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OBJECTIVE: Abdominal aortic graft and endograft infections (AGIs) are rare complications following aortic surgery. Radical surgery (RS) with resection of the infected graft and reconstruction with extra-anatomical bypass or in situ reconstruction is the preferred therapy. For patients unfit for RS, a semi-conservative (SC), graft-preserving strategy is possible. This paper aimed to compare survival and infection outcomes between RS and SC treatment for AGI in a nationwide cohort. METHODS: Patients with abdominal AGI-related surgery in Sweden between January 1995 and May 2017 were identified. The Management of Aortic Graft Infection Collaboration (MAGIC) criteria were used for definition of AGI. Multivariable regression was performed to identify factors associated with mortality. RESULTS: A total of 169 patients with surgically treated abdominal AGI were identified, comprising 43 SC [14 endografts; 53% with a graft-enteric fistula (GEF) in total] and 126 RS [26 endografts; 50% with a GEF in total]. The SC cohort was older and had a higher frequency of cardiac comorbidities. There was a non-significant trend towards lower Kaplan-Meier estimated 5-year survival for SC versus RS (30.2% vs. 48.4%; p = .066). A non-significant trend was identified towards worse Kaplan-Meier estimated 5-year survival for SC patients with a GEF versus without a GEF (21.7% vs. 40.1%; p = .097). There were significantly more recurrent graft infections comparing SC versus RS (45.4% vs. 19.3%; p < .001). In a Cox regression model adjusting for confounders, there was no difference in 5-year survival comparing SC versus RS (HR 1.0, 95% CI 0.6 - 1.5). CONCLUSION: In this national AGI cohort, we could not identify any mortality difference comparing SC versus RS for AGI when adjusting for comorbidities. Presence of GEF likely negatively impacts survival outcomes of SC patients. Rates of recurrent infection remain high for SC-treated patients.

BACKGROUND: Hemodynamic instability due to torso hemorrhage can be managed with the assistance of resuscitative endovascular balloon occlusion of the aorta (REBOA). This is a report of a single-center experience using the ER-REBOA™ catheter for traumatic and non-traumatic cases as an adjunct to hemorrhage control and as part of the EndoVascular resuscitation and Trauma Management (EVTM) concept. The objective of this report is to describe the clinical usage, technical success, results, complications and outcomes of the ER-REBOA™ catheter at Örebro University hospital, a middle-sized university hospital in Europe. METHODS: Data concerning patients receiving the ER-REBOA™ catheter for any type of hemorrhagic shock and hemodynamic instability at Örebro University hospital in Sweden were collected prospectively from October 2015 to May 2020. RESULTS: A total of 24 patients received the ER-REBOA™ catheter (with the intention to use) for traumatic and non-traumatic hemodynamic control; it was used in 22 patients. REBOA was performed or supervised by vascular surgeons using 7-8 Fr sheaths with an anatomic landmark or ultrasound guidance. Systolic blood pressure (SBP) increased significantly from 50 mmHg (0-63) to 95 mmHg (70-121) post REBOA. In this cohort, distal embolization and balloon rupture due to atherosclerosis were reported in one patient and two patients developed renal failure. There were no cases of balloon migration. Overall 30-day survival was 59%, with 45% for trauma patients and 73% for non-traumatic patients. Responders to REBOA had a significantly lower rate of mortality at both 24 h and 30 days. CONCLUSIONS: Our clinical data and experience show that the ER-REBOA™ catheter can be used for control of hemodynamic instability and to significantly increase SBP in both traumatic and non-traumatic cases, with relatively few complications. Responders to REBOA have a significantly lower rate of mortality., Funding Agencies:Örebro University Prytime

