Life over limb: Arterial access-related limb ischemic complications in 48-hour REBOA survivors

Abstract

BACKGROUND:Resuscitative endovascular balloon occlusion of the aorta (REBOA) is increasingly used in some trauma settings. Arterial access-related limb ischemic complications (ARLICs) resulting from the femoral arterial access required for REBOA are largely under reported. We sought to describe the incidence of these complications and the clinical, technical, and device factors associated with their development. METHODS:This was a retrospective cohort study of records of adult trauma patients from the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute care surgery registry between October 2013 and September 2020 who had REBOA and survived at least 48 hours. The primary outcome was ARLIC, defined as clinically relevant extremity ischemia or distal embolization. Relevant factors associated with ARLIC were also analyzed. RESULTS:Of 418 identified patients, 36 (8.6%) sustained at least one ARLIC; 22 with extremity ischemia, 25 with distal embolism, 11 with both. Patient demographics and injury characteristics were similar between ARLIC and no ARLIC groups. Access-related limb ischemic complication was associated with larger profile devices ( p = 0.009), cutdown access technique ( p = 0.02), and the presence of a pelvic external fixator/binder ( p = 0.01). Patients with ARLIC had higher base deficit ( p = 0.03) and lactate ( p = 0.006).One hundred fifty-six patients received tranexamic acid (TXA), with 22 (14%) ARLICs. The rate of TXA use among ARLIC patients was 61% (vs. 35% TXA for non-ARLIC patients, p = 0.002). Access-related limb ischemic complication did not result in additional in-hospital mortality, however, ARLIC had prolonged hospital LOS (31 vs. 24 days, p = 0.02). Five ARLIC required surgical intervention, three patch angioplasty (and two with associated bypass), and four ARLIC limbs were amputated. CONCLUSION:Femoral artery REBOA access carries a risk of ARLIC, which is associated with unstable pelvis fractures, severe shock, and strongly with the administration of TXA. Use of lower-profile devices and close surveillance for these complications is warranted in these settings and caution should be exercised when using TXA in conjunction with REBOA.

Cushioned on the way up, controlled on the way down during resuscitative endovascular balloon occlusion of the aorta (REBOA): investigating a novel compliant balloon design for optimizing safe overinflation combined with partial REBOA ability

“…Despite the possible benefits of partial occlusion with a 7 Fr sheath, these may have to be balanced with an elevated risk of limb complications due to the outflow obstruction. 20 Reported limb complications that happen after complete REBOA using a 7 Fr sheath primarily affect the access site limb, as opposed to both limbs, implying that this is more related to the unilateral sheath combined with aortic occlusion as opposed to the aortic occlusion itself. A recent large retrospective study by Laverty et al 20 and the AORTA (Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery) investigators reported 24 of 352 (7%) arterial access-related limb ischemic complications using the 7 Fr ER-REBOA (Prytime Medical).…”

“…One of the main concerns with current REBOA techniques is the use of a 7 Fr sheath, which can limit the outflow to a patient’s limb and may be further exacerbated over a planned longer p-REBOA period. Despite the possible benefits of partial occlusion with a 7 Fr sheath, these may have to be balanced with an elevated risk of limb complications due to the outflow obstruction 20. Reported limb complications that happen after complete REBOA using a 7 Fr sheath primarily affect the access site limb, as opposed to both limbs, implying that this is more related to the unilateral sheath combined with aortic occlusion as opposed to the aortic occlusion itself.…”

“…Reported limb complications that happen after complete REBOA using a 7 Fr sheath primarily affect the access site limb, as opposed to both limbs, implying that this is more related to the unilateral sheath combined with aortic occlusion as opposed to the aortic occlusion itself. A recent large retrospective study by Laverty et al 20 and the AORTA (Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery) investigators reported 24 of 352 (7%) arterial access-related limb ischemic complications using the 7 Fr ER-REBOA (Prytime Medical). The use of a 4 Fr REBOA device with p-REBOA abilities, such as the COBRA-OS, may help to mitigate these complications in both partial and complete REBOA.…”

Percutaneous delivery of self-propelling thrombin-containing powder increases survival from noncompressible truncal hemorrhage in a swine model of coagulopathy and hypothermia

“…However, in severe NCTH, the benefits of attempting lifesaving hemorrhage control often outweigh the risks associated with these procedures. 4,47 This study was limited by the small sample size used, although smaller sample sizes are common in swine studies. 25,26 Female pigs have increased survival during hemorrhage, 48 which may have impacted outcomes in all groups.…”

“…Inaccurate placement of the catheter due to lack of expertise or unsatisfactory operating environments may contribute to iatrogenic injuries. However, in severe NCTH, the benefits of attempting lifesaving hemorrhage control often outweigh the risks associated with these procedures 4,47 …”