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Distal pressure monitoring and titration with percent balloon volume: feasible management of partial resuscitative endovascular balloon occlusion of the aorta (P-REBOA)

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Abstract

Introduction

Resuscitative endovascular balloon occlusion of the aorta (REBOA) increases proximal arterial pressure, but may also induce life-threatening distal ischemia. Partial REBOA (P-REBOA) is thought to mitigate distal ischemia during aortic occlusion. However, feasible indicators of the degree of P-REBOA remain inconsistent. We hypothesised percent balloon volume could be a substitute for pressure measurements of gradients during P- REBOA. This study aimed to compare balloon volume and arterial pressure gradient, and analysed with intra-balloon pressure and balloon shape.

Methods

Proximal (carotid) and distal (femoral) arterial pressures were recorded and a 7-Fr REBOA catheter was placed in four swine. Total REBOA was defined as a cessation of distal pulse pressure and maximum balloon volume was documented. The balloon volume was titrated by 20% increments of maximum capacity to adjust the degree of P-REBOA. The distal/proximal arterial pressure gradient and the intra-balloon pressures were also recorded. The changes in shape and the cross-sectional area of the balloon were evaluated with computed tomography (CT) images.

Results

The proximal mean arterial pressure (MAP) plateaued after 60% balloon volume; meanwhile, distal pulse pressure was still left. The balloon pressure was traced with proximal MAP before contact with aortic wall. The balloon shape changed unevenly from “cone” to “spindle” shape, although the balloon cross-sectional area of the mid-segment linearly increased.

Conclusion

Monitoring distal pressure and titrating percent balloon volume is feasible to manage P-REBOA. In this experiment, 60% balloon volume was enough inflation to elevate central pressure allowing distal perfusion. The intra-balloon pressure was not reliable due to the strong influence of proximal MAP and uneven change of the balloon shape.

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Acknowledgements

We appreciate Tomomasa Ttateno RT(R), Sho Kawai RT(R), Fumiharu Jimbo RT(R), Ryo Owada RT(R) for taking and processing CT images. We thank all members of the Centre for Development of Advanced Medical Technology, Jichi Medical University.

Funding

Grant-in-Aid for Research Activity Start-up, Japan Society for the Promotion of Science (JSPS) KAKENHI Grant Number, 17H06567.

Author information

Authors and Affiliations

  1. Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, 260-8677, Chiba, Japan

    Yosuke Matsumura, Akiko Higashi & Shigeto Oda

  2. Department of Emergency and Critical Care Medicine, Jichi Medical University, Shimotsuke, 329-0498, Japan

    Yoshimitsu Izawa

  3. Department of Emergency and Critical Care Medicine, Saiseikai Utsunomiya Hospital, Utsunomiya, 321-0974, Japan

    Yoshimitsu Izawa

  4. Center for Development of Advanced Medical Technology, Jichi Medical University, Shimotsuke, 329-0498, Japan

    Shuji Hishikawa

  5. Department of Radiology, Teikyo University School of Medicine, Itabashi, Japan

    Hiroshi Kondo

  6. Department of War Surgery, Kirov Military Medical Academy, St Petersburg, Russia

    Viktor Reva

  7. Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Kawasaki, 216-8511, Japan

    Junichi Matsumoto

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  1. Yosuke Matsumura
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  2. Akiko Higashi
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  3. Yoshimitsu Izawa
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  5. Hiroshi Kondo
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  6. Viktor Reva
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  8. Junichi Matsumoto
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Contributions

YM, a corresponding author, was responsible for drafting, editing, and submission of the manuscript. YM, AH, SH, and YI conducted the animal experiment and collected the data. HK, VR, SO, and JM critically appraised the manuscript. All the authors read and approved the final manuscript.

Corresponding author

Correspondence to Yosuke Matsumura.

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Conflict of interest

Yosuke Matsumura was a Clinical Advisory Board Member at Tokai Medical Products. Other authors declare no conflict of interest.

Ethical approval

This study was conducted in an accredited animal research laboratory (Centre for Development of Advanced Medical Technology, Jichi Medical University, Tochigi, Japan). Institutional Animal Experiment Committee approval was obtained before beginning the study (authorisation number 17045-01).

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Matsumura, Y., Higashi, A., Izawa, Y. et al. Distal pressure monitoring and titration with percent balloon volume: feasible management of partial resuscitative endovascular balloon occlusion of the aorta (P-REBOA). Eur J Trauma Emerg Surg 47, 1023–1029 (2021). https://doi.org/10.1007/s00068-019-01257-4

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  • DOI: https://doi.org/10.1007/s00068-019-01257-4

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