Reliable and valid assessment of procedural skills in resuscitative endovascular balloon occlusion of the aorta.

BACKGROUND: Valid and reliable assessment of skills is essential for improved and evidence-based training concepts. In a recent study, we presented a novel tool to assess procedural skills in resuscitative endovascular balloon occlusion of the aorta (REBOA), REBOA-RATE, based on international expert consensus. Although expert consensus is a strong foundation, the performance of REBOA-RATE has not been explored. The study aimed to examine the reliability and validity of REBOA-RATE. METHODS: This was an experimental simulation-based study. We enrolled doctors with three levels of expertise to perform two REBOA procedures in a simulated scenario of out-of-hospital cardiac arrest. Procedures were video-recorded, and videos were blinded and randomized. Three clinical experts independently rated all procedures using REBOA-RATE. Data were analyzed using Messick's framework for validity evidence, including generalizability analysis of reliability and determination of a pass/fail standard. RESULTS: Forty-two doctors were enrolled: 16 novices, 13 anesthesiologists, and 13 endovascular experts. They all performed two procedures, yielding 84 procedures and 252 ratings. The REBOA-RATE assessment tool showed high internal consistency (Cronbach's α = 0.95) and excellent interrater reliability (intraclass correlation coefficient, 0.97). Assessment using one rater and three procedures could ensure overall reliability suitable for high-stakes testing (G-coefficient >0.80). Mean scores (SD) for the three groups in the second procedure were as follows: novices, 32% (24%); anesthesiologists, 55% (29%); endovascular experts, 93% (4%) (p < 0.001). The pass/fail standard was set at 81%, which all experts but no novices passed. CONCLUSION: Data strongly support the reliability and validity of REBOA-RATE, which successfully discriminated between all experience levels. The REBOA-RATE assessment tool requires minimal instruction, and one rater is sufficient for reliable assessment. Together, these are strong arguments for the use of REBOA-RATE to assess REBOA skills, allowing for competency-based training and certification concepts. LEVEL OF EVIDENCE: Diagnostic test, no or poor gold standard, level V.

Experiment on endoscopic balloon dilation for esophageal stenosis after endoscopic submucosal dissection in pigs.

BACKGROUND AND AIM: Endoscopic balloon dilation (EBD) is effective for esophageal stenosis caused by ESD. However, an efficient EBD method has not been established. We, therefore, conducted EBD experiments on porcine esophageal stenosis models. METHODS: Study 1: in dilation models (day 22 after ESD), the thickness of the outer muscle layer (as an index of the extension effect) and the area of muscle fiber bundle necrosis in the inner muscle layer (as an index of thermal damage) were evaluated. Study 2: in restenosis models (day 43 after ESD), the thickness of the fibrous plexus (as an index of restenosis) was evaluated. In total, 12 porcine models were created. RESULTS: Study 1: the thickness of the outer muscle layer was 1243 ± 322 µm in surrounding locations and it was 803 ± 145 µm beneath the laceration (p = 0.005). In cases of muscular layer injury, the area of necrosis was 15,500 ± 10400 µm2 in surrounding locations and it was 40,200 ± 12900 µm2 at the laceration site (p < 0.001). Study 2: the thickness of the fibrous plexus was 1359 ± 196 µm in surrounding locations and it was 1322 ± 136 µm2 in the laceration scar site (p = 0.74). CONCLUSION: Since thermal damage persists until the completion of stenosis, EBD in the initial stage should be carefully performed. An extension effect was observed only at the laceration site and it later returned to a status similar to that of surrounding locations. Additional intervention would be required for preventing restenosis.

Preoperative Prophylactic Balloon-Assisted Occlusion of the Internal Iliac Arteries in the Management of Placenta Increta/Percreta.

