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REBOA for the IVC? Resuscitative balloon occlusion of the inferior vena cava (REBOVC) to abate massive hemorrhage in retro-hepatic vena cava injuries.

Reynolds, Cassandra L. M.D., FACS; Celio, Adam C. M.D.; Bridges, Lindsay C. M.D.; Mosquera, Catalina M.D.; O’Connell, Brian M.D., Ph.D.; Bard, Michael R. M.D., FACS; DeLa’o, Connie M. M.D.; Toschlog, Eric A. M.D., FACS, FCCM
Journal of Trauma and Acute Care Surgery: Post Acceptance: July 8, 2017
doi: 10.1097/TA.0000000000001641
2017 WTA Podium Paper: PDF Only

Background: The use of resuscitative endovascular balloon occlusion as a maneuver for occlusion of the aorta is well described. This technique has life-saving potential in other cases of traumatic hemorrhage. Retro-hepatic inferior vena cava (IVC) injuries have a high rate of mortality, in part, due to the difficulty in achieving total vascular isolation. This studies purpose was to investigate the ability of resuscitative balloon occlusion of the IVC (REBOVC) to control supra-hepatic IVC hemorrhage in a swine model of trauma.

Methods: Thirteen swine were randomly assigned to control (7 animals) vs intervention (6 animals). In both groups, an injury was created to the IVC. Hepatic inflow control was obtained via clamping of the hepatoduodenal ligament and infra-hepatic IVC. In the intervention group, supra-hepatic IVC control was obtained via a REBOVC placed through the femoral vein. In the control group, no supra-hepatic IVC control was established. Vital signs, arterial blood gases and lactate were monitored until death. Primary endpoints were blood loss and time to death. Lactate, pH, and vital signs were secondary endpoints. Groups were compared using chi square and Student's T test with significance at p<0.05.

Results: Intervention group's time to death was significantly prolonged; 59.3 (+/-1.6) vs 33.4 (+/-12.0) minutes (p=0.001) and total blood loss was significantly reduced; 333 (+/-122) vs 1701 (+/-358) mL (p=0.001). In the intervention group, 5 of the 6 swine were alive at 1 hour (83.3%) compared to 0 of 7 (0%) in the control group (p=0.002). There was a trend toward worsening acidosis, hypothermia, elevated lactate and hemodynamic instability in the control group.

Conclusions: REBOVC demonstrates superior hemorrhage control and prolonged time to death in a swine model of liver hemorrhage. This technique may be considered as an adjunct to total hepatic vascular isolation in severe liver hemorrhage and could provide additional time needed for definitive repair.

Level of Evidence: Level II, study type therapeutic

(C) 2017 Lippincott Williams & Wilkins, Inc.