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- Wikström, Maria B., 1972-
(author)
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Resuscitative Endovascular Balloon Occlusion of the Inferior Vena Cava (REBOVC) : Experimental and clinical studies
- 2024
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Doctoral thesis (other academic/artistic)abstract
- Juxtahepatic venous injuries often cause life-threatening hemorrhagic shock, the mortality is high and new management methods are needed. The aims were to explore endovascular methods for retrohepatic vascu-lar isolation, their effects on survival, hemodynamics, metabolism, end-organ damage and bleeding, and if ultrasound and anatomical land-marks could be used to guide placement of resuscitative endovascular balloon occlusion of the inferior vena cava (REBOVC). Study I ex-plored the effects of different combinations of REBOVC +/- endovascu-lar aortic balloon occlusion (REBOA) +/- the Pringle maneuver (PM) for 5 minutes in anesthetized pigs (n=9). REBOVC was found to be tol-erated hemodynamically if combined with REBOA whereas REBOVC alone or combined with PM was not. In study II, REBOA was com-pared to REBOA + REBOVC in normovolemia and in hemorrhagic shock in anesthetized pigs (n=6-7/group). REBOA + REBOVC was tol-erated for 45 minutes, but negative hemodynamic and metabolic ef-fects in hemorrhagic shock must be considered. In Study III, the effects in anesthetized pigs of different combinations of balloon occlusion (REBOA vs REBOA + REBOVC vs REBOA + infra- and suprahepatic REBOVC + portal vein occlusion) on survival, hemodynamics, retrohe-patic bleeding, metabolism, and collateral flow were compared to no occlusion. REBOA was found to most efficiently stabilize hemodynam-ics and prolong survival despite larger collateral flow and retrohepatic bleeding. The inability of venous occlusion to stabilize hemodynamics as efficiently as REBOA was probably due to a combination of arterial collateral flow combined with reduced venous return. Studies IV + V examined if ultrasound (in anesthetized pigs, n=9) and anatomical landmarks (computerized tomography images from 50 humans) could be used to position REBOVC and found that subxiphoidal ultrasound and external landmarks can be useful tools to adequately position RE-BOVC in the inferior vena cava.
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| 2. |
- Wikström, Maria B, 1972-, et al.
(author)
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The effect of an endovascular Heaney maneuver to achieve total hepatic isolation on survival, hemodynamic stability, retrohepatic bleeding, and collateral flow in a porcine model
- 2024
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In: European Journal of Trauma and Emergency Surgery. - : Springer Medizin. - 1863-9933 .- 1863-9941.
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Journal article (peer-reviewed)abstract
- PURPOSE: Combining resuscitative endovascular balloon occlusion of the aorta (REBOA) and the inferior vena cava (REBOVC) with open surgery is a new hybrid approach for treating retrohepatic vena caval injuries. We compared endovascular total hepatic isolation with supraceliac REBOA ± suprahepatic REBOVC and no occlusion in experimental retrohepatic vena cava bleeding regarding survival, bleeding volume, hemodynamic stability, and arterial collateral blood flow.METHODS: Twenty-five anesthetized pigs (n = 6-7/group) were randomized to REBOA; REBOA + REBOVC; REBOA + infra and suprahepatic REBOVC + portal vein occlusion (endovascular Heaney maneuver, four-balloon-occlusion, 4BO) or no occlusion. After balloon inflation, free bleeding was initiated from an open sheath in the retrohepatic vena cava. Bleeding volume, right internal thoracic artery (RITA) blood flow, hemodynamics, and arterial blood variables were measured until death or up to 90 min.RESULTS: The REBOA group had a longer median survival time (63 min) compared with the 4BO (24 min, P = 0.02) and no occlusion (30 min, P = 0.02) groups, not versus the REBOA + REBOVC group (49 min, P > 0.05). The first 15 min accumulated bleeding was comparable in all groups (P > 0.05); Thereafter, bleeding volume was higher in the REBOA group versus the 4BO group (P < 0.05), not versus the other groups. RITA blood flow and MAP were higher in the REBOA group versus the other groups after 10 min of bleeding (P < 0.05).CONCLUSIONS: Endovascular Heaney maneuver was not beneficial for survival or hemodynamic stability in this porcine model, whereas supraceliac REBOA was. Anatomical differences in thoracoabdominal collaterals between pigs and humans must be considered when interpreting these results.
