Resection of large sacral tumors is challenging for surgeons and anesthesiologists, in particular due to extensive hemorrhage, which is often refractory to control strategies (1). Complications related to large intravascular volume transfusion such as coagulopathy, hypothermia, and hypocalcemia contribute to morbidity, as does the rare, but possible, complication of an incompatible transfusion reaction. Bleeding can be so extensive at times that complete tumor resection becomes impossible without threatening the patient's life. Blood-cell salvage has been used to diminish the requirement for autologous blood transfusion, but is not recommended in malignant tumor surgery. Preoperative arterial embolization of the tumor's blood supply may be an effective technique for reducing the blood loss during surgery (2,3). However, embolization is not always practical in sacral surgery, as multiple arteries supply blood to the pelvis and sacrum. Therefore, embolizing only the lateral common iliac arterial or the internal iliac artery will not completely block the blood supply to this area. Because the collateral circulation is usually reestablished within 24 h after embolization, the tumor resection should be scheduled soon afterward. In addition, some serious complications after embolization have been reported, including neurological deficits and pain (4,5). In clinical practice, effective and safe methods to control massive blood loss during sacral surgery remain elusive.
A sizing balloon catheter is a single or double-lumen catheter with a distal balloon, which is used to measure cardiovascular structures during percutaneous transcatheter closure of atrial defect. We present usage of this catheter as an occlusion balloon placed in the distal abdominal aorta and used to control bleeding during sacrococcygeal tumor resections.
This study was approved by the hospital Research and Ethics Committee, and written informed consent was obtained from all patients. Autologous blood (5000 mL) was prepared to meet the transfusion requirements related to surgical blood loss in each patient. After anesthesia induction, both groin regions were sterilized with iodine solution. One femoral artery was punctured with a 5F arterial catheter needle and a guidewire was introduced, then an 8F percutaneous introducer sheath (PCI) with dilator (Introflex Introducer, Edwards lifesciences LLC, Irvine, CA) was inserted. Before the double-lumen sizing balloon catheter (Sideris Sizing Balloon, NuMed Canada, Inc.) was inserted, the catheter's balloons were completely evacuated of air with a syringe. The balloon catheter was then inserted through the PCI (Figure 1). Pulse oximeter oxygen saturation (Spo2) signals were measured from bilateral toes simultaneously during balloon catheter placement. Because the abdominal aorta bifurcates into the right and left common iliac arteries at the approximate level of the fourth lumbar vertebra, the insertion depth of the balloon catheter was estimated to be the distance from the puncture site to the umbilicus. After insertion to the predicted depth and balloon inflation, there would be two conditions in Spo2 signals: 1) The Spo2 signals were only available from the contralateral toe, indicating that the balloon was placed in the common iliac artery, or 2) both Spo2 signals disappeared, indicating that the balloon was placed in the abdominal aorta. The depth of the catheter was adjusted under the guide of Spo2 signals in both toes to attempt to locate the balloon in the abdominal aorta below the renal arteries. If the Spo2 signals were only shown on the contralateral toe, the catheter was advanced in 2–3 cm increments until Spo2 signals just disappeared in both toes when the balloon was inflated. If the Spo2 signals in bilateral toes were initially not present, the balloon catheter was withdrawn 2–3 cm incrementally until Spo2 signals were only present on the contralateral toe when the balloon was inflated. Then, the catheter was readvanced into the abdominal aorta until both signals disappeared. Before securing the inserted balloon catheter in place, bilateral renal artery flow was confirmed by ultrasonography with the balloon inflated to insure that neither one nor both of the renal arteries were occluded. The patient was then turned to the prone position for surgery.
At the beginning of the surgery, saline was injected into the balloon slowly until Spo2 signals in both oximeters disappeared. After abdominal aortic occlusion, 200 mL of heparinized saline (1.25-U heparin in 1 mL) was flushed into the aorta inferior to the balloon via the PCI lumen line to prevent thrombus formation in the blood distal to the occlusion. Then 1–2 mL heparinized saline (12.5-U heparin in 1 mL) was injected every 15 min into the abdominal aorta via the distal lumen to prevent thrombus around the balloon during occlusion. The balloon was deflated completely for 10 min after each 60 min occlusion and the surgeon would stop resecting tumor until the abdominal aorta was completely occluded again. After the surgery, the balloon was deflated and the catheter was removed. External pressure was applied to the puncture site for 30 min and a pressure dressing applied for 24 h. The function of the kidneys, pelvic organs, and lower limbs was observed for 3 days after surgery. Before and after occlusion of the aorta, arterial blood gas and plasma electrolytes and activated clotting time were measured.
