Clamp Before You Cut: Proximal Control of Ruptured Abdominal Aortic Aneurysms Using Endovascular Balloon Occlusion

Abstract

While the mortality rate for elective abdominal aortic aneurysm (AAA) repair has declined over the last several decades, the rate for ruptured abdominal aortic aneurysm (RAAA) has unfortunately remained disturbingly high. Undiagnosed aneurysms may present with little warning until abdominal pain, syncope, and hypotension signify rupture. Fifty percent of patients with ruptured aneurysms die before reaching a medical facility, and their survival is highly dependent on hemodynamic stability at presentation. The degree of rupture containment and comorbid status of the patient determine hemodynamic stability. Endovascular stent grafting has significantly improved perioperative morbidity and mortality rates for elective AAA repair, and some of the same endovascular techniques can be used to obtain proximal control in patients presenting with RAAA. We describe 3 consecutive cases of RAAA where proximal control was obtained using a percutaneously placed, transfemoral aortic occlusion balloon before induction of anesthesia.

Survival of severe blunt trauma patients treated with resuscitative endovascular balloon occlusion of the aorta compared with propensity score‐adjusted untreated patients

“…6 Since then, REBOA has been used in multiple settings including massive gastrointestinal bleeding, 28 gynecologic emergencies, 29 and ruptured aortic aneurysms. 30,31 Recent clinical studies suggest a potential benefit of REBOA in the setting of critically uncontrolled hemorrhagic shock, 11,32 but these studies are relatively small and lack a control group to compare the efficacy of REBOA placement. However, our present study shows that REBOA treatment is associated with higher mortality compared with similarly ill trauma patients who did not receive a REBOA.…”

Physiologic tolerance of descending thoracic aortic balloon occlusion in a swine model of hemorrhagic shock

“…[10][11][12] One such alternative is endovascular balloon occlusion, which is practiced by vascular surgeons to control the inflow of an abdominal aortic aneurysm during the placement of a stent graft. 13,14 It is interesting that the use of balloon occlusion of the aorta in trauma is not a new concept, having been reported as early as the 1950s during the Korean War, 15 but balloon occlusion has never gained widespread acceptance. With refinements in surgical technology and improved critical care, this technique is now being revisited clinically.…”

Endovascular balloon occlusion of the aorta is superior to resuscitative thoracotomy with aortic clamping in a porcine model of hemorrhagic shock

“…Notably, BO has been shown as a stabilizing tactic in cases when open endoaneurysmorrhaphy is used as the method of repair. 17,18 In these instances we advocate hemostatic resuscitation, including permissive hypotension in combination with initiation of central venous access and balanced blood product transfusion.…”

“…Balloon inflation decreases blood loss and supports perfusion while resuscitation is initiated, anesthesia induced, and surgical hemostasis is established. 17,18 Use of this adjunct in the setting of ruptured aneurysms has contributed to the first decrease in mortality after this lethal disease in approximately 4 decades. In that ruptured aneurysms represent a model of noncompressible torso hemorrhage, it is plausible that this benefit may translate to traumatic forms of hemorrhagic shock as well.…”