Aortic balloon occlusion (REBOA) in pelvic ring injuries: preliminary results of the ABO Trauma Registry.

EndoVascular and Hybrid Trauma Management (EVTM) has been recently introduced in the treatment of severe pelvic ring injuries. This multimodal method of hemorrhage management counts on several strategies such as the REBOA (resuscitative endovascular balloon occlusion of the aorta). Few data exist on the use of REBOA in patients with a severely injured pelvic ring. The ABO (aortic balloon occlusion) Trauma Registry is designed to capture data for all trauma patients in hemorrhagic shock where management includes REBOA placement. Among all patients included in the ABO registry, 72 patients presented with severe pelvic injuries and were the population under exam. 66.7% were male. Mean and median ISS were respectively 43 and 41 (SD ± 13). Isolated pelvic injuries were observed in 12 patients (16.7%). Blunt trauma occurred in 68 patients (94.4%), penetrating in 2 (2.8%) and combined in 2 (2.8%). Type of injury: fall from height in 15 patients (23.1%), traffic accident in 49 patients (75.4%), and unspecified impact in 1 patient (1.5%). Femoral access was gained pre-hospital in 1 patient, in emergency room in 43, in operating room in 12 and in angio-suite in 16. REBOA was positioned in zone 1 in 59 patients (81,9%), in zone 2 in 1 (1,4%) and in zone 3 in 12 (16,7%). Aortic occlusion was partial/periodical in 35 patients (48,6%) and total occlusion in 37 patients (51,4%). REBOA associated morbidity rate: 11.1%. Overall mortality rate was 54.2% and early mortality rate (≤ 24 h) was 44.4%. In the univariate analysis, factors related to early mortality (≤ 24 h) are lower pH values (p = 0.03), higher base deficit (p = 0.021), longer INR (p = 0.012), minor increase in systolic blood pressure after the REBOA inflation (p = 0.03) and total aortic occlusion (p = 0.008). None of these values resulted significant in the multivariate analysis. In severe hemodynamically unstable pelvic trauma management, REBOA is a viable option when utilized in experienced centers as a bridge to other treatments; its use might be, however, accompanied with severe-to-lethal complications.

Feasibility and Clinical Outcome of Reboa in Patients with Impending Traumatic Cardiac Arrest.

BACKGROUND: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) may improve Systolic Blood Pressure (SBP) in hypovolemic shock. It has, however, not been studied in patients with impending traumatic cardiac arrest (ITCA). We aimed to study the feasibility and clinical outcome of REBOA in patients with ITCA using data from the ABOTrauma Registry. METHODS: Retrospective and prospective data on the use of REBOA from 16 centers globally were collected. SBP was measured both at pre- and post-REBOA inflation. Data collected included patients' demography, vascular access technique, number of attempts, catheter size, operator, zone and duration of occlusion, and clinical outcome. RESULTS: There were 74 patients in this high-risk patient group. REBOA was performed on all patients. A 7-10Fr catheter was used in 66.7% and 58.5% were placed on the first attempt, 52.1% through blind insertion and 93.2% inflated in Zone I, 64.8% for a period of 30 to 60 min, 82.1% by ER doctors, trauma surgeons, or vascular surgeons. SBP significantly improved to 90 mm Hg following the inflation of REBOA. 36.6% of the patients survived. CONCLUSIONS: Our study has shown that REBOA may be performed in patients with ITCA, SBP can be elevated, and 36.6% of the patients survived if REBOA placement is successful.

Radiological classification of retroperitoneal hematoma resulting from lumbar vertebral fracture.

PURPOSE: Lumbar vertebral fracture (LVF) infrequently produces massive retroperitoneal hematoma (RPH). This study aimed to systematically review the clinical and radiographic characteristics of RPH resulting from LVF. METHODS: For 193 consecutive patients having LVF who underwent computed tomography (CT), demographic data, physiological conditions, and outcomes were reviewed from their medical records. Presence or absence of RPH, other bone fractures, or organ/vessel injury was evaluated in their CT images, and LVF or RPH, if present, was classified according to either the Orthopaedic Trauma Association classification or the concept of interfascial planes. RESULTS: RPH resulting only or dominantly from LVF was found in 66 (34.2%) patients, whereas among the others, 64 (33.2%) had no RPH, 38 (19.7%) had RPH from other injuries, and 25 (13.0%) had RPH partly attributable to LVF. The 66 RPHs resulting only or dominantly from LVF were radiologically classified into mild subtype of minor median (n = 35), moderate subtype of lateral (n = 11), and severe subtypes of central pushing-up (n = 13) and combined (n = 7). Of the 20 patients with severe subtypes, 18 (90.0%) were in hemorrhagic shock on admission, and 6 (30.0%) were clinically diagnosed as dying due to uncontrollable RPH resulting from vertebral body fractures despite no anticoagulant medication. CONCLUSIONS: LVF can directly produce massive RPH leading to hemorrhagic death. A major survey of such pathology should be conducted to establish appropriate diagnosis and treatment.

