Advertisement

Resuscitative endovascular balloon occlusion of the aorta (REBOA) in a swine model of hemorrhagic shock and blunt thoracic injury

  • Carl A. BeyerEmail author
  • Guillaume L. Hoareau
  • Harris W. Kashtan
  • Andrew M. Wishy
  • Connor Caples
  • Marguerite Spruce
  • John K. Grayson
  • Lucas P. Neff
  • Timothy K. Williams
  • Michael A. Johnson
Original Article
  • 20 Downloads

Abstract

Purpose

While resuscitative endovascular balloon occlusion of the aorta (REBOA) is contraindicated in patients with aortic injuries, this technique may benefit poly-trauma patients with less extreme thoracic injuries. The purpose of this study was to characterize the effects of thoracic injury on hemodynamics during REBOA and the changes in pulmonary contusion over time in a swine model.

Methods

Twelve swine were anesthetized, instrumented, and randomized to receive either a thoracic injury with 5 impacts to the chest or no injury. All animals underwent controlled hemorrhage of 25% blood volume followed by 45 min of Zone 1 REBOA. Animals were then resuscitated with shed blood, observed during a critical care period, and euthanized after 6 h of total experimental time.

Results

There were no differences between the groups at baseline. The only difference after 6 h was a lower hemoglobin in the thoracic trauma group (8.4 ± 0.8 versus 9.4 ± 0.6 g/dL, P = 0.04). The average proximal mean arterial pressures were significantly lower in the thoracic trauma group during aortic occlusion [103 (98–108) versus 117 (115–124) mmHg, P = 0.04]. There were no differences between the pulmonary contusion before REBOA and at the end of the experiment in size (402 ± 263 versus 356 ± 291 mL, P = 0.782) or density (− 406 ± 127 versus − 299 ± 175 HFU, P = 0.256).

Conclusions

Thoracic trauma blunted the proximal arterial pressure augmentation during REBOA but had minimal impacts on resuscitative outcomes. This initial study indicates that REBOA does not seem to exacerbate pulmonary contusion in swine, but blunt thoracic injuries may attenuate the expected rises in proximal blood pressure during REBOA.

Keywords

Resuscitative endovascular balloon occlusion of the aorta (REBOA) Blunt thoracic trauma Pulmonary contusion Poly-trauma Hemorrhagic shock 

Notes

Acknowledgements

We thank SFC Casey Hicks, Mr. Carl Gibbins, Ms. Sally Knode, Ms. Amy Taylor, SSgt Sasha Palen, and SrA Natalya Clifton for their outstanding technical assistance, and the other staff of the Clinical Investigation Facility, David Grant USAF Medical Center for their support. We also thank The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. for their administrative support.

Funding

This work is supported by the Office of the Assistant Secretary of Defense for Health Affairs, through the Defense Medical Research and Development Program under Award No. W81XWH-16–2-0043. Opinions, interpretations, conclusions and recommendations are those of the authors and are not necessarily endorsed by the Department of Defense.

Compliance with ethical standards

Conflict of interest

T.K.W., M.A.J., and L.P.N. are founders and stockholders of Certus Critical Care, Inc. All the other authors report no conflicts of interest.

Disclaimer

The views expressed in this material are those of the authors and do not reflect the official policy of the US Government, the Department of Defense, the Department of the Air Force, the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., the University of California Davis, or Wake Forest University. The animals involved in this study were procured, maintained, and used in accordance with the Laboratory Animal Welfare Act of 1966, as amended, and the Guide for the Care and Use of Laboratory Animals, National Research Council. The work reported herein was performed under United States Air Force Surgeon General approved Clinical Investigation Number FDG20170021A.

