Disclosures REBOA: Rapid Aortic Control in the Trauma Patient I - - PowerPoint PPT Presentation

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Disclosures REBOA: Rapid Aortic Control in the Trauma Patient I - - PowerPoint PPT Presentation

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u 4/7/2017 Disclosures REBOA: Rapid Aortic Control in the Trauma Patient I have nothing to disclose Shant M. Vartanian, MD Assistant Professor of Surgery Division of Vascular and Endovascular Surgery University of California, San Francisco

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REBOA: Rapid Aortic Control in the Trauma Patient

Shant M. Vartanian, MD Assistant Professor of Surgery Division of Vascular and Endovascular Surgery University of California, San Francisco

Disclosures

I have nothing to disclose

  • Rapid Endovascular Balloon Occlusion of the Aorta
  • Hemorrhage is the leading cause of preventable death in trauma
  • Torso hemorrhage is particularly challenging to control
  • Control hemorrhage
  • Increase proximal aortic pressure
  • Maintain perfusion to heart and brain

Overview

  • Rapid Endovascular Balloon Occlusion of the Aorta
  • Applied to:
  • Ruptured AAA
  • GI hemorrhage
  • Post partum hemorrhage
  • Elective pelvic oncologic surgery
  • Reappraisal with recent combat experience in Afghanastan and

Iraq

  • New technology -> push to enter mainstream practice

Overview

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  • Series of 2 patients during

Korean War

  • 10 french Dotter-Lukas balloons
  • Both died

Initial Experience

  • Series from 1986
  • 40% with vital signs on balloon insertion
  • Failed percutaneous access x 5
  • Failed cut down x 1
  • 13/15 died (70% mortality)

Initial Experience

  • Ultrasound guided femoral access -> upsize to 12 f sheath
  • J tip guide wire measured and marked to insertion depth
  • On table XRAY to confirm wire location
  • Mark and advance CODA balloon
  • On table XRAY to confirm markers in correct zone
  • Inflate balloon with contrast/saline until “moderate resistance”
  • XRAY to confirm position

Early Generation REBOA

  • Zone I:
  • ~20 cm length
  • Superficial projection to xiphoid
  • Zone III:
  • ~10 cm length
  • Superficial projection to umbilicus

Anatomy

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  • Balloons
  • #8 Fogarty
  • IABP
  • Percluder, MaxiLD, Bernstein
  • Coda, Reliant
  • Approach
  • Femoral vs. Brachial
  • Percutaneous vs open
  • Confirmation
  • Fluoro vs XRAY
  • Ultrasound
  • No confirmation

Early Generation Variations

  • Post partum hemorrhage
  • 5 case reports/series with total 10 patients
  • No deaths

Efficacy: Non-Trauma

  • Upper GI bleed
  • 3 patients reported
  • No deaths

Efficacy: Non-Trauma

  • Elective pelvic/sacral oncologic surgery
  • 2 series w/ combined 165 patients
  • Combined mortality 0%
  • Fem artery thrombosis in 3
  • Embolism in 3

Efficacy: Non-Trauma

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  • Systematic review: Mean SBP increase > 50 mm Hg

Efficacy: Blood Pressure

  • Registry data: Japanese Trauma Data Bank over 10 years
  • 452 patients treated w/ REBOA
  • Propensity matched w/ controls

Efficacy: Mortality

  • Registry data: Japanese Trauma Data Bank over 10 years
  • 452 patients treated w/ REBOA
  • Propensity matched w/ controls

Efficacy: Mortality

  • US experience
  • Registry data from two Level I centers that performed REBOA
  • Compared thoracotomy (RT) to REBOA
  • 96 total patients
  • REBOA 24
  • RT 72

Efficacy: Mortality

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SLIDE 5
  • 4/7/2017
  • 5

Efficacy: Mortality

  • Iraq and Afganistan experience
  • Stabilize and transport

Modern Combat Experience

  • Not designed for trauma applications
  • Slow process in unexperienced hands
  • Long, unwieldy guide wire
  • Issues with 12 f sheath
  • Occlusive in setting of hemorrhagic shock
  • Managing the arteriotomy after the fact

Early Generation REBOA

  • FDA approval Oct 2015
  • but not a “fluroscopy free” indication
  • 7 fr system
  • No guidewire required
  • Nitinol reinforced catheter to resist retrograde pulsation

ER-REBOA – Prytime Medical

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  • 4/7/2017
  • 6
  • PEA arrest (< 10 min) secondary to exsanguination from sub-

diaphragmatic hemorrhage

  • Hypovolemic shock and SBP < 70 mmHg
  • Non responders/partial responders with non-compressible

hemorrhage

  • Intrabd hemorrhage 2/2 blunt or penetrating trauma -> Zone I
  • Blunt trauma with isolated pelvic fracture -> Zone III
  • Penetrating pelvic injury -> Zone III

Indications

  • Obstructive shock
  • Tamponade, tension pneumothorax, etc
  • Inaccessible femoral vessels
  • High clinical suspicion of proximal aortic injury
  • Age > 70 years
  • Pre-existing terminal illness or significant comorbidities

Contraindications Procedural Steps

  • Femoral occlusion
  • 3 cases of amputation reported
  • Embolism
  • Dissection
  • Extra-luminal catheter placement
  • Balloon over-inflation
  • Un-intended zones
  • Venous cannulation
  • Stroke
  • Additional training available in multiple venues

Potential Complications

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  • 4/7/2017
  • 7
  • High quality evidence for efficacy is lacking
  • Improvement in hemorrhage related mortality has not been

demonstrated

  • Inclusion and exclusion criteria need refining
  • May be better suited for pre-hospital settings lacking immediate

access to definitive therapy

  • If REBOA enters the mainstream, Vascular Surgeons will be

called upon to deal with complications

Summary