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Time to aortic occlusion: It’s all about access

Romagnoli, Anna MD; Teeter, William MD, MS; Pasley, Jason DO; Hu, Peter PhD; Hoehn, Melanie MD; Stein, Deborah MD, MPH; Scalea, Thomas MD; Brenner, Megan MD, MS

Journal of Trauma and Acute Care Surgery: December 2017 - Volume 83 - Issue 6 - p 1161–1164
doi: 10.1097/TA.0000000000001665
AAST 2016 Plenary Papers

INTRODUCTION Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a less invasive method of proximal aortic occlusion compared with resuscitative thoracotomy with aortic cross-clamping (RTACC). This study compared time to aortic occlusion with REBOA and RTACC, both including and excluding time required for common femoral artery (CFA) cannulation.

METHODS This was a retrospective, single-institution review of REBOA or RTACC performed between February 2013 and January 2016. Time of skin incision to aortic cross-clamp for RTACC, time required for CFA cannulation by percutaneous and open methods, and time from guide-wire insertion to balloon inflation at Zone 1 for REBOA, were obtained from videographic recordings.

RESULTS Eighteen RTACC and 21 REBOAs were performed. Median (Q1, Q3) time from skin incision to aortic cross-clamping was 317 seconds (227, 551 seconds). Median (Q1, Q3) time from start of arterial access to Zone 1 balloon occlusion was 474 seconds (431, 572 seconds) (vs. RTACC, p = 0.01). All REBOA procedures were performed with the same device. The median time to complete CFA cannulation was 247 seconds (range, 164–343 seconds), with no difference between percutaneous or open procedures (p = 0.07). The median (Q1, Q3) time to aortic occlusion in REBOA once arterial access had been established was 245 seconds (179, 295.5 seconds), which was significantly shorter than RTACC (p = 0.003).

CONCLUSIONS Once CFA access is achieved, time to aortic occlusion is faster with REBOA. Time to aortic occlusion is less than the time required to cannulate the CFA either by percutaneous or open approaches, emphasizing the importance of accurate and expedient CFA access. Resuscitative endovascular balloon occlusion of the aorta may represent a feasible alternative to thoracotomy for aortic occlusion. Time to aortic occlusion will likely decrease with the advent of newer REBOA technology. The rate-limiting portion of REBOA continues to be obtaining CFA access.

LEVEL OF EVIDENCE Therapeutic, level V.

From the Division of Trauma/Critical Care (A.N.R., W.T., J.P., M.H., D.S., T.S., M.B.), RA Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland; Division of Anesthesiology (P.M.H.), University of Maryland School of Medicine, Baltimore, Maryland; and Division of Vascular Surgery (M.H., M.B.), University of Maryland School of Medicine, Baltimore, Maryland.

Submitted: August 1, 2016, Revised: July 6, 2017, Accepted: July 16, 2017, Published online: August 3, 2017.

Presented at the 75th Annual Meeting of AAST and Clinical Congress of Acute Care Surgery; September 14, 2016; Waikoloa, Hawaii.

Address for reprints: Anna Noel Romagnoli, MD, Division of Trauma/Critical Care, RA Cowley Shock Trauma Center, University of Maryland, 22 South Greene Street, Baltimore MD 21201; email: anna.n.romagnoli.mil@mail.mil.

© 2017 Lippincott Williams & Wilkins, Inc.