Total resuscitative endovascular balloon occlusion of the aorta causes inflammatory activation and organ damage within 30 minutes of occlusion in normovolemic pigs

Abstract

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) causes physiological, metabolic, end-organ and inflammatory changes that need to be addressed for better management of severely injured patients. The aim of this study was to investigate occlusion time-dependent metabolic, end-organ and inflammatory effects of total REBOA in Zone I in a normovolemic animal model. Methods: Twenty-four pigs (25-35 kg) were randomized to total occlusion REBOA in Zone I for either 15, 30, 60 min (REBOA15, REBOA30, and REBOA60, respectively) or to a control group, followed by 3-h reperfusion. Hemodynamic variables, metabolic and inflammatory response, intraperitoneal and intrahepatic microdialysis, and plasma markers of end-organ injuries were measured during intervention and reperfusion. Intestinal histopathology was performed. Results: Mean arterial pressure and cardiac output increased significantly in all REBOA groups during occlusion and blood flow in the superior mesenteric artery and urinary production subsided during intervention. Metabolic acidosis with increased intraperitoneal and intrahepatic concentrations of lactate and glycerol was most pronounced in REBOA30 and REBOA60 during reperfusion and did not normalize at the end of reperfusion in REBOA60. Inflammatory response showed a significant and persistent increase of pro-and anti-inflammatory cytokines during reperfusion in REBOA30 and was most pronounced in REBOA60. Plasma concentrations of liver, kidney, pancreatic and skeletal muscle enzymes were significantly increased at the end of reperfusion in REBOA30 and REBOA60. Significant intestinal mucosal damage was present in REBOA30 and REBOA60. Conclusion: Total REBOA caused severe systemic and intra-abdominal metabolic disturbances, organ damage and inflammatory activation already at 30 min of occlusion.

Partial Versus Complete Resuscitative Endovascular Balloon Occlusion of the Aorta in Exsanguinating Trauma Patients With Non-Compressible Torso Hemorrhage

“…Since c-REBOA prevents blood supply to the SMA, the organs supplied by this artery are compromised and can undergo irreversible cell injury. The repercussion of this is duodenal necrosis, as previously discussed, in addition to the elevation of pancreatic enzymes, as described by Sadeghi et al [10]. Other tissues and organs that have been reportedly affected are skeletal muscle, kidneys, and the liver, which was reported in Sadeghi et al's study with 24 swine ( Table 2) [10].…”

“…The repercussion of this is duodenal necrosis, as previously discussed, in addition to the elevation of pancreatic enzymes, as described by Sadeghi et al [10]. Other tissues and organs that have been reportedly affected are skeletal muscle, kidneys, and the liver, which was reported in Sadeghi et al's study with 24 swine ( Table 2) [10]. These abnormalities were either not seen or seen only to a lesser degree in a partial occlusion compared to complete occlusion.…”

“…The purpose of this procedure is to bridge the gap from the onset of bleeding to surgical repair. REBOA allows for quick stabilization and immediate increase in systemic arterial blood pressure and cardiac output, thereby preventing cardiovascular collapse by sustaining adequate perfusion to the coronary and cerebral arteries [5,[10][11][12][13][14][15][16][17][18]. Despite the prospects of such a simple device, there are still gaps in training in terms of ensuring proper catheter placement and accurate monitoring during deflation of the balloon; this combined with the various complications that can follow the procedure means that there is still much research to be done relating to the use of REBOA.…”

“…It has been shown that complete occlusion for 30-60 minutes can lead to a multitude of metabolic derangements [4,5]. Besides the increase of pancreatic, kidney, liver, and skeletal muscle enzymes, elevated lactate secondary to prolonged ischemia, the elevation of pro-inflammatory cytokines [interleukin-6 (IL-6), Interleukin-1β (IL-1β), and tumor necrosis factor-alpha (TNF-α)] and anti-inflammatory cytokines [interleukin 10 (IL-10)] are also predominantly observed after the occurrence of reperfusion [10,18,20,21]. Another serious complication seen in c-REBOA is the risk of profound distal ischemia to the lower extremities and spinal cord with complications as severe as amputation and paraplegia, respectively [4,5,22,23].…”

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): update and insights into current practices and future directions for research and implementation

“…In a separate study conducted by Sadeghi et al, severe intestinal damage was reported in two of three groups of swine undergoing REBOA separated by duration of inflation. Both the 30-min and 60-min groups showed damage not seen in the 15-min group [ 89 ].…”