Objective: Abdominal aortic graft and endograft infection (AGI) is primarily treated by resection of the infected graft and restoration of distal perfusion through extra-anatomic bypass (EAB) or in situ reconstruction/repair (ISR). The aim of this study was to compare these surgical strategies in a nationwide multicentre retrospective cohort study. Methods: The Swedish Vascular Registry (Swedvasc) was used to identify surgically treated abdominal AGIs in Sweden between January 1995 andMay 2017. The primary aimwas to compare short and long termsurvival, as well as complications for EAB and ISR. Results: Some 126 radically surgically treated AGI patients were identified - 102 graft infections and 24 endograft infections - treated by EAB: 71 and ISR: 55 (23 neo-aorto-iliac systems, NAISs). No differences in early 30 day (EAB 81.7% vs. ISR 76.4%, p = .46), or long term five year survival (48.2% vs. 49.9%, p = .87) were identified. There was no survival difference comparing NAIS to other ISR strategies. The frequency of recurrent graft infection during follow up was similar: EAB 20.3% vs. ISR 17.0% (p = .56). Survival and re-infection rates of the new conduit did not differ between NAIS and other ISR strategies. Age >= 75 years (odds ratio [OR] 4.0, confidence interval [CI] 1.1 - 14.8), coronary artery disease (OR 4.2, CI 1.2 - 15.1) and post-operative circulatory complications (OR 5.2, CI 1.2 - 22.5) were associated with early death. Prolonged antimicrobial therapy (> 3 months) was associated with reduced long term mortality (HR 0.3, CI 0.1 - 0.9). Conclusion: In this nationwide multicentre study comparing outcomes of radically treated AGI, no differences in survival or re-infection rate could be identified comparing EAB and ISR.

INTRODUCTION: It is difficult to estimate the ischemic consequences when using partial resuscitative endovascular balloon occlusion of the aorta (REBOA). The aim was to investigate if end-tidal carbon dioxide (ETCO2) is correlated to degree of aortic occlusion, measured as distal aortic blood flow, and distal organ metabolism, estimated as systemic oxygen consumption (VO2), in a porcine model of normovolemia and hemorrhagic shock. MATERIALS AND METHODS: Nine anesthetized pigs (25-32 kg) were subjected to incremental steps of zone 1 aortic occlusion (reducing distal aortic blood flow by 33%, 66% and 100%) during normovolemia and hemorrhagic grade IV shock. Hemodynamic and respiratory variables, and blood samples, were measured. Systemic VO2 was correlated to ETCO2 and measures of partial occlusion previously described. RESULTS: Aortic occlusion gradually lowered distal blood flow and pressure, whereas ETCO2, VO2 and carbon dioxide production decreased at 66% and 100% aortic occlusion. Aortic blood flow correlated significantly to ETCO2 during both normovolemia and hemorrhage (R=0.84 and 0.83, respectively) and to femoral mean pressure (R = 0.92 and 0.83, respectively). Systemic VO2 correlated strongly to ETCO2 during both normovolemia and hemorrhage (R = 0.91 and 0.79, respectively), blood flow of the superior mesenteric artery (R = 0.77 and 0.85, respectively) and abdominal aorta (R = 0.78 and 0.78, respectively), but less to femoral blood pressure (R = 0.71 and 0.54, respectively). CONCLUSION: End-tidal carbon dioxide was correlated to distal aortic blood flow and VO2 during incremental degrees of aortic occlusion thereby potentially reflecting the degree of aortic occlusion and the ischemic consequences of partial REBOA. Further studies of ETCO2, and potential confounders, in partial REBOA are needed before clinical use., Funding Agencies:Nyckelfonden at Orebro University HospitalALF Grants

BACKGROUND: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) may improve Systolic Blood Pressure (SBP) in hypovolemic shock. It has, however, not been studied in patients with impending traumatic cardiac arrest (ITCA). We aimed to study the feasibility and clinical outcome of REBOA in patients with ITCA using data from the ABOTrauma Registry. METHODS: Retrospective and prospective data on the use of REBOA from 16 centers globally were collected. SBP was measured both at pre- and post-REBOA inflation. Data collected included patients' demography, vascular access technique, number of attempts, catheter size, operator, zone and duration of occlusion, and clinical outcome. RESULTS: There were 74 patients in this high-risk patient group. REBOA was performed on all patients. A 7-10Fr catheter was used in 66.7%, 58.5% were placed on the first attempt, 52.1% through blind insertion and 93.2% inflated in Zone I, 64.8% for a period of 30 to 60 minutes, 82.1% by ER doctors, trauma surgeons or vascular surgeons. SBP significantly improved to 90 mmHg following the inflation of REBOA. 36.6% of the patients survived. CONCLUSIONS: Our study has shown that REBOA may be performed in patients with ITCA, SBP can be elevated and 36.6% of the patients survived if REBOA placement is successful.

