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Vascular Trauma
Published in Ian Greaves, Keith Porter, Jeff Garner, Trauma Care Manual, 2021
Ian Greaves, Keith Porter, Jeff Garner
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emerging technique for temporary control of non-compressible haemorrhage due to torso or lower limb junctional trauma. The technique works by inserting an endovascular balloon via the common femoral artery into the aorta which is inflated at an appropriate level to control haemorrhage and augment cardiac afterload in hypovolaemia and arrest states. For the purposes of REBOA, the aorta is divided into three zones of treatment according to the level of injury requiring control12 (see Figure 18.4).
Damage Control
Published in Kenneth D Boffard, Manual of Definitive Surgical Trauma Care: Incorporating Definitive Anaesthetic Trauma Care, 2019
The operative process works through the following (see also Section 9.1): Arrest arterial and major venous bleeding. Failure to control ongoing bleeding will lead to the patient's demise: Major arterial bleeding must be controlled at the index procedure. A temporary intravascular shunt is preferred for named vessels; however, ligation may be required to save an exsanguinating patient.Resuscitative endovascular balloon occlusion of the aorta (REBOA) may be effective in controlling arterial haemorrhage in difficult access areas such as the pelvis, the retroperitoneum, or the kidney (see also Section 15.3).Temporary intravascular shunting (see Figure 6.1) Use tubing approximately 50% of the diameter of the vessel being shunted.Allow 3–4 cm of the tube in each end of the vessel.The shunt can either be a straight (linear) shunt (Figure 6.1a), for example, for iliac vessels, portal vein, etc., or a ‘pig-tail’ shunt (Figure 6.1b) where access is difficult (e.g. superior mesenteric artery, or some temporary mobility is expected (e.g. shunting a superficial popliteal or distal femoral artery prior to orthopaedic repair.Tamponade using wraps or packs.Occlusion of inflow into the bleeding organ (e.g. Pringle's manoeuvre for bleeding liver).Repair or ligation of accessible blood vessels.Intra-operative or post-operative catheter directed embolization.
A femoral ImpellaTM CP plus REBOA for combined cardiogenic and haemorrhagic shock
Published in Acta Cardiologica, 2023
Christophe Vandenbriele, Stefaan Nijs, Filip Rega, Tim Balthazar
A 70-year old female patient received veno-arterial extracorporeal membrane oxygenation (V-A-ECMO) assisted resuscitation because of cardiac arrest at the end of a coronary angiography, revealing a critical left main. After restoration of circulation with peripheral VA-ECMO in the left groin and successful percutaneous coronary intervention (PCI) of the left main, an ImpellaTM-CP device (Figure 1(B), #) was inserted via the right femoral artery. With full ImpellaTM support, V-A-ECMO weaning was successful and left groyne cannulas were removed. At the end of the procedure, haemodynamic instability returned, but was responsive to fluids and abdominal tension was noted. Bedside ultrasound was suspicious for hepatic bleeding, confirmed by urgent computer tomography (CT; Figure 1(A)). The patient was urgently transferred to the operating room for a laparotomy which showed ongoing bleeding from a large posterior liver laceration, probably related to chest compressions. Because of uncontrolled bleeding and persistent instability despite massive transfusion, a Resuscitative-Endovascular-Balloon-Occlusion of the Aorta (REBOA)-technique was attempted, floating an inflatable balloon catheter towards the level of the diaphragm via left femoral arterial approach (Figure 1(B)). Transient blockage (20 min) of distal aortic outflow allowed a thorough exploration of the liver, whilst brain perfusion was preserved. The ImpellaTM device did not interfere with insertion or insufflation of the REBOA-device nor did insufflation of the balloon result in any position change of the ImpellaTM pump. The balloon was progressively deflated and source control of the haemorrhage could be obtained.