Louis Alarcon MD FACS FCCM

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2 TR AUM A RO U N DS,REBOA Continued from Page 1, Resuscitative endovascular balloon occlusion of the aorta REBOA is. a novel and minimally invasive technique to curtail hemorrhage to. the subdiaphragmatic torso i e abdomen and pelvis in patients. presenting in hypovolemic hemorrhagic shock It is considered of. particular utility in circum stances of hypotension and cardiovascular. collapse that otherwise would merit resuscitative left anterolateral. thoracotomy and aortic clamping Similar to a non tunneled central. line the device is placed in a modified Seldinger technique and is. simple enough to be mastered by all personnel involved in the care of. the critically injured patient The apparatus is comprised of a 7 French. intro ducer catheter and a 100 cm balloon tipped occlusion catheter. that is similar in design to a Swan Ganz catheter see Figure 1. Through a sheath placed into the femoral artery the balloon. occlusion catheter is threaded and advanced to a predetermined. position upstream of the estimated regional source of bleeding 1. rostral to the iliac bifurcation for pelvic hemorrhage see Figure 2. and 2 subdiaphragmatic for abdominopelvic bleeding. Figure 2 Advancement of REBOA catheter through a femoral arterial. sheath and positioned rostral to the bifurcation of the iliac vessels. Image courtesy of Prytime Medical, Figure 1 Retrograde endovascular occlusion of the aorta REBOA. catheter Pictured here is the ER REBOA Catheter made by Prytime. Medical Devices Inc Image courtesy of Prytime Medical. An algorithmic calculation of balloon diameter with stepwise. increases in the volume of instillate enables one to estimate final. balloon diameter and thereby more accurately occlude the aorta. The use of radiopaque contrast and C arm fluoroscopy confirms. appropriate positioning see Figure 3 The physiologic ramifications. of successful and well positioned occlusion should become manifest. seconds after placement A new handheld smartphone based infrared. imaging device is in development to assess the adequate level of. aortic occlusion during REBOA 5 Yes even for the frantic resuscitation. of the critically injured patient there s an app for that. As with most novel technologies that offer hope for near futile. cases the theoretical benefits of REBOA were widely embraced. and its use rapidly adopted despite a paucity of data supporting its. benefit Over time however data has amassed typically from trauma. registries that enable observational analyses comparing REBOA. Figure 3 Fluoroscopic image of a REBOA catheter positioned. with other measures of resuscitation including thoracotomy In. rostral to the bifurcation of the iliac arteries at approximately the. a retrospective analysis of two trauma centers REBOA as an. third lumbar level,UPMC com TraumaRounds, alternative to resuscitative thoracotomy for noncompressible truncal References. hemorrhage was associated with reduced rates of death in the 1. Brown J B et al Systolic blood pressure criteria in the National Trauma. emergency department setting 26 7 vs 62 5 p 0 001 and Triage Protocol for geriatric trauma 110 is the new 90 J Trauma Acute. improved overall survival 37 5 vs 9 7 p 0 003 6 Care Surg 78 352 359 2015. However the American Association for the Surgery of Trauma just. Rhee P M et al Survival after emergency department thoracotomy. review of published data from the past 25 years J Am Coll Surg 190. reported initial results of their prospective Aortic Occlusion for. 288 298 2000, Resuscitation in Trauma and Acute Care Surgery AORTA registry 7. Over a 16 month period 114 patients underwent aortic occlusion. Moore E E et al Defining the limits of resuscitative emergency department. thoracotomy a contemporary Western Trauma Association perspective. AO REBOA 46 open AO 68 There was no difference in time to. J Trauma 70 334 339 2011, successful AO between REBOA and open AO 6 6 minutes vs 7 2.