Early arterial access for resuscitative endovascular balloon occlusion of the aorta is related to survival outcome in trauma.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been used in refractory hemorrhagic shock patients. Since the optimal timing of arterial access remains unclear, we evaluated the preocclusion status of patients, and elapsed time from the arrival to the hospital is associated with the survival outcomes in the REBOA patients. METHODS: From August 2011 to December 2016, The Diagnostic and Interventional Radiology in Emergency, Critical care and Trauma-Intra-Aortic Balloon Occlusion (DIRECT-IABO) investigators registered refractory hemorrhagic shock patients undergoing REBOA from 23 hospitals in Japan. Patient characteristics, mechanism of injury, Injury Severity Score (ISS), preocclusion and postocclusion systolic blood pressure, duration of aortic occlusion, clinical time course, and survival outcome were recorded and analyzed. Binary logistic regression analysis was used with mortality and Kaplan-Meier survival analysis was conducted to demonstrate the difference between early and delayed access groups. RESULTS: Among the enrolled 207 cases, the following patients were excluded from the analysis: five since they were younger than 18 years, nine due to failed attempts at REBOA, 51 nontrauma patients, and 33 who received resuscitative thoracotomy plus REBOA. Thus, the remaining 109 cases were analyzed (30-day survivors, n = 60; nonsurvivors, n = 49). The preocclusion systolic blood pressure was higher, and both hospital arrival to initial arterial access and duration of occlusion were shorter in the survivors. Lower ISS (odds ratio, 0.944; 95% confidence interval, 0.907-0.982; p = 0.0039) and shorter arrival to access (odds ratio, 0.989; 95% confidence interval, 0.979-0.999; p = 0.034) were significantly associated with 30-day survival in the logistic regression analysis. The cutoff point of 21.5 minutes was used in the receiver operating characteristic analysis. The early access group showed a significantly shorter time of arrival to definitive hemostasis and also demonstrated a significantly higher survival in the Kaplan-Meier survival analysis (p = 0.014, Log-rank test). CONCLUSION: The arrival to access time and ISS were significantly associated with mortality in the REBOA patients in Japan. The early access group demonstrated better survival. The proactive early access in the resuscitation phase might be related to better patient outcomes. LEVEL OF EVIDENCE: Therapeutic/care management, level V.

Abdominal aortic aneurysm with periaortic malignant lymphoma differentiated from aneurysmal rupture by clinical presentation and magnetic resonance imaging.

Abdominal aortic aneurysm (AAA) associated with periaortic malignant lymphoma is difficult to differentiate from aneurysmal rupture because of similarities in their clinical presentation and appearance on computed tomography images. We here report a case of AAA associated with periaortic malignant lymphoma diagnosed preoperatively with an absence of typical symptoms, showing that AAA in periaortic malignant lymphoma can present without any clinical correlates. Magnetic resonance imaging was used to confirm the diagnosis. The patient was treated by endovascular repair, which may be safer and more effective than open surgery for AAA associated with malignant lymphoma because of the tight adhesion between the aneurysm and the lymphoid tissue.

Partial occlusion, conversion from thoracotomy, undelayed but shorter occlusion: resuscitative endovascular balloon occlusion of the aorta strategy in Japan.