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| 4. |
- Wikström, Maria B, 1972-, et al.
(author)
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A porcine study of ultrasound-guided versus fluoroscopy-guided placement of endovascular balloons in the inferior vena cava (REBOVC) and the aorta (REBOA)
- 2023
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In: Trauma surgery & acute care open. - : BMJ Publishing Group Ltd. - 2397-5776. ; 8:1
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Journal article (peer-reviewed)abstract
- OBJECTIVES: In fluoroscopy-free settings, alternative safe and quick methods for placing resuscitative endovascular balloon occlusion of the aorta (REBOA) and resuscitative endovascular balloon occlusion of the inferior vena cava (REBOVC) are needed. Ultrasound is being increasingly used to guide the placement of REBOA in the absence of fluoroscopy. Our hypothesis was that ultrasound could be used to adequately visualize the suprahepatic vena cava and guide REBOVC positioning, without significant time-delay, when compared with fluoroscopic guidance, and compared with the corresponding REBOA placement.METHODS: Nine anesthetized pigs were used to compare ultrasound-guided placement of supraceliac REBOA and suprahepatic REBOVC with corresponding fluoroscopic guidance, in terms of correct placement and speed. Accuracy was controlled by fluoroscopy. Four intervention groups: (1) fluoroscopy REBOA, (2) fluoroscopy REBOVC, (3) ultrasound REBOA and (4) ultrasound REBOVC. The aim was to carry out the four interventions in all animals. Randomization was performed to either fluoroscopic or ultrasound guidance being used first. The time required to position the balloons in the supraceliac aorta or in the suprahepatic inferior vena cava was recorded and compared between the four intervention groups.RESULTS: Ultrasound-guided REBOA and REBOVC placement was completed in eight animals, respectively. All eight had correctly positioned REBOA and REBOVC on fluoroscopic verification. Fluoroscopy-guided REBOA placement was slightly faster (median 14 s, IQR 13-17 s) than ultrasound-guided REBOA (median 22 s, IQR 21-25 s, p=0.024). The corresponding comparisons of the REBOVC groups were not statistically significant, with fluoroscopy-guided REBOVC taking 19 s, median (IQR 11-22 s) and ultrasound-guided REBOVC taking 28 s, median (IQR 20-34 s, p=0.19).CONCLUSION: Ultrasound adequately and quickly guide the placement of supraceliac REBOA and suprahepatic REBOVC in a porcine laboratory model, however, safety issues must be considered before use in trauma patients.LEVEL OF EVIDENCE: Prospective, experimental, animal study. Basic science study.
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| 5. |
- Wikström, Maria B, 1972-, et al.
(author)
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A randomized porcine study of the hemodynamic and metabolic effects of combined endovascular occlusion of the vena cava and the aorta in normovolemia and in hemorrhagic shock
- 2021
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In: Journal of Trauma and Acute Care Surgery. - : Lippincott Williams & Wilkins. - 2163-0755 .- 2163-0763. ; 90:5, s. 817-826
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Journal article (peer-reviewed)abstract
- BACKGROUND: Mortality from traumatic retrohepatic venous injuries is high and methods for temporary circulatory stabilization are needed. We investigated survival, and hemodynamic and metabolic effects of resuscitative endovascular balloon occlusion of the aorta (REBOA) and vena cava inferior (REBOVC) in anesthetized pigs.METHODS: Twenty-five anesthetized pigs in normovolemia or severe hemorrhagic shock (controlled arterial bleeding in blood bags targeting systolic arterial pressure of 50 mmHg, corresponding to 40-50% of the blood volume) were randomized to REBOA zone 1 or REBOA+REBOVC zone 1 (n=6-7/group) for 45 minutes occlusion, followed by 3-hour resuscitation and reperfusion. Hemodynamic and metabolic variables and markers of end-organ damage were measured regularly.RESULTS: During occlusion, both the REBOA groups had higher systemic mean arterial pressure (MAP) and cardiac output (P<0.05) compared to the two REBOA+REBOVC groups. After 60 minutes reperfusion, there were no statistically significant differences between the two REBOA groups and the two REBOA+REBOVC groups in MAP and cardiac output. The two REBOA+REBOVC groups had higher arterial lactate and potassium concentrations during reperfusion, compared to the two REBOA groups (P<0.05). There was no major difference in end-organ damage markers between REBOA and REBOA+REBOVC. Survival after one-hour reperfusion was 86% and 100% respectively in the normovolemic REBOA and REBOA+REBOVC groups, and 67% and 83% respectively in the corresponding hemorrhagic shock REBOA and REBOA+REBOVC groups.CONCLUSION: Acceptable hemodynamic stability during occlusion and short-term survival can be achieved by REBOA+REBOVC with adequate resuscitation; however, the more severe hemodynamic and metabolic impacts of REBOA+REBOVC compared to REBOA must be considered.LEVEL OF EVIDENCE: Prospective, randomized, experimental animal study. Basic science study, therapeutic.