Background and Objectives: Preoperative prophylactic balloon-assisted occlusion (PBAO) of the internal iliac arteries minimizes blood loss and facilitates surgery performance, through reductions in the rate of uterine perfusion, which allow for better control in hysterectomy performance, with decreased rates of bleeding and surgical complications. We aimed to investigate the maternal and fetal outcomes associated with PBAO use in women with placenta increta or percreta. Material and Methods: The records of 42 consecutive patients with a diagnosis of placenta increta or percreta were retrospectively reviewed. Of 42 patients, 17 patients (40.5%) with placenta increta or percreta underwent cesarean delivery after prophylactic balloon catheter placement in the bilateral internal iliac artery (balloon group). The blood loss volume, transfusion volume, postoperative hemoglobin changes, rates of hysterectomy and hospitalization, and infant Apgar score in this group were compared to those of 25 similar women who underwent cesarean delivery without balloon placement (surgical group). Results: The mean intraoperative blood loss volume in the balloon group (2319 ± 1191 mL, range 1000-4500 mL) was significantly lower than that in the surgical group (4435 ± 1376 mL, range 1500-10,500 mL) (p = 0.037). The mean blood unit volume transfused in the balloon group (2060 ± 1154 mL, range 1200-8000 mL) was significantly lower than that in the surgical group (3840 ± 1464 mL, range 1800-15,200 mL) (p = 0.043). There was no significant difference in the postoperative hemoglobin change, hysterectomy rates, length of hospitalization, or infant Apgar score between the groups. Conclusion: PBAO of the internal iliac artery prior to cesarean delivery in patients with placenta increta or percreta is a safe and minimally invasive technique that reduces the rate of intraoperative blood loss and transfusion requirements.

Current Approaches to the Treatment of Gastric Varices: Glue, Coil Application, TIPS, and BRTO.

Gastric varices are less common than esophageal varices, and their treatment is quite challenging. Gastric varix bleedings (GVB) occur less frequently than esophageal varix (EV) bleedings and represent 10% to 30% of all variceal bleedings. They are; however, more severe and are associated with high mortality. Re-bleeding may occur in 35% to 90% of cases after spontaneous hemostasis. GV bleedings represent a serious clinical problem compared with esophageal varices due to their location. Sclerotherapy and band ligation, in particular, are less effective. Based on the anatomic site and location, treatment differs from EV and is categorized into two groups (i.e., endoscopic or radiologic treatment). Surgical management is used less frequently. Balloon-occluded retrograde transvenous obliteration (BRTO) and cyanoacrylate are safe but there is a high risk of re-bleeding. Portal pressure elevates following BRTO and leads to worsening of esophageal varix pressure. Other significant complications may include hemoglobinuria, abdominal pain, fever, and pleural effusion. Shock and atrial fibrillation are major complications. New and efficient treatment modalities will be possible in the future.

Does the conventional landmark help to place the tip of REBOA catheter in the optimal position? A non-controlled comparison study.

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) for patients with traumatic torso hemorrhagic shock is available to keep a minimum level of circulatory status as a bridge to definitive therapy. However, the trajectory for placement of REBOA in the aorta has not yet been clearly defined. Methods: We conducted a retrospective observational cohort study in the two tertiary critical care and emergency center from December 2014 to October 2018. A total of 28 patients who underwent focused assessment with sonography for trauma (FAST) were studied via contrast computed tomography (CT), and 27 were analyzed. Results: We divided patients into two groups based on our CT findings. The REBOA deflate group included 16 patients, and the inflate group included 11 patients. The median trace value (interquartile range) of the blood vessel center line from the common femoral artery to the tip of REBOA (blood vessel length) and the length of REBOA itself from the common femoral artery to the tip of REBOA (REBOA insertion length) were 56.2 cm (54.5-57.2) and 55.2 cm (54.2-55.6), respectively (p < 0.0001) for the deflated group, and 51.4 cm (42.1-56.6) and 50.3 cm (42.3-55.0) (p = 0.594), respectively, for the inflated group. Conclusions: If REBOA was deflated, it was placed 1.0 cm longer than the insertion length of REBOA catheter itself, but that was not the case when inflating REBOA. The individual difference was large to the extent that the balloon inflated and the extent to which the balloon was pushed back toward the caudal depending on the degree of blood pressure. Further studies would be needed to validate the study findings.

Thoracic trauma in military settings: a review of current practices and recommendations.

PURPOSE OF REVIEW: To examine current literature on thoracic trauma related to military combat and to explore its relevance to the civilian population. RECENT FINDINGS: Damage control resuscitation (DCR) has improved the management of hemorrhaging trauma patients. Permissive hypotension below 110 mmHg and antifibrinolytic use during DCR is widely accepted, whereas the use of freeze-dried plasma and whole blood is gaining popularity. The Modified Physiologic Triaging Tool can be used for primary triage and it may have applications in civilian trauma systems. Although Tactical Combat Casualty Care protocol recommends the Cric-Key device for surgical cricothyroidotomies, other devices may offer comparable performance. Recommendations for regional anesthesia after blunt trauma are not well defined. Increasing amounts of evidence favor the use of extracorporeal membrane oxygenation for refractory hypoxemia and resuscitative endovascular balloon occlusion of the aorta (REBOA) for severe hemorrhage. REBOA outcomes are potentially improved by partial occlusion and small 7 Fr catheters. SUMMARY: The Global War on Terror has provided opportunities to better understand and treat thoracic trauma in military settings. Trauma registries and other data sources have contributed to significant advancements in the management of thoracic trauma in military and civilian populations.

