injury. Efforts should therefore be made to utilize partial balloon occlusion when employing the REBOA catheter.

Acute Kidney Injury in Hypotensive Trauma Patients Following Resuscitative Endovascular Balloon Occlusion of the Aorta Placement

BACKGROUND

ER-Resuscitative Endovascular Balloon Occlusion of the Aorta (ER-REBOA) is an adjunct tool to achieve hemostasis in trauma patients with non-compressible torso hemorrhage. The development of the partial REBOA (pREBOA) allows for distal perfusion of organs while maintaining occlusion of the aorta. The primary aim of this study was to compare rates of acute kidney injury (AKI) in trauma patients who had placement of either a pREBOA or ER-REBOA.

METHODS

A retrospective chart review of adult trauma patients who underwent REBOA placement between September 2017 and February 2022 was performed. Baseline demographics, information on REBOA placement, and post-procedure complications including AKI, amputations, and mortality were recorded. Chi-squared and T-test analyses were performed with P < .05 considered to be significant.

RESULTS

A total of 68 patients met study inclusion criteria with 53 patients (77.9%) having an ER-REBOA. 6.7% of patients treated with pREBOA had a resulting AKI, while 40% of patients treated with ER-REBOA had a resulting AKI, and this difference was significant (P < .05). The rates of rhabdomyolysis, amputations, and mortality were not significantly different between the two groups.

CONCLUSION

The results from this case series suggest that patients treated with pREBOA have a significantly lower incidence of developing an AKI compared to ER-REBOA. There were no significant differences in rates of mortality, and amputations. Future prospective studies are needed to further characterize the indications and optimal use for pREBOA.

Emergency department initiated resuscitative endovascular balloon occlusion of the aorta (REBOA) for out-of-hospital cardiac arrest is feasible and associated with improvements in end-tidal carbon dioxide

Objectives

Out-of-hospital cardiac arrest (OHCA) claims the lives of approximately 350,000 people in the United States each year. Resuscitative endovascular balloon occlusion of the aorta (REBOA) when used as an adjunct to advanced cardiac life support may improve cardio-cerebral perfusion. Our primary research objective was to determine the feasibility of emergency department (ED)-initiated REBOA for OHCA patients in an academic urban ED.

Methods

This was a single-center, single-arm, early feasibility trial that used REBOA as an adjunct to advanced cardiac life support (ACLS) in OHCA. Subjects under 80 years with witnessed OHCA and who received cardiopulmonary rescuitation (CPR) within 6 minutes were eligible.

Results

Five patients were enrolled between February 2020 and April 2021. The procedure was successful in all patients and 4 of 5 (80%) patients had transient return of spontaneous circulation (ROSC) after aortic occlusion. Unfortunately, all patients re-arrested soon after intra-aortic balloon deflation and none survived to hospital admission. At 30 seconds post-aortic occlusion, investigators noted a statistically significant increase in end tidal carbon dioxide of 26% (95% confidence interval, 10%, 44%).

Conclusion

Initiating REBOA for OHCA patients in an academic urban ED setting is feasible. Aortic occlusion during chest compressions is temporally associated with improvements in end tidal carbon dioxide 30 seconds after aortic occlusion. Four of 5 patients achieved ROSC after aortic occlusion; however, deflation of the intra-aortic balloon quickly led to re-arrest and death in all patients. Future research should focus on the utilization of partial-REBOA to prevent re-arrest after ROSC, as well as the optimal way to incorporate this technique with other endovascular reperfusion strategies.

Cushioned on the way up, controlled on the way down during resuscitative endovascular balloon occlusion of the aorta (REBOA): investigating a novel compliant balloon design for optimizing safe overinflation combined with partial REBOA ability

Background

There are a variety of devices capable of performing resuscitative endovascular balloon occlusion of the aorta (REBOA), with most containing compliant balloon material. While compliant material is ideal for balloon inflation due to its “cushioning” effect, it can be problematic to “control” during deflation. The COBRA-OS (Control Of Bleeding, Resuscitation, Arterial Occlusion System) was designed to optimize inflation and deflation of its compliant balloon and was tested in vitro and in vivo with respect to its overinflation and partial REBOA abilities.

Methods

For overinflation, the COBRA-OS was inflated in three differently sized inner diameter (ID) vinyl tubes until balloon rupture. It was then overinflated in six harvested swine aortas and in all three REBOA zones of three anesthetized swine. For partial REBOA, the COBRA-OS underwent incremental deflation in a pulsatile benchtop aortic model and in zone 1 of three anesthetized swine.

