BACKGROUND Resuscitative endovascular balloon occlusion of the vena cava inferior (REBOVC) may provide a minimal invasive alternative for hepatic vascular and inferior vena cava isolation in severe retrohepatic bleeding. However, circulatory stability may be compromised by the obstruction of venous return. The aim was to explore which combinations of arterial and venous endovascular balloon occlusions, and the Pringle maneuver, are hemodynamically possible in a normovolemic pig model. The hypothesis was that lower-body venous blood pooling from REBOVC can be avoided by prior resuscitative endovascular aortic balloon occlusion (REBOA). METHODS Nine anesthetized, ventilated, instrumented, and normovolemic pigs were used to explore the hemodynamic effects of 11 combinations of REBOA and REBOVC, with or without the Pringle maneuver, in randomized order. The occlusions were performed for 5 minutes but interrupted if systolic blood pressure dropped below 40 mm Hg. Hemodynamic variables were measured. RESULTS Proximal REBOVC, isolated or in combination with other methods of occlusion, caused severely decreased systemic blood pressure and cardiac output, and had to be terminated before 5 minutes. The decreases in systemic blood pressure and cardiac output were avoided by REBOA at the same or a more proximal level. The Pringle maneuver had similar hemodynamic effects to proximal REBOVC. CONCLUSION A combination of REBOA and REBOVC provides hemodynamic stability, in contrast to REBOVC alone or with the Pringle maneuver, and may be a possible adjunct in severe retrohepatic venous bleedings.

BACKGROUND Mortality from traumatic retrohepatic venous injuries is high and methods for temporary circulatory stabilization are needed. We investigated survival and hemodynamic and metabolic effects of resuscitative endovascular balloon occlusion of the aorta (REBOA) and vena cava inferior (REBOVC) in anesthetized pigs. METHODS Twenty-five anesthetized pigs in normovolemia or severe hemorrhagic shock (controlled arterial bleeding in blood bags targeting systolic arterial pressure of 50 mm Hg, corresponding to 40–50% of the blood volume) were randomized to REBOA zone 1 or REBOA+REBOVC zone 1 (n = 6–7/group) for 45 minutes occlusion, followed by 3-hour resuscitation and reperfusion. Hemodynamic and metabolic variables and markers of end-organ damage were measured regularly. RESULTS During occlusion, both the REBOA groups had higher systemic mean arterial pressure (MAP) and cardiac output ( p < 0.05) compared with the two REBOA+REBOVC groups. After 60 minutes reperfusion, there were no statistically significant differences between the two REBOA groups and the two REBOA+REBOVC groups in MAP and cardiac output. The two REBOA+REBOVC groups had higher arterial lactate and potassium concentrations during reperfusion, compared with the two REBOA groups ( p < 0.05). There was no major difference in end-organ damage markers between REBOA and REBOA+REBOVC. Survival after 1-hour reperfusion was 86% and 100%, respectively, in the normovolemic REBOA and REBOA+REBOVC groups, and 67% and 83%, respectively, in the corresponding hemorrhagic shock REBOA and REBOA+REBOVC groups. CONCLUSION Acceptable hemodynamic stability during occlusion and short-term survival can be achieved by REBOA+REBOVC with adequate resuscitation; however, the more severe hemodynamic and metabolic impacts of REBOA+REBOVC compared with REBOA must be considered. LEVEL OF EVIDENCE Prospective, randomized, experimental animal study. Basic science study, therapeutic.