| 1. |
- McGreevy, David T., 1988-
(author)
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EndoVascular resuscitation and Trauma Management in hemodynamic instability
- 2024
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Doctoral thesis (other academic/artistic)abstract
- Massive bleeding is a significant health care challenge, particularly in the case of non-compressible torso hemorrhage, with both traumatic and non-traumatic causes. The management of bleeding in the torso poses unique challenges, both anatomically and physiologically. The concept of Endo-Vascular resuscitation and Trauma Management (EVTM) has evolved alongside endovascular surgery over the past two decades. It combines modern endovascular surgical techniques with traditional open surgical management to provide early evaluation, resuscitation, and definitive treatment of both traumatic and non-traumatic bleeding patients. The purpose of this thesis was to investigate the feasibility, outcomes and practice patterns of EVTM in patients with hemodynamic instability.Study I was a retrospective cohort study assessing the consecutive use of Endovascular Aortic Repair (EVAR) for all 100 patients with ruptured ab-dominal aortic aneurysms (rAAA). Mortality at 30 days was 27% with a turndown rate of 3.5%.Study II was a retrospective cohort study examining the use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in patients with impending traumatic cardiac arrest showing that vascular access is feasible and REBOA increases systolic blood pressure (SBP).Study III & IV were animal experimental studies evaluating the use of RE-BOA for hemodynamic instability due to intrathoracic bleeding or acute cardiac tamponade. They showed that REBOA, using different occlusion techniques, maintains permissive hypotension, carotid blood flow and prolongs survival.Study V was a retrospective cohort study comparing outcomes and practice patterns for patients with grade 3 or 4 blunt thoracic aortic injury (BTAI) treated with TEVAR. Hemodynamically unstable patients have increased risk of complications, prolonged length of hospital stay and increased levels of in-hospital mortality.
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| 2. |
- Ordoñez, Carlos A., et al.
(author)
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Critical systolic blood pressure threshold for endovascular aortic occlusion : A multinational analysis to determine when to place a REBOA
- 2024
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In: Journal of Trauma and Acute Care Surgery. - : Lippincott Williams & Wilkins. - 2163-0755 .- 2163-0763. ; 96:2, s. 247-255
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Journal article (peer-reviewed)abstract
- BACKGROUND: Systolic blood pressure (SBP) is a potential indicator that could guide when to use a resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma patients with life-threatening injuries. This study aims to determine the optimal SBP threshold for REBOA placement by analyzing the association between SBP pre-REBOA and 24-hour mortality in severely injured hemodynamically unstable trauma patients.METHODS: We performed a pooled analysis of the Aortic Balloon Occlusion (ABO) trauma and AORTA registries. These databases record the details related to the use of REBOA and include data from 14 countries worldwide. We included patients who had suffered penetrating and/or blunt trauma. Patients who arrived at the hospital with a SBP pre-REBOA of 0 mm Hg and remained at 0 mm Hg after balloon inflation were excluded. We evaluated the impact that SBP pre-REBOA had on the probability of death in the first 24 hours.RESULTS: A total of 1107 patients underwent endovascular aortic occlusion, of these, 848 met inclusion criteria. The median age was 44 years [IQR, 27-59 years] and 643(76%) were male. The median injury severity score was 34 [IQR, 25-45]. The median SBP pre-REBOA was 65 mm Hg [IQR: 49-88 mm Hg]. Mortality at 24-hours was reported in 279 (32%) patients. Math modelling shows that predicted probabilities of the primary outcome increased steadily in SBP pre-REBOA below 100 mm Hg. Multivariable mixed-effects analysis shows that when SBP pre-REBOA was lower than 60 mm Hg, the risk of death was more than 50% (relative risk, 1.5; 95%CI, 1.17-1.92; P = .001).DISCUSSION: In patients who do not respond to initial resuscitation, the use of REBOA in SBP's between 60- and 80-mm Hg may be a useful tool in resuscitation efforts before further decompensation or complete cardiovascular collapse. The findings from our study are clinically important as a first step in identifying candidates for REBOA.STUDY TYPE: Observational Study. LEVEL OF EVIDENCE: Level IV.
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| 3. |
- Paran, Maya, et al.
(author)
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International registry on aortic balloon occlusion in major trauma : Partial inflation does not improve outcomes in abdominal trauma
- 2024
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In: The Surgeon. - : Elsevier. - 1479-666X. ; 22:1, s. 37-42
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Journal article (peer-reviewed)abstract
- BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a method for temporary hemorrhage control used in haemodynamically unwell patients with severe bleeding. In haemodynamically unwell abdominal trauma patients, laparotomy remains the initial procedure of choice. Using REBOA in patients as a bridge to laparotomy is a novel option whose feasibility and efficacy remain unclear. We aimed to assess the clinical outcome in patients with abdominal injury who underwent both REBOA placement and laparotomy.METHODS: This is a retrospective study, including trauma patients with an isolated abdominal injury who underwent both REBOA placement and laparotomy, during the period 2011-2019. All data were collected via the Aortic Balloon Occlusion Trauma Registry database.RESULTS: One hundred and three patients were included in this study. The main mechanism of trauma was blunt injury (62.1%) and the median injury severity score (ISS) was 33 (14-74). Renal failure and multi-organ dysfunction syndrome (MODS) occurred in 15.5% and 35% of patients, respectively. Overall, 30-day mortality was 50.5%. Post balloon inflation systolic blood pressure (SBP) >80 mmHg was associated with lower 24-h mortality (p = 0.007). No differences in mortality were found among patients who underwent partial occlusion vs. total occlusion of the aorta.CONCLUSIONS: Our results support the feasibility of REBOA use in patients with isolated abdominal injury, with survival rates similar to previous reports for haemodynamically unstable abdominal trauma patients. Post-balloon inflation SBP >80 mmHg was associated with a significant reduction in 24-h mortality rates, but not 30-day mortality. Total aortic occlusion was not associated with increased mortality, MODS, and complication rates compared with partial occlusion.
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