A Randomized Controlled Trial using iTClamp, Direct Pressure, and Balloon Catheter Tamponade to Control Neck Hemorrhage in a Perfused Human Cadaver Model.

BACKGROUND: Penetrating neck wounds are common in the civilian and military realms. Whether high or low velocity, they carry a substantial morbidity and mortality rate. OBJECTIVES: We endeavored to ascertain whether the iTClamp is equivalent to direct manual pressure (DMP) and Foley catheter balloon tamponade (BCT). METHODS: Using a perfused cadaver, a 4.5-cm wound was made in Zone 2 of the neck with a 1-cm carotid arteriotomy. Each of the hemorrhage control modalities was randomized and then applied to the wound separately. Time to apply the device and fluid loss with and without neck motion was recorded. RESULTS: There was no significant difference between the fluid loss/no movement (p > 0.450) and fluid loss/movement (p > 0.215) between BCT and iTClamp. There was significantly more fluid lost with DMP than iTClamp with no movement (p > 0.000) and movement (p > 0.000). The iTClamp was also significantly faster to apply than the Foley (p > 0.000). CONCLUSIONS: The iTClamp and BCT were associated with significantly less fluid loss than DMP in a perfused cadaver model. The iTClamp required significantly less time to apply than the BCT. Both the iTClamp and the BCT were more effective than simple DMP. The iTClamp offers an additional option for managing hard-to-control bleeding in the neck.

Resuscitative endovascular balloon occlusion of the aorta (REBOA): a scoping review protocol concerning indications-advantages and challenges of implementation in traumatic non-compressible torso haemorrhage.

INTRODUCTION: Haemorrhage remains the leading cause of preventable death in trauma. Damage control measures applied to patients in extremis in order to control exsanguinating bleeding from non-compressible torso injuries use different techniques to limit blood flow from the aorta to the rest of the body. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is regaining momentum recently as an adjunct measure that can provide the same results using less invasive approaches. This scoping review aims to provide a comprehensive understanding of the existing literature on REBOA. The objective is to analyse evidence and non-evidence-based medical reports and to describe current gaps in the literature about the best indication and implementation strategies for REBOA. METHODS AND ANALYSIS: Using the five-stage framework of Arksey and O'Malley's scoping review methodology as a guide, we will perform a systematic search in the following databases: MEDLINE, EMBASE, BIOSIS, COCHRANE CENTRAL, PUBMED and SCOPUS from the earliest available publications. The aim is to identify diverse studies related to the topic of REBOA. For a comprehensive search, we will explore organisational websites, key journals and hand-search reference lists of key studies. Data will be charted and sorted using a descriptive analytical approach. ETHICS AND DISSEMINATION: Ethics approval is not necessary as the data are collected from publicly available sources and there will be no consultative phase. The results will be disseminated through presentations at local, national, clinical and medical education conferences and through publication in a peer-reviewed journal.

Minimally invasive preperitoneal balloon tamponade and abdominal aortic junctional tourniquet versus open packing for pelvic fracture-associated hemorrhage: Not all extrinsic compression is equal.

