Resuscitative Endovascular Balloon Occlusion of the Aorta and Concomitant Tranexamic Acid for Cesarean Hysterectomy Complicated by Common Femoral Artery Thrombosis: A Case Report

Herbert, Katherine A.; Buchbinder, Lindsey; Seshachellam, Vishwas; Lee, Linden

doi:10.7759/cureus.11197

Cited by 5 publications

(3 citation statements)

References 13 publications

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“…This is not surprising given that in one military study and in the prehospital STAAMP trial, TXA was associated with increased rates of deep venous thrombosis and pulmonary embolism, although arterial thromboembolism is not reported in these publications 19,20 . Similar findings to those we observed have also been demonstrated in the use of REBOA in controlling postpartum hemorrhage: a recent case study reported bilateral femoral arterial thrombi requiring surgical thrombectomy following the use of REBOA with concomitant use of TXA 21 . As the use of both REBOA and TXA as adjuncts to trauma resuscitation increase, a high index of suspicion for arterial access complications should be maintained if both REBOA and TXA are used, and we urge caution when deciding to use them concurrently.…”

Section: Discussionsupporting

confidence: 79%

“…19,20 Similar findings to those we observed have also been demonstrated in the use of REBOA in controlling postpartum hemorrhage: a recent case study reported bilateral femoral arterial thrombi requiring surgical thrombectomy following the use of REBOA with concomitant use of TXA. 21 As the use of both REBOA and TXA as adjuncts to trauma resuscitation increase, a high index of suspicion for arterial access complications should be maintained if both REBOA and TXA are used, and we urge caution when deciding to use them concurrently.…”

Section: Discussionmentioning

confidence: 99%

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

Laverty

Treffalls

McEntire

et al. 2021

J Trauma Acute Care Surg

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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.

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Section: Discussionsupporting

confidence: 79%

Section: Discussionmentioning

confidence: 99%

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

Laverty

Treffalls

McEntire

et al. 2021

J Trauma Acute Care Surg

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“…The use of REBOA in non-traumatic hemorrhage has increased in a similar trajectory to its use in trauma, and similar findings of embolic complications have been published. Case reports have described distal embolic events requiring embolectomy in obstetric patients who underwent REBOA placement 15 or bilateral internal iliac artery balloons 16 to reduce hemorrhage from placental disorders. A larger case series described an embolic complication rate of 14% in similar patients, although the use of TXA was not examined.…”

Section: Discussionmentioning

confidence: 99%

Use of Tranexamic Acid With Resuscitative Endovascular Balloon Occlusion of the Aorta is Associated With Higher Distal Embolism Rates: Results From the American Association of Surgery for Trauma Aortic Occlusion and Resuscitation for Trauma and Acute Care Surgery Trial

Shaw,

Zakhary,

Coimbra

et al. 2023

The American Surgeon™

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Introduction Tranexamic acid (TXA) use has been associated with thrombotic complications. Objective We aim to investigate outcomes associated with TXA use in the setting of high- (HP) and low-profile (LP) introducer sheaths for resuscitative endovascular balloon occlusion of the aorta (REBOA). Participants The Aortic Occlusion and Resuscitation for Trauma and Acute Care Surgery (AORTA) database was queried for patients who underwent REBOA using a low-profile 7 French (LP) or high-profile, 11-14 French (HP) introducer sheaths between 2013 and 2022. Demographics, physiology, and outcomes were examined for patients who survived beyond the index operation. Results 574 patients underwent REBOA (503 LP, 71 HP); 77% were male, mean age was 44 ± 19 and mean injury severity score (ISS) was 35 ± 16. 212 patients received TXA (181 [36%] LP, 31 [43.7%] HP). There were no significant differences in admission vital signs, GCS, age, ISS, SBP at AO, CPR at AO, and duration of AO among LP and HP patients. Overall, mortality was significantly higher in the HP (67.6%) vs the LP group (54.9%; P = .043). Distal embolism was significantly higher in the HP group (20.4%) vs the LP group (3.9%; P < .001). Logistic regression demonstrated that TXA use was associated with a higher rate of distal embolism in both groups (OR = 2.92; P = .021). 2 LP patients (one who received TXA) required an amputation. Conclusion Patients who undergo REBOA are profoundly injured and physiologically devastated. Tranexamic acid was associated with a higher rate of distal embolism in those who received REBOA, regardless of access sheath size. For patients receiving TXA, REBOA placement should be accompanied by strict protocols for immediate diagnosis and treatment of thrombotic complications.

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Management of patients with suspected placenta accreta spectrum

Reale

Farber

2022

BJA Education

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Resuscitative Endovascular Balloon Occlusion of the Aorta and Concomitant Tranexamic Acid for Cesarean Hysterectomy Complicated by Common Femoral Artery Thrombosis: A Case Report

Cited by 5 publications

References 13 publications

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

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

Use of Tranexamic Acid With Resuscitative Endovascular Balloon Occlusion of the Aorta is Associated With Higher Distal Embolism Rates: Results From the American Association of Surgery for Trauma Aortic Occlusion and Resuscitation for Trauma and Acute Care Surgery Trial

Management of patients with suspected placenta accreta spectrum

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