References

  1. 1.
    Kisat M, Morrison JJ, Hashmi ZG, et al. Epidemiology and outcomes of non-compressible torso hemorrhage. J Surg Res. 2013;184(1):414–21.CrossRefGoogle Scholar
  2. 2.
    Eastridge BJ, Hardin M, Cantrell J, et al. Died of wounds on the battlefield: causation and implications for improving combat casualty care. J Trauma. 2011;71(1 Suppl):S4–8.CrossRefGoogle Scholar
  3. 3.
    White JM, Cannon JW, Stannard A, et al. Endovascular balloon occlusion of the aorta is superior to resuscitative thoracotomy with aortic clamping in a porcine model of hemorrhagic shock. Surgery. 2011;150(3):400–9.CrossRefGoogle Scholar
  4. 4.
    Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma. 2011;71(6):1869–72.PubMedGoogle Scholar
  5. 5.
    Saito N, Matsumoto H, Yagi T, et al. Evaluation of the safety and feasibility of resuscitative endovascular balloon occlusion of the aorta. J Trauma Acute Care Surg. 2015;78(5):897–903.CrossRefGoogle Scholar
  6. 6.
    Hughes CW. Use of an intra-aortic balloon catheter tamponade for controlling intra-abdominal hemorrhage in man. Surgery. 1954;36(1):65–8.PubMedGoogle Scholar
  7. 7.
    Brenner M, Hoehn M, Pasley J, et al. Basic endovascular skills for trauma course: bridging the gap between endovascular techniques and the acute care surgeon. J Trauma Acute Care Surg. 2014;77(2):286–91.CrossRefGoogle Scholar
  8. 8.
    Andres J, Scott J, Giannoudis PV. Resuscitative endovascular balloon occlusion of the aorta (REBOA): what have we learned? Injury. 2016;47(12):2603–5.CrossRefGoogle Scholar
  9. 9.
    Morrison JJ, Ross JD, Markov NP, et al. The inflammatory sequelae of aortic balloon occlusion in hemorrhagic shock. J Surg Res. 2014;191(2):423–31.CrossRefGoogle Scholar
  10. 10.
    Russo RM, Williams TK, Grayson JK, et al. Extending the golden hour: Partial resuscitative endovascular balloon occlusion of the aorta in a highly lethal swine liver injury model. J Trauma Acute Care Surg. 2016;80(3):372–8.CrossRefGoogle Scholar
  11. 11.
    Kuckelman JP, Barron M, Moe D, et al. Extending the golden hour for Zone 1 resuscitative endovascular balloon occlusion of the aorta: Improved survival and reperfusion injury with intermittent versus continuous resuscitative endovascular balloon occlusion of the aorta of the aorta in a porcine severe truncal hemorrhage model. J Trauma Acute Care Surg. 2018;85(2):318–26.CrossRefGoogle Scholar
  12. 12.
    Uchino H, Tamura N, Echigoya R, et al. “REBOA”—is it really safe? A case with massive intracranial hemorrhage possibly due to endovascular balloon occlusion of the aorta (REBOA). Am J Case Rep. 2016;17:810–3.CrossRefGoogle Scholar
  13. 13.
    Johnson MA, Williams TK, Ferencz SE, et al. The effect of resuscitative endovascular balloon occlusion of the aorta, partial aortic occlusion and aggressive blood transfusion on traumatic brain injury in a swine polytrauma model. J Trauma Acute Care Surg. 2017;83(1):61–70.CrossRefGoogle Scholar
  14. 14.
    Wasicek PJ, Teeter WA, Yang S, et al. Extended resuscitative endovascular balloon occlusion of the aorta (REBOA)-induced type 2 myocardial ischemia: a time-dependent penalty. Trauma Surg Acute Care Open. 2019;4(1):e000194.CrossRefGoogle Scholar
  15. 15.
    Maruhashi T, Minehara H, Takeuchi I, et al. Resuscitative endovascular balloon occlusion of the aorta may increase the bleeding of minor thoracic injury in severe multiple trauma patients: a case report. J Med Case Rep. 2017;11(1):347.CrossRefGoogle Scholar
  16. 16.
    Cannon J, Morrison J, Lauer C, et al. Resuscitative endovascular balloon occlusion of the aorta (REBOA) for hemorrhagic shock. Mil Med. 2018;183(2 Suppl):S55–S59.CrossRefGoogle Scholar
  17. 17.
    Pape HC, Peitzman AB, Rotondo MF. Damage control management in the polytrauma patient. 2nd ed. Cham: Springer International Publishing; 2017.CrossRefGoogle Scholar
  18. 18.
    Rodriguez RM, Friedman B, Langdorf MI, et al. Pulmonary contusion in the pan-scan era. Injury. 2016;47(5):1031–4.CrossRefGoogle Scholar
  19. 19.
    Langdorf MI, Medak AJ, Hendey GW, et al. Prevalence and clinical import of thoracic injury identified by chest computed tomography but not chest radiography in blunt trauma: multicenter prospective cohort study. Ann Emerg Med. 2015;66(6):589–600.CrossRefGoogle Scholar
  20. 20.