The clinical summary of the five patients treated with abdominal aortic balloon control is provided in Table 1. All patients were diagnosed with sacrococcygeal chordoma and underwent tumor resection. Saline 15–18 mL was needed to inflate the balloon and occlude the abdominal aorta in these cases. A representative photo of a huge sacrococcygeal chordoma is shown in Figure 2. A bloodless surgical field was created by occluding the abdominal aorta with the balloon (Figure 3). The abdominal aortic control was satisfactory, and surgery was successful in all patients.
The arterial blood pressure did not fluctuate significantly after aortic occlusion except for Patient 1. The arterial blood pressure in Patient 1 increased from 160/80 mm Hg to 220/120 mm Hg after aortic occlusion, and decreased to the basal level after infusing sodium nitroprusside. Arterial blood gases, plasma electrolytes, and activated clotting time were not changed significantly during occlusion. The function of the kidneys, pelvic organs, and lower limbs was not significantly changed after the operation in all patients. All five patients were discharged between the 11th and 13th postoperative days.
Total sacrectomy is an extensive surgical procedure requiring a significant amount of time and other resources like blood products (6). Previous experience indicated that the blood loss can be as much as 5000 mL in traditional sacrococcygeal chordoma resection and that the procedure can require more than 4 h to perform. Although 5000 mL of blood was cross-matched before surgery for the five patients treated with aortic balloon occlusion, the blood loss was <300 mL, and the surgery was accomplished within 2 h. For example, a 5.7 kg tumor in Case 1 was removed completely within 40 min. The surgical operation and anesthetic management became easier without massive blood loss during the operation. The results suggested that an inflated balloon in the aorta could provide satisfactory occlusion, reduce blood loss and the duration of the procedure.
Aortic occlusion with an inflated balloon was reported to be an effective method for controlling blood loss in some emergency conditions. David et al. (7) reported successful treatment of an abdominal aneurysm rupture during an endovascular stent-graft procedure using balloon occlusion. In this case, the angioplasty deployment balloon was repositioned and inflated proximal to the presumed site of aortic rupture. The inflated balloon provided temporary aortic control to avoid massive blood loss, and also provide the possibility of an open repair of the aorta.
The primary reason we did not use radiologic examination to confirm the position of the aortic balloon is that the renal arteries may be difficult to visualize after injecting contrast agent through the catheter located below the renal artery. On the other hand, ultrasound examination of renal artery blood flow could precisely detect whether blood flow was blocked or not. The successful cases in the present study also indicate that the method using Spo2 signals from both toes to guide the position of the balloon in the abdominal aorta is easy and reliable. Compared with preoperative iliac arterial or tumor blood supply embolization (5), balloon occlusion of the abdominal aorta is less complex and safer, and is less expensive.
We have demonstrated advantages of using aortic balloon occlusion to facilitate surgery of the pelvis and sacrum, but there are some caveats. First, inflating and deflating the balloon in the abdominal aorta may cause desquamation of atherosclerotic plaque or damage to the aortic wall. The patient's arterial condition should be evaluated by a qualified ultrasonic examiner to exclude patients with vasculopathy. Second, air in the balloon must be completely evacuated before the catheter is introduced. Liquid was used to inflate the balloon to avoid air embolism in case of balloon rupture during the operation. Third, after the balloon catheter was placed and fixed in position, ultrasonic examination should be available to reconfirm that the balloon is located between the renal arteries and the abdominal bifurcation, and that the two renal arteries are not occluded by the inflating balloon. If the balloon's location is too high, it may cause spinal cord ischemic injury and or renal ischemia. In normal adults, the distance between the renal artery and the abdominal bifurcation is more than 6 cm. Therefore, the space is sufficient for an inflated balloon. Finally, inflating and deflating the balloon should be slow to avoid large fluctuations in arterial blood pressure. If the arterial blood pressure increases significantly during aortic occlusion, vasodilators can be used to control it. During the procedure, urine output monitoring is important. If urine output is <0.5 mL · kg−1 · h−1, the position of the balloon may be too high and may require an adjustment. The duration of each occlusion should be limited to 1 h to prevent ischemic damage to the spinal cord, pelvic organs, and lower extremities.
In summary, we describe a safe, alternative method for establishing temporary abdominal aortic occlusion. This balloon occlusion technique was used during sacral tumor resection in five patients and dramatically diminished the blood loss and reduced the duration of the procedure without serious complications.
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