Traumatic hemorrhagic shock is a major cause of death worldwide. Patients enter the fatal triad of hypothermia, acidosis and coagulopathy and die quickly due to cardiovascular collapse. Ideally, procedures should be performed at the injury scene to prevent this fatal event. Unfortunately, intervention cannot be performed as soon as is needed and time to intervention becomes the enemy of survival. Hemorrhage control until definitive repair can possibly save lives. Hemorrhage from the extremities can be controlled by external pressure but severe hemorrhage from thoracic, abdominal or pelvic cavities, called non-compressible torso hemorrhage, requires internal hemorrhage control. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) uses an endovascular balloon that is inserted into the aorta using minimally invasive methods and is inflated to increase perfusion pressure and avoid cardiovascular collapse, providing a bridge to intervention. REBOA is hypothetised to increase central blood pressure but cause ischemia reperfusion injury below the occlusion level. The purpose of this thesis was to investigate the general impact of REBOA on physiology, metabolism, inflammatory response in normovolemia and hemorrhage. Investigation was conducted through clinical and experimental models. Study I was a multicentre cohort study of patients with traumatic hemorrhagic shock who received REBOA. Ninety-six patients were included, with an overall mortality of 56% and with no major complications from REBOA use. REBOA was used in a continuous and non-continuous fashion depending on the patients’ level of hypovolemia. Study II and the following three studies were animal experimental studies. Study II was a randomized control study in pigs to evaluate physiological, metabolic, inflammatory and end-organ function in a normovolemic state. It was demonstrated that REBOA increased central blood pressure but caused ischemic insult. Study III, a randomised controlled experimental

Background: Partial resuscitative endovascular balloon occlusion of the aorta (REBOA) is a concept of aortic occlusion to reduce ischemic organ injuries below the occlusion level. It is, however, difficult to determine when the occlusion is partial in clinical settings. End-tidal carbon dioxide (ETCO2) is an aerobic metabolite and its production is reduced during ischemia. The aim of this study was to investigate if ETCO2 can be used as an estimate of the degree of aortic occlusion and distal organ metabolism during normovolemia and hemorrhagic shock in a porcine model. Methods: Nine pigs (25-32 kg) were anesthetized and surgically prepared. Zone 1 aortic occlusion by 33%, 66% and 100% of aortic blood flow was induced during normovolemia and controlled hemorrhagic grade IV shock. Hemodynamic and respiratory variables including ETCO2, aortic and mesenteric blood flow, femoral arterial blood pressure and blood gases were measured. Oxygen consumption and carbon dioxide production were correlated to measures of partial occlusion used in previous studies. Results: Aortic occlusion gradually lowered distal blood flow and pressure, whereas ETCO2, oxygen consumption and carbon dioxide production decreased at 66 % and 100 % of aortic occlusion. End-tidal carbon dioxide, and blood flow of the superior mesenteric artery and abdominal aorta, strongly correlated to oxygen consumption and carbon dioxide production, whereas femoral blood pressure did not. Conclusion: End-tidal carbon dioxide may be used as an estimator of partial REBOA and distal organ metabolism in both normovolemia and hemorrhagic shock.