Results

For overinflation, compared with the known aortic rupture threshold of 4 atm, the COBRA-OS exceeded this value in only the smallest of the vinyl tubes: 8 mm ID tube, 6.5 atm; 9.5 mm ID tube, 3.5 atm; 13 mm ID tube, 1.5 atm. It also demonstrated greater than 500% overinflation ability without aortic damage in vitro and caused no aortic damage when inflated to maximum inflation volume in vivo. For partial REBOA, the COBRA-OS was able to provide a titration window of between 3 mL and 4 mL in both the pulsatile vascular model (3.4±0.12 mL) and anesthetized swine (3.8±0.35 mL).

Discussion

The COBRA-OS demonstrated the ability to have a cushioning effect during inflation combined with titration control on deflation in vitro and in vivo. This study suggests that despite its balloon compliance, both safe overinflation and partial REBOA can be successfully achieved with the COBRA-OS.

Level of evidence

Basic science.

Targeted Regional Optimization: Increasing the Therapeutic Window for Endovascular Aortic Occlusion In Traumatic Hemorrhage

ABSTRACT

Resuscitative endovascular balloon occlusion of the aorta (REBOA) allows for effective temporization of exsanguination from non-compressible hemorrhage (NCTH) below the diaphragm. However, the therapeutic window for aortic occlusion is time-limited given the ischemia-reperfusion injury generated. Significant effort has been put into translational research to develop new strategies to alleviate the ischemia-reperfusion injury and extend the application of endoaortic occlusion. Targeted regional optimization (TRO) is a partial REBOA strategy to augment proximal aortic and cerebral blood flow while targeting minimal threshold of distal perfusion beyond the zone of partial aortic occlusion. The objective of TRO is to reduce the degree of ischemia caused by complete aortic occlusion while providing control of distal hemorrhage. This review provides a synopsis of the concept of TRO, pre-clinical, translational experiences with TRO and early clinical outcomes. Early results from TRO strategies are promising; however, further studies are needed prior to large-scale implementation into clinical practice.

Resuscitative endovascular balloon occlusion of the aorta in combat casualties: The past, present, and future

BACKGROUND

Noncompressible torso hemorrhage is a leading cause of preventable death on the battlefield. Intra-aortic balloon occlusion was first used in combat in the 1950s, but military use was rare before Operation Iraqi Freedom and Operation Enduring Freedom. During these wars, the combination of an increasing number of deployed vascular surgeons and a significant rise in deaths from hemorrhage resulted in novel adaptations of resuscitative endovascular balloon occlusion of the aorta (REBOA) technology, increasing its potential application in combat. We describe the background of REBOA development in response to a need for minimally invasive intervention for hemorrhage control and provide a detailed review of all published cases (n = 47) of REBOA use for combat casualties. The current limitations of REBOA are described, including distal ischemia and reperfusion injury, as well as ongoing research efforts to adapt REBOA for prolonged use in the austere setting.

LEVEL OF EVIDENCE

Level V.

Is cerebral perfusion maintained during full and partial resuscitative endovascular balloon occlusion of the aorta in hemorrhagic shock conditions?

BACKGROUND

Partial resuscitative endovascular balloon occlusion of the aorta (pREBOA) is a technology that occludes aortic flow and allows for controlled deflation and restoration of varying distal perfusion. Carotid flow rates (CFRs) during partial deflation are unknown. Our aim was to measure CFR with the different pREBOA balloon volumes and correlate those to the proximal mean arterial pressure (PMAP) and a handheld pressure monitoring device (COMPASS; Mirador Biomedical, Seattle, WA).

METHODS

Ten swine underwent a hemorrhagic injury model with carotid and iliac arterial pressures monitored via arterial lines. Carotid and aortic flow rates were monitored with Doppler flow probes. A COMPASS was placed to monitor proximal pressure. The pREBOA was inflated for 15 minutes then partially deflated for an aortic flow rate of 0.7 L/min for 45 minutes. It was then completely deflated. Proximal mean arterial pressures and CFR were measured, and correlation was evaluated. Correlation between CRF and COMPASS measurements was evaluated.

RESULTS

Carotid flow rate increased 240% with full inflation. Carotid flow rate was maintained at 100% to 150% of baseline across a wide range of partial deflation. After full deflation, CFR transiently decreased to 45% to 95% of baseline. There was strong positive correlation (r > 0.85) between CFR and PMAP after full inflation, and positive correlation with partial inflation (r > 0.7). Carotid flow rate had strong correlation with the COMPASS with full REBOA (r > 0.85) and positive correlation with pREBOA (r > 0.65).