BACKGROUND: Minimally invasive preperitoneal balloon tamponade (PPB) and abdominal aortic junctional tourniquets (AAJT) have been proposed as alternatives to open preperitoneal packing (OP) for the management of pelvic fracture-associated hemorrhage. We hypothesized that the PPB (SpaceMaker Pro) and AAJT would result in similar rates of survival and blood loss versus OP. METHODS: Thirty-two swine underwent creation of a combined open-book pelvic fracture and major iliac vascular injuries. Animals were randomized to no intervention (n = 7), OP (n = 10), PPB (n = 9), or AAJT (n = 6) at a mean arterial pressure <40 mm Hg following initiation of uncontrolled hemorrhage. Survival (up to 60 minutes + 10 minutes after intervention reversal), hemodynamics, extraperitoneal pressures, blood loss, and associated complications were compared between groups. RESULTS: Prior to injury, no difference was measured between groups for weight, hemodynamics, lactate, and hematocrit (all p > 0.05). The injury was uniformly lethal without intervention, with survival time (mean) of 5 minutes, peak preperitoneal pressure (PP) of 14 mm Hg, blood loss of 960 g, and peak lactate of 2.6 mmol/L. Survival time was 44 minutes with OP versus 60 minutes with PPB and AAJT (p < 0.01). Peak PP (mm Hg) was 19 with OP, 23 with PPB, and 23 with AAJT (p > 0.05). Blood loss (g) was 850 with OP, 930 with PPB, and 600 with AAJT (p > 0.05). Peak lactate (mmol/L) was 3.3 with OP, 4.3 with PPB, and 6.3 with AAJT (p < 0.01). Only 33% of AAJT animals survived intervention reversal versus 60% for OP and 67% for PPB (p < 0.01). Necropsy revealed bowel/bladder injury in 50% of AAJT subjects versus 0% in all other arms (p < 0.01). CONCLUSION: Preperitoneal balloon tamponade is a safe and potentially effective alternative to OP for the management of lethal pelvic fracture-associated hemorrhage. Abdominal aortic junctional tourniquet offers a similar survival benefit to PPB but has concerning rates of ischemia-reperfusion and compressive abdominal organ injury.

Radiofrequency Identification of the ER-REBOA: Confirmation of Placement Without Fluoroscopy.

INTRODUCTION: Non-compressible torso hemorrhage accounts for 70% of battlefield deaths. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emerging technology used to mitigate massive truncal hemorrhage. Use of REBOA on the battlefield is limited by the need for radiographic guided balloon placement. Radiofrequency identification (RFID) is a simple, portable, real-time technology utilized to detect retained sponges during surgery. We investigated the feasibility of RFID to confirm the placement of ER-REBOA. MATERIALS AND METHODS: This was a single-arm prospective proof-of-concept experimental study approved by the institutional review board at Naval Medical Center San Diego. The ER-REBOA (Prytime Medical Devices, Inc, Boerne, TX, USA) was modified by placement of a RFID tag. The tagged ER-REBOA was placed in zone I or zone III of the aorta in a previously perfused cadaver. Exact location was documented with X-ray. Five blinded individuals used the RF Assure Detection System (Medtronic, Minneapolis, MN, USA) handheld detection wand to predict catheter tip location from the xiphoid process (zone I) or pubic tubercle (zone III). RESULTS: In zone I, actual distance (Da) of the catheter tip was 11 cm from the xiphoid process. Mean predicted distance (Dp) from Da was 1.52 cm (95% CI 1.19-1.85). In zone III, Da was 14 cm from the pubic tubercle. Mean Dp from Da was 4.11 cm (95% CI 3.68-4.54). Sensitivity of detection was 100% in both zones. Specificity (Defined as Dp within 2 cm of Da) was 86% in zone I and 16% in zone III. CONCLUSIONS: Using RFID to confirm the placement of ER-REBOA is feasible with specificity highest in zone I. Future work should focus on refining this technology for the forward-deployed setting.

Effect of resuscitative endovascular balloon occlusion of the aorta in hemodynamically unstable patients with multiple severe torso trauma: a retrospective study.

Background: Although resuscitative endovascular balloon occlusion of the aorta (REBOA) may be effective in trauma management, its effect in patients with severe multiple torso trauma remains unclear. Methods: We performed a retrospective study to evaluate trauma management with REBOA in hemodynamically unstable patients with severe multiple trauma. Of 5899 severe trauma patients admitted to our hospital between January 2011 and January 2018, we selected 107 patients with severe torso trauma (Injury Severity Score > 16) who displayed persistent hypotension [≥ 2 systolic blood pressure (SBP) values ≤ 90 mmHg] regardless of primary resuscitation. Patients were divided into two groups: trauma management with REBOA (n = 15) and without REBOA (n = 92). The primary endpoint was the effectiveness of trauma management with REBOA with respect to in-hospital mortality. Secondary endpoints included time from arrival to the start of hemostasis. Multivariable logistic regression analysis, adjusted for clinically important variables, was performed to evaluate clinical outcomes. Results: Trauma management with REBOA was significantly associated with decreased mortality (adjusted odds ratio of survival, 7.430; 95% confidence interval, 1.081-51.062; p = 0.041). The median time (interquartile range) from admission to initiation of hemostasis was not significantly different between the two groups [with REBOA 53.0 (40.0-80.3) min vs. without REBOA 57.0 (35.0-100.0) min ]. The time from arrival to the start of balloon occlusion was 55.7 ± 34.2 min. SBP before insertion of REBOA was 48.2 ± 10.5 mmHg. Total balloon occlusion time was 32.5 ± 18.2 min. Conclusions: The use of REBOA without a delay in initiating resuscitative hemostasis may improve the outcomes in patients with multiple severe torso trauma. However, optimal use may be essential for success.