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| 6. |
- Hovhannisyan, Karen, et al.
(author)
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Evaluation of Very Integrated Program (VIP) : Health promotion for patients with alcohol and drug addiction - A randomized trial
- 2020
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In: Alcoholism. - : Wiley. - 0145-6008 .- 1530-0277. ; 44:7, s. 1456-1467
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Journal article (peer-reviewed)abstract
- BACKGROUND: Compared to the general population, patients with alcohol and drug addiction have an increased risk of additional hazardous lifestyles and suffer from more chronic diseases, adding to their already significantly higher morbidity and mortality. The objective of this study was to test the efficacy of the Very Integrated Program (VIP) on treatment and health outcomes for patients diagnosed with alcohol and drug addiction.METHODS: Parallel randomized clinical trial with intervention as add-on to addiction care as usual. A total of 322 patients aged 18 years or older were identified, and the study requirements were fulfilled by 219 patients, 7 of whom participated in a pilot. The intervention was a 6-week intensive, tailored, educational program that included motivational interviewing, a smoking cessation program, dietary and physical activity counseling, and patient education. The main outcome measures were substance-free days, time to relapse and treatment adherence assessed after 6 weeks and 12 months. Secondary outcomes were lifestyle factors, symptoms of comorbidity, and quality of life. Missing data were imputed conservatively by using data closest to the follow-up date and baseline values in patients with no follow-up.RESULTS: The 212 patients (intervention, n=113; control, n=99) were randomized, and 202 had complete data for primary outcomes. After 6 weeks, there were no significant differences between the groups regarding primary or secondary outcomes. At the 12-month follow-up, the patients in the control group had significantly more total substance-free days (139 days; ranging 0-365 vs. 265; 0-366, p=0.021) - specifically among the patients with drug addiction - and higher physical and mental quality of life (45 vs 58, p= 0.049 and 54 vs. 66, p=0.037), but not in the per-protocol analysis (60 vs. 46, p=0.52 and 70 vs. 66, p=0.74). The sensitivity analyses did not support significant differences between the groups.CONCLUSION: Overall, adding VIP intervention did not improve outcome of the alcohol or drug addiction care or the lifestyle compared to the addiction care alone. This patient group is still in need of effective programs and new intervention research is required to develop that.
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| 7. |
- Wikström, Maria B., 1972-, et al.
(author)
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Reply to Rezende-Neto et al.
- 2020
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In: Journal of Trauma and Acute Care Surgery. - : Lippincott Williams & Wilkins. - 2163-0755 .- 2163-0763. ; 88:6, s. e151-e152
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Journal article (peer-reviewed)
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| 8. |
- Wikström, Maria, 1972-, et al.
(author)
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Resuscitative endovascular balloon occlusion of the inferior vena cava is made hemodynamically possible by concomitant endovascular balloon occlusion of the aorta : a porcine study
- 2020
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In: Journal of Trauma and Acute Care Surgery. - : Lippincott Williams & Wilkins. - 2163-0755 .- 2163-0763. ; 88:1, s. 160-168
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Journal article (peer-reviewed)abstract
- BACKGROUND: Resuscitative endovascular balloon occlusion of the vena cava inferior (REBOVC) may provide a minimal invasive alternative for hepatic vascular and inferior vena cava isolation in severe retrohepatic bleeding. However, circulatory stability may be compromised by the obstruction of venous return. The aim was to explore which combinations of arterial and venous endovascular balloon occlusions, and the Pringle maneuver, are hemodynamically possible in a normovolemic pig model. The hypothesis was that lower body venous blood pooling from REBOVC can be avoided by prior resuscitative endovascular aortic balloon occlusion (REBOA).METHODS: Nine anesthetized, ventilated, instrumented and normovolemic pigs were used to explore the hemodynamic effects of eleven combinations of REBOA and REBOVC, with or without the Pringle maneuver, in randomized order. The occlusions were performed for 5 minutes but interrupted if systolic blood pressure dropped below 40 mmHg. Hemodynamic variables were measured.RESULTS: Proximal REBOVC, isolated or in combination with other methods of occlusion, caused severely decreased systemic blood pressure and cardiac output, and had to be terminated before 5 min. The decreases in systemic blood pressure and cardiac output were avoided by REBOA at the same or a more proximal level. The Pringle maneuver had similar hemodynamic effects to proximal REBOVC.CONCLUSIONS: A combination of REBOA and REBOVC provides hemodynamic stability, in contrast to REBOVC alone or with the Pringle maneuver, and may be a possible adjunct in severe retrohepatic venous bleedings.Level of evidenceBasic science study, therapeutic.
