Anatomical landmarks for safely implementing resuscitative balloon occlusion of the aorta (REBOA) in zone 1 without fluoroscopy

Burg

Eur J Trauma Emerg Surg

et al. 2020

Purpose Use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as adjunct for temporary hemorrhage control in patients with exsanguinating torso hemorrhage is increasing. Characteristics of aortic occlusion balloons (AOB) are diverse and evolving as efforts are made to improve the technology. It is important to select a device that fits the requirements of the medical situation to minimize the risk of failure and complications. The aim of this study is to appraise guidance in the choice of an AOB in a specific situation. Methods We assessed 29 AOB for differences and outline possible advantages and disadvantages of each. Bending stiffness was measured with a three-point bending device. Results Diameter of the AOB ranged from 6 (ER-REBOA™) to 10 (Coda ®-46) French. However, some need large-bore access sheaths up to 22 French (Fogarty ®-45 and LeMaitre ®-45) or even insertion via cut-down (Equalizer™-40). Bending stiffness varied from 0.08 N/mm (± 0.008 SD; Coda ®-32) to 0.72 N/mm (± 0.024 SD; Russian prototype). Rescue Balloon™ showed kinking of the shaft at low bending pressures. The only non-compliant AOB is REBOA Balloon ®. ER-REBOA™, Fogarty ® , LeMaitre ® , REBOA Balloon ® , and Rescue Balloon™ are provided with external length marks to assist blind positioning. Conclusion In resource-limited settings, a guidewire-and fluoroscopy-free, rather stiff device, such as ER-REBOA™, Fogarty ® , and LeMaitre ® , is warranted. Of these devices, ER-REBOA™ is the only catheter compatible with seven French sheaths and specifically designed for emergency hemorrhage control. Of the over-the-wire devices, Q50 ® has several features that facilitate use and reduce the risk of malplacement or vessel damage.

Section: Discussionmentioning

confidence: 99%

A contemporary assessment of devices for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): resource-specific options per level of care

Burg

Eur J Trauma Emerg Surg

et al. 2020

“…If the xed catheters continued to be applied in zone III at this time, it may cause long-term ischemic necrosis of vital organs. Inaba and Okada proposed that sternum was likely to be used to guide the catheter length positioning in zone I [9,10], yet there is no further study on the relevant anatomical structure of zone III.…”

Section: Discussionmentioning

confidence: 99%

“…Inaba et al found that the midpoint of the sternum could be used to guide the correct placement of REBOA in zone I via the study of cadavers [9]. Then, Okada et al showed that the safe catheter length positioning in zone I should be between the distance from the femoral artery to suprasternal notch and that to the xiphoid process [10]. In comparison, the current literatures provide less guidance on good practice in regard to the placement of REBOA in zone III by external landmark.…”

Section: Introductionmentioning

confidence: 99%

Location of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in Zone III Using External Landmark Without Fluoroscopy: A CTA-based Retrospective Study

Weng¹,

Qian²,

Zhou³

et al. 2020

Preprint

Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) can timely prevent the wounded from massive hemorrhage. We aim to study whether the combination of the xiphoid process and the umbilicus could guide the placement of REBOA in zone III without fluoroscopy. Methods We conducted a retrospective study in a university hospital that included 57 subjects who underwent contrast-enhanced computed tomography (CT) from April to December in 2019. External distances and intravascular lengths were measured by three-dimensional reconstruction CT images on the workstation, including the distances from the femoral artery to the xiphoid process (FA-Xi), the midpoint between the xiphoid process and the umbilicus (FA-mXU), the umbilicus (FA-Ui), the midpoint of the zone III (FA-mZIII), the lowest renal artery (FA-LRA), and aortic bifurcation (FA-AB). The relationship between external landmarks and REBOA catheter positioning in zone III was studied, involving the quartering distances between the xiphoid process and the umbilicus, the distance below the xiphoid process and that above the umbilicus. The predicted accuracy and safety margin of the balloon (distal and proximal) were calculated by curvature plane reconstruction. The probability of balloon positioning in zone III using these three methods was compared by Chi square test. Results The average length of aortic zone III was 9.4 cm (SD = 10.0), and that of FA-mZIII on the right and left sides were 24.4 cm (SD = 2.1) ,23.8 cm (SD = 2.1), respectively. FA-Xi was significantly longer than FA-LRA, and FA-Ui was significantly shorter than FA-AB (P < 0.05). Using the quartering distances between the xiphoid and the umbilicus, the distance below the xiphoid, the distance above the umbilicus to predict the length of REBOA catheter positioning in zone III showed no statistically significant difference. Using FA-mXU to predict the accuracy of catheter positioning in zone III on the left and right sides were 84.2% and 86%. Although there was a little difference between the left side of FA-mZIII and FA-mXU, there were no statistical differences on the right side. Conclusions The midpoint between the xiphoid process and the umbilicus is a good external landmark to guide the placement of REBOA in zone III without fluoroscopy.

Current Opinion in Anaesthesiology

“…The approximate insertion depth for positioning the balloon in the desired zone should be estimated beforehand on the basis of anatomical landmarks [37][38][39][40]:…”

Section: Key Pointsmentioning

confidence: 99%

Resuscitative endovascular balloon occlusion of the aorta

Kulla

Popp

Knapp

2019

Purpose of review Hemorrhage is the major cause of early death in severely injured patients. In civilian emergency medical services, the majority of life-threatening bleedings are found in noncompressible body regions (e.g. abdomen and pelvis). Resuscitative endovascular balloon occlusion of the aorta (REBOA) has therefore been discussed in recent years as a possible lifesaving procedure and numerous studies, meta-analyses and guidelines have been published. In this review, the data situation of REBOA in the management of bleeding trauma patients is discussed and practical implementation is depicted. Recent findings The typical indication for REBOA is a traumatic life-threatening hemorrhage below the diaphragm in patients unresponsive or only transiently responsive to the usual conservative therapeutic measures. REBOA appears to be a safe and effective procedure to reduce blood loss and stabilize the patient's hemodynamic status. However, surgical hemostasis has to be achieved within 30-60 min after occlusion of the aorta. Data on clear advantages of REBOA over resuscitative thoracostomy are inconclusive. Summary REBOA could play an important role in the management of the severely bleeding patient in the future. Together with transfusion and therapy of coagulation disorders, REBOA may be an additional tool in the anesthetist's hands for trauma management in interprofessional care concepts.