Endovascular methods for aortic control in trauma
- Jonathan Morrison, MD, PhD
Jonathan Morrison, MD, PhD
- Senior Registrar in General & Vascular Surgery,
- West of Scotland Surgical Rotation, Glasgow
- Todd E Rasmussen, MD, FACS, COL, USAF, MC
Todd E Rasmussen, MD, FACS, COL, USAF, MC
- Harris B Shumacker, Jr. Professor of Surgery
- Associate Dean for Research
- F. Edward Hebért School of Medicine
- Uniformed Services University of the Health Sciences
- Bethesda, MD
- Attending Vascular Surgeon
- Walter Reed National Military Medical Center
- Bethesda, MD
- Jeremy W Cannon, MD, FACS
Jeremy W Cannon, MD, FACS
- Associate Professor of Surgery
- Perelman School of Medicine at the University of Pennsylvania
- Section Editors
- Eileen M Bulger, MD, FACS
Eileen M Bulger, MD, FACS
- Section Editor — Trauma Surgery
- Professor of Surgery
- University of Washington
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Science Center
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
Torso hemorrhage remains the leading cause of potentially preventable death following traumatic injury [1-5]. A significant proportion of patients with external bleeding can exsanguinate prior to definitive hemostasis due to the inability to apply direct pressure [6-9]. Internal hemorrhage requires rapid surgical intervention. Aortic occlusion as a part of trauma management can decrease the amount of bleeding and provide a window of opportunity for resuscitation and definitive hemorrhage control. Options for aortic occlusion include direct clamping through an open incisional technique (emergent thoracotomy) and resuscitative endovascular balloon occlusion (REBOA) .
Noncompressible torso hemorrhage remains the leading cause of preventable death following military injury  and, from registry studies, significantly contributes to mortality in civilian traumatic injury as well [3-5]. Torso hemorrhage may originate from arterial, venous, or combined sources within the chest, abdomen, or pelvis. Junctional hemorrhage from noncompressible sites in the axilla or groin is also included in this definition.
RESUSCITATIVE AORTIC OCCLUSION
Management of hemorrhage generally consists of direct pressure to limit external bleeding with resuscitation and, subsequently, definitive repair to stop bleeding. However, the inability to directly compress vessels in the torso leads to a significant proportion of patients exsanguinating prior to definitive management, often in the prehospital setting [6-9]. This risk is higher in rural or resource-limited environments where transport time to definitive surgical care may be prolonged. Management of torso hemorrhage as a result of trauma has traditionally included direct aortic clamping via a thoracotomy for patients in extremis or abdominal incision for those in the operating room. Several alternative management approaches to this vexing clinical problem have also been explored. Military antishock trousers (MAST) gained popularity many years ago as a noninvasive approach to prehospital torso hemorrhage control . However, further evaluation of this approach demonstrated no clear benefit, and they have since fallen out of use . A novel approach to torso hemorrhage that is undergoing preclinical testing is abdominal inflation with an expansile foam [13,14]. This approach is not yet approved for use in the United States. Several compression devices for junctional hemorrhage are also in development. This review focuses exclusively on the emerging use of endovascular aortic occlusion, known as resuscitative endovascular balloon occlusion of the aorta (REBOA).
With developing expertise in minimally invasive endovascular methods, REBOA has been advocated as another approach supporting perfusion of vital organs until definitive hemostasis can be achieved [10,15]. REBOA has the advantage of being less invasive than open thoracotomy and, in one small observational study, was associated with fewer early deaths and improved overall survival compared with resuscitative thoracotomy . Consequently, preemptive placement in the emergency department (ED) or in the operating room (OR) prior to full cardiovascular collapse is possible. REBOA may also facilitate further imaging and access to angiography for embolization . (See 'Timing of placement' below.)
Evolution of endovascular aortic control — The earliest reported use of aortic balloon occlusion in trauma was during the Korean War, where a balloon catheter was inserted via the femoral artery into the thoracic aorta in two patients with abdominal bleeding . Although neither patient survived deflation of the balloon, the maneuver effectively demonstrated the feasibility of balloon occlusion to aid resuscitation. Open aortic clamping in the operating room subsequently gained favor as a means to resuscitate patients in extremis. Some surgeons even advocated thoracotomy and aortic clamping for patients with extrathoracic trauma who presented with tense hemoperitoneum and preserved pulses . In subsequent years, resuscitative thoracotomy with aortic clamping, now typically performed in the emergency department, has gained acceptance for the management of patients with traumatic arrest from torso injuries within a limited time window , and for some nontorso injuries . (See "Resuscitative thoracotomy: Technique", section on 'Morbidity and mortality'.)
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- TORSO HEMORRHAGE
- RESUSCITATIVE AORTIC OCCLUSION
- Evolution of endovascular aortic control
- POTENTIAL INDICATIONS
- Abdominal trauma with shock
- Pelvic trauma with shock
- Torso trauma at risk of hemorrhagic shock
- AORTIC ANATOMY AND ZONES OF DEPLOYMENT
- Devices and equipment
- Timing of placement
- REBOA TECHNIQUE
- Obtain arterial access and place the sheath
- Insert the balloon catheter
- Inflate the balloon catheter
- Identify and control bleeding
- Deflate the balloon
- Remove the balloon catheter and sheath
- ONGOING CHALLENGES
- SUMMARY AND RECOMMENDATIONS