Background: The use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in resuscitation and trauma management in adults is increasing. However, there is limited data published concerning its use in pediatric patients. Methods: We describe a case using REBOA for traumatic hemorrhagic shock in a pediatric patient according to the concept of EndoVascular resuscitation and Trauma Management (EVTM) at Örebro University Hospital in April 2019. Informed consent has been received. Results: An 11-year-old boy arrived at the emergency room (ER) after a motor vehicle accident. Due to total hemo-dynamic collapse, cardiopulmonary resuscitation was initiated with return of spontaneous circulation. Zone 1 total REBOA was successfully performed for 7 minutes while damage control surgery was performed and massive transfu-sion was initiated to stabilize the patient. The patient survived and returned to almost normal daily activity. Conclusion: REBOA for endovascular resuscitation and trauma management may be an additional method for tem-porary hemodynamic stabilization in pediatric patients and, in this specific patient, was used instead of resuscitative thoracotomy.

PURPOSE: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a technique for temporary stabilization of patients with non-compressible torso hemorrhage. This technique has been increasingly used worldwide during the past decade. Despite the good outcomes of translational studies, clinical studies are divided. The aim of this multicenter-international study was to capture REBOA-specific data and outcomes. METHODS: REBOA practicing centers were invited to join this online register, which was established in September 2014. REBOA cases were reported, both retrospective and prospective. Demographics, injury patterns, hemodynamic variables, REBOA-specific data, complications and 30-days mortality were reported. RESULTS: Ninety-six cases from 6 different countries were reported between 2011 and 2016. Mean age was 52 ± 22 years and 88% of the cases were blunt trauma with a median injury severity score (ISS) of 41 (IQR 29-50). In the majority of the cases, Zone I REBOA was used. Median systolic blood pressure before balloon inflation was 60 mmHg (IQR 40-80), which increased to 100 mmHg (IQR 80-128) after inflation. Continuous occlusion was applied in 52% of the patients, and 48% received non-continuous occlusion. Occlusion time longer than 60 min was reported as 38 and 14% in the non-continuous and continuous groups, respectively. Complications, such as extremity compartment syndrome (n = 3), were only noted in the continuous occlusion group. The 30-day mortality for non-continuous REBOA was 48%, and 64% for continuous occlusion. CONCLUSIONS: This observational multicenter study presents results regarding continuous and non-continuous REBOA with favorable outcomes. However, further prospective studies are needed to be able to draw conclusions on morbidity and mortality., Funding Agencies:Research Committee of Region Örebro County Nyckelfonden at Örebro University Hospital ALF Grants (Agreement concerning research and education of doctors) Region Örebro County

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an effective adjunct in exsanguinating torso hemorrhage, but causes ischemic injury to distal organs. The aim was to investigate whether blood pressure targeting by partial REBOA (pREBOA) is possible in porcine severe hemorrhagic shock and to compare pREBOA and total REBOA (tREBOA) regarding hemodynamic, metabolic and inflammatory effects. Methods: Eighteen anesthetized pigs were exposed to induced controlled hemorrhage to a systolic blood pressure (SBP) of 50 mmHg and randomized into three groups of thoracic REBOA: 30 min of pREBOA (target SBP 80-100 mmHg), tREBOA, and control. They were then resuscitated by autologous transfusion and monitored for 3 h. Hemodynamics, blood gases, mesenteric blood flow, intraperitoneal metabolites, organ damage markers, histopathology from the small bowel, and inflammatory markers were analyzed. Results: Severe hemorrhagic shock was induced in all groups. In pREBOA the targeted blood pressure was reached. The mesenteric blood flow was sustained in pREBOA, while it was completely obstructed in tREBOA. Arterial pH was lower, and lactate and troponin levels were significantly higher in tREBOA than in pREBOA and controls during the reperfusion period. Intraperitoneal metabolites, the cytokine response and histological analyses from the small bowel were most affected in the tREBOA compared to the pREBOA and control groups. Conclusion: Partial REBOA allows blood pressure titration while maintaining perfusion to distal organs, and reduces the ischemic burden in a state of severe hemorrhagic shock. Partial REBOA may lower the risks of post-resuscitation metabolic and inflammatory impacts, and organ dysfunction. (C) 2018 Published by Elsevier Ltd., Funding Agencies:Research Committee of Region Örebro County Nyckelfonden at Örebro University Hospital Region Örebro County ALF