minutes REBOA proved equivalent to open techniques in improving. Soreide K Petrone P Asensio J A Emergency thoracotomy in. trauma rationale risks and realities Scand J Surg 96 4 10 2007. hemodynamics 67 4 vs 61 8 though modestly better at achieving. hemodynamic stability 47 8 vs 27 9 p 0 014 Though not 5. Sokol K K et al There s an app for that A handheld smartphone. statistically significant survival with REBOA was greater than open AO based infrared imaging device to assess adequacy and level of aortic. 28 2 vs 16 1 p 0 12 As health care personnel acquire increased occlusion during REBOA J Trauma Acute Care Surg 2016. competency in REBOA placement and data continue to be collected 6. Moore L J et al Implementation of resuscitative endovascular balloon. it is likely that definitive evidence supporting REBOA use as a life occlusion of the aorta as an alternative to resuscitative thoracotomy. saving treatment will be made manifest At UPMC trauma surgeons for noncompressible truncal hemorrhage J Trauma Acute Care Surg 79. 523 530 discussion 530 522 2015, use REBOA to temporarily control hemorrhage below the diaphragm. as part of the operative management of life threatening bleeding 7. DuBose J J et al The AAST prospective Aortic Occlusion for. Resuscitation in Trauma and Acute Care Surgery AORTA registry. Data on contemporary utilization and outcomes of aortic occlusion and. Matthew R Rosengart MD MPH is co director resuscitative balloon occlusion of the aorta REBOA J Trauma Acute. of the Surgical Trauma Intensive Care Unit at Care Surg 81 409 419 2016. UPMC Presbyterian and serves as associate,professor of Surgery and Critical Care Medicine. at University of Pittsburgh School of Medicine,He earned his medical degree from the University. of Alabama at Birmingham,Children s Hospital of Pittsburgh. of UPMC Pediatric Surgeons,Front row left to right Juan Calisto MD.
George K Gittes MD Gary Nace MD,Barbara A Gaines MD Michael J. Morowitz MD Kelly M Austin MD,and Dominic Papandria MD. Back row left to right Marcus M,Malek MD Stefan Scholz MD. Geoffrey Bond MD Kevin P Mollen,MD Aviva L Katz MD Ward M. Richardson MD Luis De La Torre MD,and Douglas A Potoka MD.
UPMC MedCall 1 800 544 2500,4 TR AUM A RO U N DS,Minimally Invasive Stent Grafting Has Become the. Standard of Care for Blunt Thoracic Aortic Injury, by Nathan L Liang MD MS and Efthymios D Avgerinos MD PhD. Blunt thoracic aortic injury BTAI due to trauma is an uncommon The most recent guidelines from the Society for Vascular Surgery in. condition that traditionally carries a high mortality rate Although the 2011 and the Eastern Association for the Surgery of Trauma in 2015. incidence is less than 1 of trauma admissions 1 an estimated 75 of have both recommended the use of TEVAR over open repair for the. patients with BTAI die prior to hospital arrival and the mortality rate treatment of BTAI with the Eastern guidelines strongly recommending. after admission may be as high as 50 within the first 24 hours Due to the use of TEVAR in the absence of contraindications 3 Both guidelines. the massive polytrauma sustained in these situations many patients noted the rapid increase over time in the use of TEVAR in these. present with additional life threatening injuries and can be challenging situations with recent estimates suggesting that 85 of treated. to manage even in the setting of an experienced trauma center patients underwent endovascular stent grafting in 2011 up from 65. in 2008 A recent multicenter prospective trial evaluating the usage of. In most cases BTAI is localized to the proximal descending thoracic thoracic endovascular grafts for BTAI also showed a low overall rate. aorta just distal to the left subclavian artery origin The tethering of the of short and long term stent graft related complications supporting. aorta by the ligamentum arteriosum at this location predisposes the the continuing preferential usage of TEVAR in most situations 4. area to injury during severe blunt trauma such as a rapid deceleration. impact during a motor vehicle collision In the trauma bay diagnosis Currently all major thoracic aortic stent grafts have received FDA. and identification of the location of BTAI is most often made by approval to treat thoracic aortic lesions including BTAI However. computed tomography Modern CT scanners are fast and reliable and certain anatomic factors such as injury distance from the left subclavian. show associated soft tissue structures in addition to identifying injuries artery origin the radius of the aortic arch or the size of access vessels. of the vasculature may complicate TEVAR necessitating adjunctive procedures such as. left subclavian revascularization or even the need for an open surgical. Severity of the aortic injury is graded on a four point scale2 ranging procedure in extreme cases of unsuitable anatomy. from local tearing of the arterial intima Grade I least severe to. uncontained rupture into the chest Grade IV most severe Patients Treatment of BTAI at