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Background Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) increases cardiac-afterload and is used for patients in hemorrhagic shock. The cardiac tolerance of prolonged afterload augmentation in this context is unknown. The aim of this study is to quantify cardiac injury, if any, following 2, 3 and 4 hours of REBOA.Methods Anesthetized swine (70–90 kg) underwent a 40% controlled hemorrhage, followed by supraceliac resuscitative endovascular balloon occlusion of the aorta (REBOA) for 2 (n=5), 3 (n=5), and 4 hours (n=5). High-fidelity arterial wave form data were collected, and signal processing techniques were used to extract key inflection points. The adjusted augmentation index (AIx@75; augmentation pressure/pulse pressure, normalized for heart rate) was derived for use as a measure of aortic compliance (higher ratio = less compliance). Endpoints consisted of electrocardiographic, biochemical, and histologic markers of myocardial injury/ischemia. Regression modeling was used to assess the trend against time.Results All animals tolerated instrumentation, hemorrhage, and REBOA. The mean (±SD) systolic blood pressure (mm Hg) increased from 65±11 to 212±39 (p

Background: The objective of this study was to investigate changes in the diameters of major arteries in trauma patients at the time of severe intravascular volume depletion. Methods: Patients admitted from January 2008–June 2017 in extremis or in arrest who had an immediate computed tomography (CT) scan in the resuscitation period and at least one subsequent CT scan after hemodynamic stabilization and admission to the intensive care unit were included. Diameter in millimeters (mm) of the common carotid, subclavian, common iliac, external iliac, common femoral arteries, and aorta at the following locations were obtained: ascending, proximal descending, and mid-descending thoracic and supra-celiac, renal, and aortic bifurcation. Results: Fourteen patients (93% male) were included. Mean injury severity score was 37 ± 8 and age 36 ± 18 years. Ten patients received a resuscitative endovascular balloon occlusion of the aorta and four patients received a resuscitative thoracotomy prior to the first CT. A maximum increase of the aorta of 63.6%, and 116.9% in the common carotid, subclavian, common iliac, external iliac, and common femoral arteries was observed. For patients aged 18–39 years, increases in diameter were statistically significant (p < 0.05) at all locations except the peri-renal aorta and left subclavian. Patients ≥40 years had a less robust change, with a significant diameter increase only with the proximal descending aorta (p = 0.02). Conclusions: Large arterial diameters in the setting of severe hemorrhage are significantly reduced particularly in younger patients. This has significant implications for emergent placement of endovascular devices such as introducer sheaths, balloon catheters, and stent grafts where the determination of arterial diameter is critical.

Background: Patients who receive resuscitative endovascular balloon occlusion of the aorta (REBOA) for temporization ofexsanguinating hemorrhage may have occult injuries sustained to the iliac arteries or aorta which may pose increased risks in performing REBOA. Caution is essential in performing REBOA in these patients as the injuries are not clearly defined on admission. REBOA is currently performed in select centers without fluoroscopy, leading to blind placement of devices and an essential reliance on tactile feedback. Methods: Patients admitted between February 2013 and July 2017 at a tertiary center who had a successful or unsuccessful blind placement of a REBOA catheter or wire through a damaged iliac artery or aorta were included. Results: Three patients were identified. Two patients had successful placement of the REBOA catheter; one sustained injury to the external iliac artery and the other sustained injury to the abdominal aorta. Confirmation of catheter placement was obtained before balloon inflation, and the damaged vessels were identified upon immediate operative intervention. One patient had unsuccessful placement of the REBOA catheter during cardiac arrest despite accurate access of the common femoral artery (CFA). Conclusions: Emergent, blind placement of wires and catheters past arterial injuries is possible but may result in procedural abandonment and/or arterial injury. Physical exam and/or tactile feedback should alert the surgeon to the possibility of arterial injury. Imaging confirmation should precede balloon inflation if at all possible.