Targeted Regional Optimization: Increasing the Therapeutic Window for Endovascular Aortic Occlusion In Traumatic Hemorrhage

Ronaldi, Alley E.; Madurska, Marta J; Bozzay, Joseph; Polcz, Jeanette E.; Baer, David G.; Burmeister, David M.; White, Paul W.; Rasmussen, Todd E.; White, Joseph

doi:10.1097/shk.0000000000001814

Cited by 6 publications

(9 citation statements)

References 76 publications

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“…This result is concordant with the single-center study, 28 which concluded that partial REBOA may be associated with less end-organ dysfunction than complete REBOA. The results are also concordant with a large (and growing) body of preclinical literature documenting reduced ischemia/reperfusion injury in animals treated with partial compared with complete endovascular aortic occlusion 24,27,32,33 …”

Section: Discussionsupporting

confidence: 84%

“…The results are also concordant with a large (and growing) body of preclinical literature documenting reduced ischemia/reperfusion injury in animals treated with partial compared with complete endovascular aortic occlusion. 24,27,32,33 While the data on pREBOA-PRO represent current clinical use, the limited market release at select level I trauma centers may limit the generalizability of the findings. Furthermore, there are known limitations of registry studies, including missing data and lack of a nontreated control group.…”

Section: Discussionmentioning

confidence: 99%

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Titratable partial aortic occlusion: Extending Zone I endovascular occlusion times

Gomez

Naveed²,

Rezende

et al. 2023

J Trauma Acute Care Surg

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Background Extending the time to definitive hemorrhage control in non-compressible torso hemorrhage (NCTH) is of particular importance in the battlefield where transfer times are prolonged and NCTH remains the leading cause of death. While REBOA is widely practiced as an initial adjunct for the management of NCTH, concerns for ischemic complications after 30 minutes of compete aortic occlusion deters many from Zone 1 deployment. We hypothesize that extended zone 1 occlusion times will be enabled by novel purpose built devices that allow for titratable partial aortic occlusion. Methods This is a cross sectional analysis describing pREBOA-PRO zone 1 deployment characteristics at 7 level-1 trauma centers in the US and Canada (March 30, 2021 and June 30, 2022). In order to compare patterns of zone 1 aortic occlusion, the AORTA registry was utilized. Data was limited to adult patients who underwent successful occlusion in zone 1 (2013-2022). Results One hundred twenty-two patients pREBOA-PRO patients were included. Most catheters were deployed in zone 1 (73% n = 89) with a median zone 1 total occlusion time of 40 minutes (IQR 25-74). A sequence of complete followed by partial occlusion was used in 42% (n = 37) of zone 1 occlusion patients; a median of 76% (IQR 60-87%) of total occlusion time was partial occlusion in this group. As was seen in the prospectively collected data, longer median total occlusion times were observed in the titratable occlusion group in AORTA compared to the complete occlusion group. Conclusions Longer zone 1 aortic occlusion times seen with titratable aortic occlusion catheters appear to be driven by the feasibility of controlled partial occlusion. The ability to extend safe aortic occlusion times may have significant impact to combat casualty care where exsanguination from non-compressible torso hemorrhage is the leading source of potentially preventable deaths. Level of evidence Level IV evidence

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Section: Discussionsupporting

confidence: 84%

Section: Discussionmentioning

confidence: 99%

Titratable partial aortic occlusion: Extending Zone I endovascular occlusion times

Gomez

Naveed²,

Rezende

et al. 2023

J Trauma Acute Care Surg

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“…However, these guidelines are based on complete aortic occlusion. pREBOA allows for partial occlusion and thus a variable degree of distal blood flow [7][8][9]. A flow rate of 0.5 L/min has been shown to be effective at preventing ischemia while minimizing hemorrhage in swine [10].…”

Section: Discussionmentioning

confidence: 99%

Prolonged Partial REBOA: A Practice Paradigm for Managing Hemorrhage from Abdominal Gunshot Wounds