UPMC. presenting with grades I III are often hemodynamically stable whereas. patients with grade IV BTAI may be in extremis and require expeditious The Vascular Surgery Division at UPMC has performed more than. treatment Regardless the Society for Vascular Surgery2 and the 100 repairs of BTAI since 1999 and has exclusively utilized TEVAR for. Eastern Association for the Surgery of Trauma3 both recommend treatment of this condition since 2007 with more than 70 thoracic. repair of grade II IV injuries within 24 hours aortic stent graft implantations for BTAI alone Analysis of our. outcomes through 20125 have shown a postprocedural mortality rate. after TEVAR for BTAI of 6 zero spinal cord ischemia complications. TEVAR A New Standard of Care, and a graft related complication rate of less than 16 8 required. Conventional surgery for the repair of TBAI prior to the use of late open conversion Most of the complications were related to graft. endovascular stent grafts carried high post procedure mortality rates malpositioning resulting either in coverage of the left subclavian. ranging from 19 28 with associated spinal cord ischemia rates of artery or collapse. around 9 However since the introduction of endovascular stent. grafts thoracic endovascular aortic repair TEVAR has become The resources available at UPMC s trauma centers and close coordination. the standard therapy for BTAI TEVAR involves the placement of an between teams of trauma surgeons emergency physicians and vascular. intravascular stent covered with prosthetic material over the area of surgeons allow for rapid diagnosis and successful treatment of BTAI. injury excluding the injury from the circulation and preventing further Twenty four hour availability of multiple specialized hybrid vascular. hemorrhage or rupture This minimally invasive procedure offers operating suites enables high resolution imaging and accurate stent. several major advantages over conventional surgery such as avoiding graft placement while mobile fluoroscopic imaging systems allow for. the need for a thoracotomy or cardiopulmonary bypass and is able to flexibility in combining TEVAR with concurrent repair or exploration of. be performed rapidly and with minimal sedation or anticoagulation other traumatic injuries in the same setting. Current estimates place the post procedure mortality rate of TEVAR. for BTAI at less than 9 which is often related to other severe injuries. sustained during the original trauma,UPMC com TraumaRounds. Figure 1 A Preoperative CT angiogram indicating the aortic transection B Intraoperative angiogram C Final angiogram after endograft. deployment and D Follow up CT angiogram indicating good graft wall apposition and periaortic hematoma resolution. Case Presentation Nathan L Liang MD MS is a resident physician. in the Division of Vascular Surgery Department, A 19 year old woman was admitted to the UPMC Presbyterian.
of Surgery at UPMC He earned his medical, Emergency Department as a Level I trauma patient after falling from. degree from Texas A M University, an eight story height Her fall was later determined to be a suicide. attempt In the trauma bay she was hypotensive and required. intubation and bilateral chest tubes She had a pelvic fracture and a. negative FAST or focused assessment with sonography for trauma. exam The FAST exam screens for blood around the heart or abdominal. organs after a trauma The patient was taken urgently to the operating. room for an exploratory laparotomy with pericardial window A liver. Efthymios Avgerinos MD is a vascular surgeon, laceration was repaired and her abdomen was closed with a wound. at UPMC He completed his vascular surgery, vacuum assisted closure VAC She underwent a full body CT scan. residency at the University of Athens in Greece, revealing a thoracic aortic transection liver laceration mesocolonic.
and had clinical fellowships in London UK and, hematoma retroperitoneal hematoma pelvic fracture and right orbital. Frankfurt Germany before joining UPMC in 2011, floor fracture She was immediately transferred to the endovascular. suite and underwent percutaneous TEVAR see Figure 1. Her recovery was complicated by compartment syndrome lactic. acidosis a urinary tract infection and a Clostridium difficile infection. all of which were adequately controlled and treated prior to being. discharged to the Children s Institute for continuation of rehabilitation References. and psychiatric care The patient had fully recovered by her six month 1 Tefera G Traumatic thoracic aortic injury and ruptures J Vasc Surg. a novel and minimally invasive technique to curtail hemorrhage to the subdiaphragmatic torso i e abdomen and pelvis in patients presenting in hypovolemic hemorrhagic shock It is considered of particular utility in circumstances of hypotension and cardiovascular collapse that otherwise would merit resuscitative left anterolateral thoracotomy and aortic clamping Similar to a non tunneled

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