INTRODUCTION: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a viable alternative to resuscitative thoracotomy (RT) in refractory hemorrhagic patients. We evaluated REBOA strategies using Japanese multi-institutional data. PATIENTS AND METHODS: The DIRECT-IABO investigators registered trauma patients requiring REBOA from 18 hospitals. Patients' characteristics, outcomes, and time in initial treatment were collected and analyzed. RESULTS: From August 2011 to December 2015, 106 trauma patients were analyzed. The majority of patients were men (67%) (median BMI of 22 kg/m, 96% blunt injured). REBOA occurred in the field (1.9%, all survived >30 days), emergency department (75%), angiography suite (17%), and operating room (1.9%). Initial deployment was at zone I in 93% and partial occlusion in 70% of cases. RT and REBOA were combined in 30 patients (RT+REBOA group) who showed significantly higher injury severity score (44 vs. 36, P=0.001) and chest abbreviated injury scale (4 vs. 3; P<0.001) than the REBOA-alone group (n=76). Frequent cardiopulmonary resuscitation (73%), longer prothrombin time-international normalised ratio, lower pH, and higher lactate were observed in the RT+REBOA. Among 24 h nonsurvivors (n=30) of the REBOA alone, preocclusion systolic blood pressure was lower (43 vs. 72 mmHg; P=0.002), indicating impending cardiac arrest, and duration of occlusion was longer (60 vs. 31 min; P=0.010). In the RT+REBOA (n=30), six survived beyond 24 h, three beyond 30 days, and achieved survival discharge. CONCLUSION: Partial occlusion was performed in 70% of patients. Undelayed deployment of REBOA without presenting impending cardiac arrest with shorter balloon occlusion (<30 min at zone I with partial occlusion) might be related to successful hemodynamic stabilization and improved survival. Further evaluation should be performed prospectively.

Fewer REBOA complications with smaller devices and partial occlusion: evidence from a multicentre registry in Japan.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) performed by emergency physicians has been gaining acceptance as a less invasive technique than resuscitative thoracotomy. OBJECTIVE: To evaluate access-related complications and duration of occlusions during REBOA. METHODS: Patients with haemorrhagic shock requiring REBOA, from 18 hospitals in Japan, included in the DIRECT-IABO Registry were studied. REBOA-related characteristics were compared between non-survivors and survivors at 24 hours. 24-Hour survivors were categorised into groups with small (≤8 Fr), large (≥9 Fr) or unusual sheaths (oversized or multiple) to assess the relationship between the sheath size and complications. Haemodynamic response, occlusion duration and outcomes were compared between groups with partial and complete REBOA. RESULTS: Between August 2011 and December 2015, 142 adults undergoing REBOA were analysed. REBOA procedures were predominantly (94%) performed by emergency medicine (EM) physicians. The median duration of the small sheath (n=53) was 19 hours compared with 7.5 hours for the larger sheaths (P=0.025). Smaller sheaths were more likely to be removed using external manual compression (96% vs 45%, P<0.001). One case of a common femoral artery thrombus (large group) and two cases of amputation (unusual group) were identified. Partial REBOA was carried out in more cases (n=78) and resulted in a better haemodynamic response than complete REBOA (improvement in haemodynamics, 92% vs 70%, P=0.004; achievement of stability, 78% vs 51%, P=0.007) and allowed longer occlusion duration (median 58 vs 33 min, P=0.041). No statistically significant difference in 24-hour or 30-day survival was found between partial and complete REBOA. CONCLUSION: In Japan, EM physicians undertake the majority of REBOA procedures. Smaller sheaths appear to have fewer complications despite relatively prolonged placement and require external compression on removal. Although REBOA is a rarely performed procedure, partial REBOA, which may extend the occlusion duration without a reduction in survival, is used more commonly in Japan.

Smaller introducer sheaths for REBOA may be associated with fewer complications.