Zebley¹,

Halpern²,

Matecki³

et al. 2023

JEVTM

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Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a valuable tool for management of life-threateningtruncal hemorrhage. However, prolonged use of REBOA is limited by the ischemia that it causes distalto the occlusion. Partial REBOA (pREBOA) is a developing technique to inflate the balloon partially to allow for avariable degree of distal blood flow and mitigate some of the complications of prolonged occlusion of the aortawhile also ameliorating ongoing blood loss. We describe a case of a patient who presented with a gunshot woundto the right upper quadrant of the abdomen with significant liver, kidney, and colon injuries. The patient was successfullytreated with pREBOA for 20 hours without ischemic sequalae. This is the longest reported use of prolongedpREBOA and suggests that this technique may offer a means for hemorrhage control in the pre-/intra- andpostoperative settings..

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“…Distal ischemia and Ischemia-Reperfusion-Injury (IRI) is often blamed for the hemodynamic instability associated with aortic occlusion (19). Interestingly, the more classical serologic indicators of IRI, such as lactate or creatinine kinase, were not significantly different among cohorts (Table 1).…”

Section: Discussionmentioning

confidence: 99%

Targeted Regional Optimization in Action: Dose-dependent End-organ Ischemic Injury with Partial Aortic Occlusion in the Setting of Ongoing Liver Hemorrhage

Ronaldi

Lauria

Paterson

et al. 2022

Shock

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Introduction: Targeted regional optimization (TRO) describes partial resuscitative endovascular balloon occlusion of the aorta strategy that allows for controlled distal perfusion to balance hemostasis and tissue perfusion. This study characterized hemodynamics at specific targeted distal flow rates in a swine model of uncontrolled hemorrhage to determine if precise TRO by volume was possible. Methods: Anesthetized swine were subjected to liver laceration and randomized into TRO at distal flows of 300 mL/min (n ¼ 8), 500 mL/min (n ¼ 8), or 700 mL/min (n ¼ 8). After 90 min, the animals received damage control packing and were monitored for 6 h. Hemodynamic parameters were measured continuously, and hematology and serologic labs obtained at predetermined intervals. Results: During TRO, the average percent deviation from the targeted flow was lower than 15.9% for all cohorts. Average renal flow rates were significantly different across all cohorts during TRO phase (P < 0.0001; TRO300 ¼ 63.1 AE 1.2; TRO500 ¼ 133.70 AE 1.93; TRO700 ¼ 109.3 AE 2.0), with the TRO700 cohort having less renal flow than TRO500. The TRO500 and TRO700 average renal flow rates inverted during the intensive care unit phase (P < 0.0001; TRO300 ¼ 86.20 AE 0.40; TRO500 ¼ 148.50 AE 1.45; TRO700 ¼ 181.1 AE 0.70). There was higher blood urea nitrogen, creatinine, and potassium in the TRO300 cohort at the end of the experiment, but no difference in lactate or pH between cohorts. Conclusion: This study demonstrated technical feasibility of TRO as a strategy to improve outcomes after prolonged periods of aortic occlusion and resuscitation in the setting of ongoing solid organ hemorrhage. A dose-dependent ischemic end-organ injury occurs beginning with partial aortic occlusion that progresses through the critical care phase, with exaggerated effect on renal function.

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Targeted Regional Optimization: Increasing the Therapeutic Window for Endovascular Aortic Occlusion In Traumatic Hemorrhage

Cited by 6 publications

References 76 publications

Titratable partial aortic occlusion: Extending Zone I endovascular occlusion times

Titratable partial aortic occlusion: Extending Zone I endovascular occlusion times

Prolonged Partial REBOA: A Practice Paradigm for Managing Hemorrhage from Abdominal Gunshot Wounds

Targeted Regional Optimization in Action: Dose-dependent End-organ Ischemic Injury with Partial Aortic Occlusion in the Setting of Ongoing Liver Hemorrhage

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