Resuscitative endovascular balloon occlusion of the aorta deployed by acute care surgeons in patients with morbidly adherent placenta: a feasible solution for two lives in peril.

Morbidly adherent placenta (MAP), which includes accreta, increta, and percreta, is a condition characterized by the invasion of the uterine wall by placental tissue. The condition is associated with higher odds of massive post-partum hemorrhage. Several interventions have been developed to improve hemorrhage-related outcomes in these patients; however, there is no evidence to prefer any intervention over another. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an endovascular intervention that may be useful and effective to reduce hemorrhage and transfusions in MAP patients. The objective of this narrative review is to summarize the evidence for REBOA in patients with MAP. We posit that acute care surgeons can perform REBOA for patients with MAP.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for Hemorrhagic Shock.

This clinical practice guideline (CPG) reviews the range of accepted management approaches to profound shock and post-traumatic cardiac arrest and establishes indications for considering Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as a hemorrhage control adjunct. The specific management approach - within the parameters of mission, resources, and tactical situation - will depend on the casualty's physical location, mechanism and pattern of injury, and the experience level of the surgeon. The optimal management strategy is best determined by the surgeon at the bedside.

Resuscitative Endovascular Balloon Occlusion of the Aorta: A Bridge to Flight Survival.

Trauma endures as the leading cause of death worldwide, and most deaths occur in the first 24 hours after initial injury as a result of hemorrhage. Historically, about 90% of battlefield deaths occur before the injured person arrives at a theater hospital, and most are due to noncompressible hemorrhage of the torso. Resuscitative endovascular balloon occlusion of the aorta is an evolving technique to quickly place a balloon into the thoracic or abdominal aorta to efficiently block blood flow to distal circulation. Maneuvers, such as resuscitative endovascular balloon occlusion of the aorta, to control endovascular hemorrhage offer a potential intervention to control noncompressible hemorrhage. This technique can be performed percutaneously or open in prehospital environments to restore hemodynamic functions and serve as a survival bridge until the patient is delivered to a treatment facility for definitive surgical hemostasis. This article describes the indications, complications, and application of resuscitative endovascular balloon occlusion of the aorta to military and civilian aeromedical transport.

Resuscitative Endovascular Balloon Occlusion of the Aorta Using a Low-Profile Device is Easy and Safe for Emergency Physicians in Cases of Life-Threatening Hemorrhage.

BACKGROUND: Bleeding from hemorrhagic shock can be immediately controlled by blocking the proximal part of the hemorrhagic point using either resuscitative thoracotomy for aortic cross-clamping or insertion of a large-caliber (10-14Fr) resuscitative endovascular balloon occlusion of the aorta (REBOA) device via the femoral artery. However, such methods are very invasive and have various complications. With recent progress in endovascular treatment, a low-profile REBOA device (7Fr) has been developed. OBJECTIVE: The objective of this study was to report our experience of this low-profile REBOA device and to evaluate the usefulness of emergency physician-operated REBOA in life-threatening hemorrhagic shock. METHODS: Ten patients with refractory hemorrhagic shock underwent REBOA using this device via the femoral artery. All REBOA procedures were performed by emergency physicians. The success rate of the insertion, vital signs, and REBOA-related complications were evaluated. RESULTS: Median age was 54 years (interquartile range 33-78 years). The causes of hemorrhagic shock were trauma (n = 4; 1 blunt and 3 penetrating), ruptured abdominal aortic aneurysm (n = 3), and obstetric hemorrhage (n = 3). Two patients had cardiopulmonary arrest upon arrival. REBOA procedure was successful in all patients, and all became hemodynamically stable to undergo definitive interventions after REBOA. There were no REBOA-related complications. The mortality rate within 24 h and 30 days was 40%. CONCLUSIONS: This REBOA device was useful for emergency physicians in life-threatening hemorrhagic shock because of its ease in handling and low invasiveness.

