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 Overview Overview Rapid Endovascular Balloon Occlusion of the Aorta • Rapid Endovascular Balloon Occlusion of the Aorta • Applied to: • Hemorrhage is the leading cause of preventable death in trauma Ruptured AAA • • Torso hemorrhage is particularly challenging to control • GI hemorrhage • Post partum hemorrhage • Elective pelvic oncologic surgery • Control hemorrhage • Increase proximal aortic pressure • Reappraisal with recent combat experience in Afghanastan and • Iraq Maintain perfusion to heart and brain • New technology -> push to enter mainstream practice • u 1
u 4/7/2017 Initial Experience Initial Experience Series from 1986 • 40% with vital signs on balloon insertion • Failed percutaneous access x 5 Series of 2 patients during • • Korean War Failed cut down x 1 • 13/15 died (70% mortality) • 10 french Dotter-Lukas balloons • Both died • Early Generation REBOA Anatomy Ultrasound guided femoral access -> upsize to 12 f sheath Zone I: • • ~20 cm length • Superficial projection to xiphoid J tip guide wire measured and marked to insertion depth • • Zone III: • ~10 cm length • On table XRAY to confirm wire location • Superficial projection to umbilicus • 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 • u 2
u 4/7/2017 Early Generation Variations Efficacy: Non-Trauma Balloons • #8 Fogarty • IABP • Percluder, MaxiLD, Bernstein • Coda, Reliant • Approach • Femoral vs. Brachial • Percutaneous vs open • Post partum hemorrhage Confirmation • • 5 case reports/series with total 10 patients • Fluoro vs XRAY • No deaths Ultrasound • • No confirmation • Efficacy: Non-Trauma Efficacy: Non-Trauma Elective pelvic/sacral oncologic surgery • 2 series w/ combined 165 patients • Upper GI bleed • Combined mortality 0% • 3 patients reported • Fem artery thrombosis in 3 • No deaths • Embolism in 3 • u 3
u 4/7/2017 Efficacy: Blood Pressure Efficacy: Mortality Systematic review: Mean SBP increase > 50 mm Hg • Registry data: Japanese Trauma Data Bank over 10 years • 452 patients treated w/ REBOA • Propensity matched w/ controls • Efficacy: Mortality Efficacy: Mortality Registry data: Japanese Trauma Data Bank over 10 years US experience • • 452 patients treated w/ REBOA Registry data from two Level I centers that performed REBOA • • Propensity matched w/ controls Compared thoracotomy (RT) to REBOA • • 96 total patients • REBOA 24 • RT 72 • u 4
4/7/2017 � Efficacy: Mortality Modern Combat Experience Iraq and Afganistan experience • Stabilize and transport • Early Generation REBOA ER-REBOA – Prytime Medical Not designed for trauma applications FDA approval Oct 2015 • • Slow process in unexperienced hands but not a “fluroscopy free” indication • • 7 fr system Long, unwieldy guide wire • • No guidewire required • Nitinol reinforced catheter to resist retrograde pulsation Issues with 12 f sheath • • Occlusive in setting of hemorrhagic shock • Managing the arteriotomy after the fact • 5 �
4/7/2017 � Indications Contraindications PEA arrest (< 10 min) secondary to exsanguination from sub- • diaphragmatic hemorrhage Obstructive shock • Tamponade, tension pneumothorax, etc • Hypovolemic shock and SBP < 70 mmHg Inaccessible femoral vessels • • High clinical suspicion of proximal aortic injury • Non responders/partial responders with non-compressible Age > 70 years • • hemorrhage Pre-existing terminal illness or significant comorbidities • Intrabd hemorrhage 2/2 blunt or penetrating trauma -> Zone I • Blunt trauma with isolated pelvic fracture -> Zone III • Penetrating pelvic injury -> Zone III • Procedural Steps Potential Complications 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 • 6 �
4/7/2017 � Summary 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 7 �
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