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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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.
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.
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.
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.
KeywordsResuscitative endovascular occlusion of the aorta REBOA Partial REBOA Degree of occlusion Balloon volume
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.
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.
Grant-in-Aid for Research Activity Start-up, Japan Society for the Promotion of Science (JSPS) KAKENHI Grant Number, 17H06567.
Compliance with ethical standards
Conflict of interest
Yosuke Matsumura was a Clinical Advisory Board Member at Tokai Medical Products. Other authors declare no conflict of interest.
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).
- 2.Matsumura Y, Matsumoto J, Kondo H, Idoguchi K, Funabiki T, investigators D-I. Partial occlusion, conversion from thoracotomy, undelayed but shorter occlusion: resuscitative endovascular balloon occlusion of the aorta strategy in Japan. Eur J Emerg Med. 2018;25(5):348–54. https://doi.org/10.1097/MEJ.0000000000000466.CrossRefPubMedGoogle Scholar
- 3.Brenner M, Inaba K, Aiolfi A, DuBose J, Fabian T, Bee T, et al. Resuscitative endovascular balloon occlusion of the aorta and resuscitative thoracotomy in select patients with hemorrhagic shock: early results from the american association for the surgery of Trauma's aortic occlusion in resuscitation for trauma and acute care surgery registry. J Am Coll Surg. 2018;226(5):730–40. https://doi.org/10.1016/j.jamcollsurg.2018.01.044.CrossRefPubMedGoogle Scholar
- 4.Lendrum R, Perkins Z, Chana M, Marsden M, Davenport R, Grier G, et al. Pre-hospital resuscitative endovascular balloon occlusion of the aorta (REBOA) for exsanguinating pelvic haemorrhage. Resuscitation. 2019;135:6–13. https://doi.org/10.1016/j.resuscitation.2018.12.018.CrossRefPubMedGoogle Scholar
- 5.Manzano-Nunez R, Orlas CP, Herrera-Escobar JP, Galvagno S, DuBose J, Melendez JJ, et al. A meta-analysis of the incidence of complications associated with groin access after the use of resuscitative endovascular balloon occlusion of the aorta in trauma patients. J Trauma Acute Care Surg. 2018;85(3):626–34. https://doi.org/10.1097/TA.0000000000001978.CrossRefPubMedGoogle Scholar
- 6.Davidson AJ, Russo RM, Reva VA, Brenner ML, Moore LJ, Ball C, et al. The pitfalls of resuscitative endovascular balloon occlusion of the aorta: risk factors and mitigation strategies. J Trauma Acute Care Surg. 2018;84(1):192–202. https://doi.org/10.1097/TA.0000000000001711.CrossRefPubMedGoogle Scholar
- 10.Reva VA, Matsumura Y, Horer T, Sveklov DA, Denisov AV, Telickiy SY, et al. Resuscitative endovascular balloon occlusion of the aorta: what is the optimum occlusion time in an ovine model of hemorrhagic shock? Eur J Trauma Emerg Surg. 2018;44(4):511–8. https://doi.org/10.1007/s00068-016-0732-z.CrossRefPubMedGoogle Scholar
- 11.Russo RM, Williams TK, Grayson JK, Lamb CM, Cannon JW, Clement NF, 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. https://doi.org/10.1097/TA.0000000000000940 (discussion 8–80).CrossRefPubMedGoogle Scholar
- 12.Kuckelman J, Barron M, Moe D, Derickson M, Phillips C, Kononchik J, et al. Extending the golden hour for zone 1 reboa: improved survival and reperfusion injury with intermittent versus continuous reboa in a porcine severe truncal hemorrhage model. J Trauma Acute Care Surg. 2018. https://doi.org/10.1097/TA.0000000000001964.CrossRefPubMedGoogle Scholar
- 13.Sadeghi M, Horer TM, Forsman D, Dogan EM, Jansson K, Kindler C, et al. Blood pressure targeting by partial REBOA is possible in severe hemorrhagic shock in pigs and produces less circulatory, metabolic and inflammatory sequelae than total REBOA. Injury. 2018;49(12):2132–41. https://doi.org/10.1016/j.injury.2018.09.052.CrossRefPubMedGoogle Scholar
- 18.Williams TK, Neff LP, Johnson MA, Ferencz SA, Davidson AJ, Russo RM, et al. Extending resuscitative endovascular balloon occlusion of the aorta: endovascular variable aortic control in a lethal model of hemorrhagic shock. J Trauma Acute Care Surg. 2016;81(2):294–301. https://doi.org/10.1097/TA.0000000000001075.CrossRefPubMedPubMedCentralGoogle Scholar
- 21.Rasmussen TE. Update on Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Remote Damage Control Resuscitation Symposium. 2016. https://rdcr.org/wp-content/uploads/2016/07/13-Rasmussen-20116-RDCR-Symposium-V2.pdf. Accessed 15 Nov 2019