    Sondeen JL, Dubick MA, Holcomb JB, et al. Uncontrolled hemorrhage differs from volume- or pressure-matched controlled hemorrhage in swine. Shock. 2007;28(4):426–33.CrossRefGoogle Scholar
  21. 21.
    Horst K, Simon TP, Pfeifer R, et al. Characterization of blunt chest trauma in a long-term porcine model of severe multiple trauma. Sci Rep. 2016;6:39659.CrossRefGoogle Scholar
  22. 22.
    Williams TK, Tibbits EM, Hoareau GL, et al. Endovascular variable aortic control (EVAC) versus resuscitative endovascular balloon occlusion of the aorta (REBOA) in a swine model of hemorrhage and ischemia reperfusion injury. J Trauma Acute Care Surg. 2018;85(3):519–26.PubMedGoogle Scholar
  23. 23.
    Batchinsky AI, Weiss WB, Jordan BS, et al. Ventilation-perfusion relationships following experimental pulmonary contusion. J Appl Physiol. 2007;103(3):895–902.CrossRefGoogle Scholar
  24. 24.
    Lendrum R, Perkins Z, Chana M, et al. Pre-hospital resuscitative endovascular balloon occlusion of the aorta (REBOA) for exsanguinating pelvic haemorrhage. Resuscitation. 2018;135:6–13.CrossRefGoogle Scholar
  25. 25.
    Butler F, Holcomb J, Shackelford S, et al. Advanced resuscitative care in tactical combat casualty care: TCCC guidelines change 18–01. J Spec Oper Med. 2018;18(4):37–55.PubMedGoogle Scholar
  26. 26.
    Woolcock AJ, Macklem PT. Mechanical factors influencing collateral ventilation in human, dog, and pig lungs. J Appl Physiol. 1971;30(1):99–115.CrossRefGoogle Scholar
  27. 27.
    ER-REBOA Catheter Reference Guide. Prytime Medical. https://prytimemedical.com/product/er-reboa/. Accessed 20 Jan 2019.
  28. 28.
    Huis I, Veld MA, Craft CA, Hood RE. Blunt cardiac trauma review. Cardiol Clin. 2018;36(1):183–91.CrossRefGoogle Scholar
  29. 29.
    Dhainaut JF, Brunet F. Right ventricular performance in adult respiratory distress syndrome. Eur Respir J Suppl. 1990;11:490–5.Google Scholar
  30. 30.
    Niesler U, Palmer A, Fröba JS, et al. Role of alveolar macrophages in the regulation of local and systemic inflammation after lung contusion. J Trauma Acute Care Surg. 2014;76(2):386–93.CrossRefGoogle Scholar
  31. 31.
    Störmann P, Auner B, Schimunek L, et al. Leukotriene B4 indicates lung injury and on-going inflammatory changes after severe trauma in a porcine long-term model. Prostaglandins Leukot Essent Fatty Acids. 2017;127:25–31.CrossRefGoogle Scholar
  32. 32.
    Beyer CA, Hoareau GL, Tibbits EM, et al. Resuscitative endovascular balloon occlusion of the aorta (REBOA) induced myocardial injury is mitigated by endovascular variable aortic control (EVAC). J Trauma Acute Care Surg. 2019 (Epub ahead of print)Google Scholar
  33. 33.
    Ordoñez CA, Parra MW, Manzano-Nunez R, et al. Intraoperative combination of resuscitative endovascular balloon occlusion of the aorta and a median sternotomy in hemodynamically unstable patients with penetrating chest trauma: Is this feasible? J Trauma Acute Care Surg. 2018;84(5):752–7.CrossRefGoogle Scholar
  34. 34.
    Judge EP, Hughes JML, Egan JJ, et al. Anatomy and bronchoscopy of the porcine lung: a model for translational respiratory medicine. Am J Respir Cell Mol Biol. 2014;51(3):334–43.CrossRefGoogle Scholar
  35. 35.
    Al-Tarrah K, Moiemen N, Lord JM. The influence of sex steroid hormones on the response to trauma and burn injury. Burns Trauma. 2017;5:29.CrossRefGoogle Scholar
  36. 36.
    Martini WZ, Pusateri AE, Uscilowicz JM, et al. Independent contributions of hypothermia and acidosis to coagulopathy in swine. J Trauma. 2005;58(5):1002–9.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Carl A. Beyer
    • 1
    • 2
    Email author
  • Guillaume L. Hoareau
    • 1
  • Harris W. Kashtan
    • 1
    • 2
  • Andrew M. Wishy
    • 1
    • 2
  • Connor Caples
    • 1
    • 2
  • Marguerite Spruce
    • 1
    • 2
  • John K. Grayson
    • 1
  • Lucas P. Neff
    • 3
  • Timothy K. Williams
    • 3
  • Michael A. Johnson
    • 1
    • 4
  1. 1.Clinical Investigation Facility, David Grant USAF Medical CenterTravis Air Force BaseFairfieldUSA
  2. 2.Department of SurgeryUniversity of California Davis Medical CenterSacramentoUSA
  3. 3.Department of SurgeryWake Forest Baptist Medical CenterWinston-SalemUSA
  4. 4.Department of Emergency MedicineUniversity of California Davis Medical CenterSacramentoUSA

Personalised recommendations