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| 9. |
- Hovhannisyan, Karen, et al.
(author)
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Compliance with the Very Integrated Program (VIP) for smoking cessation, nutrition, physical activity and comorbidity education among patients in treatment for alcohol and drug addiction
- 2019
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In: International Journal of Environmental Research and Public Health. - : MDPI AG. - 1661-7827 .- 1660-4601. ; 16:13
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Journal article (peer-reviewed)abstract
- Meeting adherence is an important element of compliance in treatment programmes. It is influenced by several factors one being self-efficacy. We aimed to investigate the association between self-efficacy and meeting adherence and other factors of importance for adherence among patients with alcohol and drug addiction who were undergoing an intensive lifestyle intervention. The intervention consisted of a 6-week Very Integrated Programme. High meeting adherence was defined as >75% participation. The association between self-efficacy and meeting adherence were analysed. The qualitative analyses identified themes important for the patients and were performed as text condensation. High self-efficacy was associated with high meeting adherence (ρ = 0.24, p = 0.03). In the multivariate analyses two variables were significant: avoid complications (OR: 0.51, 95% CI: 0.29-0.90) and self-efficacy (OR: 1.28, 95% CI: 1.00-1.63). Reflections on lifestyle change resulted in the themes of Health and Wellbeing, Personal Economy, Acceptance of Change, and Emotions Related to Lifestyle Change. A higher level of self-efficacy was positively associated with meeting adherence. Patients score high on avoiding complications but then adherence to the intervention drops. There was no difference in the reflections on lifestyle change between the group with high adherence and the group with low adherence.
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| 10. |
- Hovhannisyan, Karen, et al.
(author)
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Very Integrated Program (VIP): Smoking and other lifestyles, co-morbidity and quality of life in patients undertaking treatment for alcohol and drug addiction in Sweden.
- 2018
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In: Clinical Health Promotion. - : Clinical Health Promotion Centre. - 2226-5864. ; 8:1, s. 14-19
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Journal article (peer-reviewed)abstract
- Background Most patients with alcohol and drug addiction have other risky lifestyles and non-communicable diseases (NCDs), adding to their morbidity and pre-mortality. Those are, however, potentially preventable. The aim was to identify and compare the patients in treatment for alcohol and drug addiction and identify important factors for high risk. Methods Data was collected prospectively by interviews, questionnaires, examinations and laboratory tests regarding demographics, smoking, overweight, malnutrition, sedentary lifestyle, heart, lung and liver diseases, diabetes and quality of life. High-risk was identified by >2 NCDs and risky lifestyles. Results 322 (192 and 130) patients participated, aged 52 years in median (ranging 24-80) and 67% men. Only 7% had no other risky lifestyles and NCDs. 62% were smokers, 11% in risk of malnutrition, 36% physical inactive and BMI was 27 (17-50). Furthermore, 41% had cardiovascular illness, 27% liver and 25% respiratory diseases, and 7% diabetes. After adjustment for confounders, drug addiction was significantly associated to younger age (46 vs. 56 years; OR 0.92 [CI 0.89-0.94]), unemployment (85% vs 66%; 0.35 [0.17-0.72]) and liver disease (49% vs. 12%; 0.21 [0.11-0.40]). The high-risk group was significantly older and more often unemployed. Health-related quality of life was not different between the groups. Conclusion The large majority of patients in treatment for alcohol and drug addiction have common risky lifestyles and NCD comorbidity. They also have similar conditions, including quality of life. This may be important when planning a future very intergrated program (VIP) of health promotion.
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