Titratable partial aortic occlusion: Extending Zone I endovascular occlusion times

Abstract

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

Complications associated with the use of resuscitative endovascular balloon occlusion of the aorta (REBOA): an updated review

“…Despite limited clinical evidence for pREBOA, 34 35 48 studies by Matsumura et al 48 and others show promising outcomes. Matsumura et al demonstrated that patients undergoing pREBOA had better hemodynamic responses and longer occlusion time compared with conventional REBOA (median 58 minutes vs. 33 minutes), with comparable mortality.…”

“… 38 52–55 The pREBOA-PRO device enables longer zone 1 deployment without frequent adjustments, improving outcomes. 34 38 Its dual arterial line capability allows real-time monitoring of central aortic and distal femoral artery pressures, providing evidence of ongoing perfusion and guiding resuscitation. 34 In a clinical setting, the use of pREBOA-PRO devices allowed longer zone 1 total occlusion times without worsening distal ischemic injury compared with complete occlusion devices.…”

“… 34 38 Its dual arterial line capability allows real-time monitoring of central aortic and distal femoral artery pressures, providing evidence of ongoing perfusion and guiding resuscitation. 34 In a clinical setting, the use of pREBOA-PRO devices allowed longer zone 1 total occlusion times without worsening distal ischemic injury compared with complete occlusion devices. 34 Improved feasibility and controlled partial occlusion make pREBOA-PRO a promising advancement for trauma patients, providing improved outcomes while avoiding hemodynamic collapse.…”

Partial Resuscitative Endovascular Balloon Occlusion of the Aorta Aids in the Successful Non-Operative Management of a Life-Threatening Penetrating Liver Injury

“…They demonstrated the safety of Zone 1 partial occlusion for extended periods, but the majority of patients from this study suffered blunt injuries, and injury patterns were not included. 3 In our case, we present a patient with a life-threatening penetrating liver injury that was successfully managed non-operatively by leveraging PBAO. A 46-year-old male suffered gunshot wounds (GSW) to the epigastrium, right flank, right shoulder, and back.…”

“…Utilizing REBOA for partial aortic occlusion (PBAO) has gained attention over the past several years because PBAO affords improvement in central blood pressure while minimizing the amount and duration of distal ischemia. 2,3 Partial aortic occlusion allows the provider to make targeted changes in volume and thus titrate the amount of aortic occlusion, and thereby the amount of blood flow distally. This may provide more time to mobilize resources for definitive hemorrhage control while minimizing the morbidity of ischemia.…”