CONCLUSION

Carotid flow rate is increased in a hemorrhagic model during full and partial inflation of the pREBOA and correlates well with PMAP. Carotid perfusion appears maintained across a wide range of pREBOA deflation and could be readily monitored with a handheld portable COMPASS device instead of a standard arterial line setup.

A novel partial resuscitative endovascular balloon aortic occlusion device that can be deployed in zone 1 for more than 2 hours with minimal provider titration

BACKGROUND

Hemorrhage is a leading cause of mortality in trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) can control hemorrhage, but distal ischemia, subsequent reperfusion injury, and the need for frequent balloon titration remain problems. Improved device design can allow for partial REBOA (pREBOA) that may provide hemorrhage control while also perfusing distally without need for significant provider titration.

METHODS

Female Yorkshire swine (N = 10) were subjected to 40% hemorrhagic shock for 1 hour (mean arterial pressure [MAP], 28-32 mm Hg). Animals were then randomized to either complete aortic occlusion (ER-REBOA) or partial occlusion (novel pREBOA-PRO) without frequent provider titration or distal MAP targets. Detection of a trace distal waveform determined partial occlusion in the pREBOA-PRO arm. After 2 hours of zone 1 occlusion, the hemorrhaged whole blood was returned. After 50% autotransfusion, the balloon was deflated over a 10-minute period. Following transfusion, the animals were survived for 2 hours while receiving resuscitation based on objective targets: lactated Ringer's fluid boluses (goal central venous pressure, ≥ 6 mm Hg), a norepinephrine infusion (goal MAP, 55-60 mm Hg), and acid-base correction (goal pH, >7.2). Hemodynamic variables, arterial lactate, lactate dehydrogenase, aspartate aminotransferase, and creatinine levels were measured.

RESULTS

All animals survived throughout the experiment, with similar increase in proximal MAPs in both groups. Animals that underwent partial occlusion had slightly higher distal MAPs. At the end of the experiment, the partial occlusion group had lower end levels of serum lactate (p = 0.006), lactate dehydrogenase (p = 0.0004) and aspartate aminotransferase (p = 0.004). Animals that underwent partial occlusion required less norepinephrine (p = 0.002), less bicarbonate administration (p = 0.006), and less fluid resuscitation (p = 0.042).

CONCLUSION

Improved design for pREBOA can decrease the degree of distal ischemia and reperfusion injury compared with complete aortic occlusion, while providing a similar increase in proximal MAPs. This can allow pREBOA zone-1 deployment for longer periods without the need for significant balloon titration.

Partial Resuscitative Endovascular Balloon Occlusion of the Aorta via the Tri-Lobe Balloon Catheter

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) provides a minimally invasive alternative to resuscitative thoracotomy. The high morbidity associated with prolonged aortic occlusion has given rise to the concept of partial REBOA (pREBOA). We evaluated the novel use of the GORE Tri-Lobe Balloon Catheter (GORE) as a functional pREBOA catheter and compared it with existing REBOA and pREBOA techniques in a porcine hemorrhagic shock model.

MATERIALS AND METHODS

Fifteen male Yorkshire swine were subjected to hemorrhagic shock with zone 1 aortic occlusion via standard REBOA techniques or a partial occlusion approach using a prototype pREBOA or GORE catheter. Continuous invasive monitoring was performed and laboratory values were analyzed every 30 min.

RESULTS

One animal from the GORE cohort was excluded because of early demise from nonstudy factors. Survival to 120 mins was comparable between all study groups: REBOA resulting in 40% survival, pREBOA 60%, and Gore 50% (P = 0.685). No differences in lactate, base deficit, and pH between the cohorts were demonstrated at all measured time points; however, trends toward more physiologic values were appreciated in the GORE and pREBOA cohorts. Urine output was significantly improved during the course of the study in the GORE cohort (8.77 mL/kg) versus REBOA (5.46 mL/kg) and pREBOA (4.48 mL/kg) (P = 0.001).

CONCLUSIONS

The GORE Tri-Lobe Balloon Catheter represents a potentially viable and commercially available alternative device for pREBOA that may achieve survivable hemorrhage control while preventing lethal reperfusion injury. Further studies should be performed after instrument refinement with larger study populations to confirm this potential.