Study of the utility and problems of common iliac artery balloon occlusion for placenta previa with accreta.

AIMS: We investigated whether common iliac artery balloon occlusion (CIABO) was effective for decreasing blood loss during cesarean hysterectomy (CH) in patients with placenta previa with accreta and was safe for mothers and fetuses. METHODS: Of the 67 patients who underwent CH for placenta previa with accreta at our facility from 1985 to 2014, 57 patients were eligible for the study. The amount of intraoperative bleeding during CH was compared between three groups: surgery without blood flow occlusion (13 patients), internal iliac artery ligation (15 patients) and CIABO (29 patients). Additionally, multivariate analysis was performed to assess risk factors for massive bleeding during CH. RESULTS: The mean blood loss in the CIABO group (2027 ± 1638 mL) was significantly lower than in the other two groups (3787 ± 2936 mL in the no occlusion, 4175 ± 1921 mL in the internal iliac artery ligation group; P < 0.05). Multivariate analysis showed that spontaneous placental detachment during surgery (odds ratio [OR] 49.174, 95% confidence interval [CI] 4.98-1763.67), a history of ≥ 2 cesarean sections (OR 9.226, 95% CI 1.07-231.15) and no use of CIABO (OR 26.403, 95% CI 3.20-645.17) were significantly related to massive bleeding during surgery. There was no case of necrosis resulting from ischemia. The mean radiation dose during balloon placement never exceeded the threshold value for fetal exposure. CONCLUSION: Bleeding during CH for placenta previa with accreta can be decreased by CIABO. This study also confirmed the safety of CIABO in regard to maternal lower limb ischemia and fetal radiation exposure during balloon placement.

Predictors of a Persistent Status of Pulmonary Vein Electrical Isolation by a Cryoballoon Application for Drug-Refractory Atrial Fibrillation.

BACKGROUND: Pulmonary vein isolation (PVI) using a cryoballoon (CB) is utilized for treating atrial fibrillation. This study aimed to assess the effect of the procedural characteristics of CB-based PVI (CB-PVI) on late PV reconnections.Methods and Results:A total of 389 consecutive patients underwent the CB-PVI as their index procedure; 45 consecutive patients underwent re-do procedures (184±87 days after the index CB-PVI). A total of 146 of 178 PVs (82%) remained isolated. The occlusion grade was evaluated in 171 PVs. Complete PV occlusion by the CB (grade 4) was obtained in 122 of 171 PVs (71%) during the index CB-PVI and the PVI status was maintained in 111 PVs (91%). Among the remaining 49 CB-PVIs without complete PV occlusion (grades 1-3), 20 PVs (41%) had late PV reconnections despite successful PVI during the index CB-PVI. A "pull-down maneuver" was performed in 20 PVs because of leakage of blood at the inferior aspect of the PVs, and all those PVs with a successful pull-down maneuver maintained their PVI status. A multivariate analysis demonstrated that the presence of complete PV occlusion was the only independent predictor for persistence of PVI. CONCLUSIONS: The occlusion grade was a reliable predictor of the long-term durability of PVI.

PROTECT: PRoximal balloon Occlusion TogEther with direCt Thrombus aspiration during stent retriever thrombectomy - evaluation of a double embolic protection approach in endovascular stroke treatment.

PURPOSE: Stent retriever-based mechanical thrombectomy (MT) for emergent large vessel occlusions (ELVO) is often complicated by thrombus fragmentation causing distal embolization and embolization to new vascular territories. Well-established embolic protection approaches include proximal flow arrest and distal aspiration techniques during stent retriever maneuvers. Aiming at the reduction of thrombus fragmentation during MT we evaluated a technical approach combining proximal balloon occlusion together with direct thrombus aspiration during MT: the PROTECT technique. METHODS: We performed a case-control study comparing the PROTECT technique with sole distal aspiration during MT regarding technical and procedural parameters, n=200 patients with ELVO of either the terminus of the internal carotid artery or the proximal middle artery were included. RESULTS: PROTECT resulted in a shorter procedure time (29 vs 40 min; P=0.002), in a higher rate of successful recanalizations (100% vs 78%; P=0.001) and a higher rate of complete reperfusions (70% vs 39%; P<0.001) compared with sole distal aspiration during MT. CONCLUSION: The PROTECT technique is a promising new approach to significantly reduce thrombus fragmentation and, hence distal embolization during MT. This safe and efficient technique needs to be validated in larger trials to confirm our results.