Whole Blood Selective Aortic Arch Perfusion for Exsanguination Cardiac Arrest: Assessing Myocardial Tolerance to the Duration of Cardiac Arrest

Abstract

Introduction: Selective aortic arch perfusion (SAAP) is an endovascular technique that consists of aortic occlusion with perfusion of the coronary and cerebral circulation. It been shown to facilitate return of spontaneous circulation (ROSC) after exanguination cardiac arrest (ECA), but it is not known how long arrest may last before the myocardium can no longer be durably recovered. The aim of this study is to assess the myocardial tolerance to exsanguination cardiac arrest before successful ROSC with SAAP. Methods: Male adult swine (n ¼ 24) were anesthetized, instrumented, and hemorrhaged to arrest. Animals were randomized into three groups: 5, 10, and 15 min of cardiac arrest before resuscitation with SAAP. Following ROSC, animals were observed for 60 min in a critical care environment. Primary outcomes were ROSC, and survival at 1-h post-ROSC. Results: Shorter cardiac arrest time was associated with higher ROSC rate and better 1-h survival. ROSC was obtained for 100% (8/8) of the 5-min ECA group, 75% (6/8) of the 10-min group, 43% (3/7) of the 15-min group (P ¼ 0.04). One-hour post-ROSC survival was 75%, 50%, and 14% in 5-, 10-, and 15-min groups, respectively (P ¼ 0.02). One-hour survivors in the 5-min group required less norepinephrine (1.31 mg AE 0.83 mg) compared with 10-SAAP (0.76 mg AE 0.24 mg), P ¼ 0.008. Conclusion: Whole blood SAAP can accomplish ROSC at high rates even after 10 min of unsupported cardiac arrest secondary to hemorrhage, with some viability beyond to 15 min. This is promising as a tool for ECA, but requires additional optimization and clinical trials. Animal Use Protocol, IACUC: 0919015.

Damage control surgery: old concepts and new indications

“…While REBOA preserves passive cerebral and cardiac perfusion, selective aortic arch perfusion is an emerging catheter-based resuscitation technique which combines closed thoracic aortic occlusion with active perfusion of coronary and cerebral vasculature with an oxygen-carrying perfusate. Investigation in a porcine model using whole blood perfusate has demonstrated return of spontaneous circulation even at 15 min after exsanguination cardiac arrest [84]. While the concept has been evaluated in preclinical animal models, clinical experience is not yet possible due to a lack of commercially available catheter system to simultaneously perform aortic occlusion and proximal infusion resuscitation.…”

Selective Aortic Arch Perfusion: A First-in-Man Report of a Novel Endovascular Resuscitation Modality

“…[8 9] In situations of established cardiovascular collapse pure aortic occlusion might not be su cient to enable a return of spontaneous circulation. [10][11][12] Selective aortic arch perfusion (SAAP) is an endovascular technique that combines thoracic aortic occlusion with extracorporeal perfusion of the brain and heart. [13] SAAP has been shown to be superior to both REBOA and conventional open techniques in animal models of haemorrhagic cardiac arrest.…”

Selective aortic arch perfusion: a first-in-human observational cadaveric study

“…However, REBOA is not currently supported by robust evidence from randomised control trials and may in some settings cause harm [ 8 , 9 ]. In situations of established cardiovascular collapse pure aortic occlusion might not be sufficient to enable a return of spontaneous circulation [ 10 – 12 ].…”

“…Despite promising animal studies of SAAP [ 12 , 14 , 15 ], no feasibility data exist to support its use in humans. In addition, no SAAP device currently has regulatory body approval for human use.…”