INTRODUCTION: Large arterial sheaths currently used for resuscitative endovascular balloon occlusion of the aorta (REBOA) may be associated with severe complications. Smaller diameter catheters compatible with 7Fr sheaths may improve the safety profile. METHODS: A retrospective review of patients receiving REBOA through a 7Fr sheath for refractory traumatic hemorrhagic shock was performed from January 2014 to June 2015 at five tertiary-care hospitals in Japan. Demographics were collected including method of arterial access; outcomes included mortality and REBOA-related access complications. RESULTS: Thirty-three patients underwent REBOA at Zone 1 (level of the diaphragm). Most patients were male (70%), with a mean age (+SD) 50 ± 18 years, mean BMI 23 ± 4, and a median [IQR] ISS of 38 [34, 52]. Ninety-four percent of patients presented after sustaining injuries from blunt mechanisms. Twenty-four percent underwent CPR before arrival, and an additional 15% received CPR after admission. Percutaneous arterial access without ultrasound or fluoroscopy was achieved in all patients. Systolic blood pressure increased significantly following balloon occlusion (mean 62 ± 36 to 106 ± 40 mm Hg, p < 0.001). Median total duration of complete initial occlusion was 26 [range 10-35] minutes. Sixteen patients (49%) survived beyond 24 hours, and 14 patients (42%) survived beyond 30 days. Twenty-four-hour and 30-day survival were 48% and 42%, respectively. Of the patients surviving 24 hours (n = 16), median duration of sheath placement was 28 [range 18-45] hours with all removed using manual pressure to achieve hemostasis. Of 33 REBOAs, 20 were performed by Emergency Medicine practitioners, 10 by Emergency Medicine practitioners with endovascular training, and 3 by Interventional Radiologists. No complication related to sheath insertion or removal was identified during the follow-up period, including dissection, pseudoaneurysm, retroperitoneal hematoma, leg ischemia, or distal embolism. CONCLUSIONS: 7Fr REBOA catheters can significantly elevate systolic blood pressure with no access-related complications. Our results suggest that a 7Fr introducer device for REBOA may be a safe and effective alternative to large-bore sheaths, and may remain in place during the post-procedure resuscitative phase without sequelae. LEVEL OF EVIDENCE: Therapeutic/care management, level V.

A case of delayed hemothorax with an inferior phrenic artery injury detected and treated endovascularly.

We report the rare case of delayed hemothorax (DHX) with an inferior phrenic artery (IPA) injury due to blunt thoracic trauma. Our case suggests that DHX almost always occurs early after injury, and endovascular treatment is an effective procedure for traumatic hemothorax including DHX.

Veno-venous extracorporeal membrane oxygenation (ECMO) for acute respiratory failure caused by liver abscess.

Liver abscess remains a life-threatening disease, particularly when it results in systemic organ failure necessitating intensive care. Only few cases of respiratory failure caused by liver abscess and treated with veno-venous extracorporeal membrane oxygenation (ECMO) have been reported. Here we present a case of liver abscess with rapid progression of multiple organ dysfunction, including severe acute respiratory failure on admission to the intensive care unit (ICU). Upon admission, we immediately initiated artificial organ support systems, including ventilator, continuous renal replacement therapy, and cardiovascular drug infusion for septic multiple organ failure and source control. Despite this initial management, respiratory failure deteriorated and V-V ECMO was introduced. The case developed abdominal compartment syndrome, for which we performed a bedside decompressive laparotomy in the ICU. The case gradually recovered from multiple organ failure and was discharged from the ICU on day 22 and from the hospital on day 53. Since liver abscess is potentially lethal and respiratory failure on admission is an additional risk factor of mortality, V-V ECMO may serve as an adjunctive choice of artificial organ support for cases of severe acute respiratory failure caused by liver abscess.

Management of type II endoleak after endovascular repair of arteriocaval fistula complicating aortoiliac aneurysm: case report and literature review.

Endovascular treatment for arteriocaval fistula (ACF) has become the preferred alternative to open repair. However, endoleaks sometimes occur and maintain the ACF. A 64-year-old man presented with persistent fistula after placement of a bifurcated stent-graft for ACF complicating an aortoiliac aneurysm that was maintained by endoleaks from the inferior mesenteric and lumbar arteries. Transarterial embolization of the aneurysm sac and inferior mesenteric artery successfully resolved the problem without any complications observed over 16 months of follow-up. A literature review and discussion of the management options for this entity are presented. A combination of inflow and outflow control is important to obtain better long-term outcomes.

Modified interventional obliteration for variceal hemorrhage from elevated jejunum after pylorus-preserving pancreatoduodenectomy.

Ectopic variceal hemorrhage caused by sinistral portal hypertension after splenic vein ligation during a pyloric-preserving pancreatoduodenectomy is a rare entity. We report the case of a 58-year-old man with symptoms of refractory melena. The varices could not be treated endoscopically and surgery was considered unsuitable due to severe adhesions and altered anatomy. Following clinical failure of partial splenic embolization, an alternative obliteration method by a retrograde trans-portal-venous approach was successfully performed and resolved the problem. It seems to be an effective method for ectopic variceal bleeding, especially when other interventions are unavailable or highly risky.

Inhibition of growth in a rabbit VX2 thigh tumor model with intraarterial infusion of carbon dioxide-saturated solution.

PURPOSE: To evaluate the efficacy of intraarterial infusion of CO2-saturated solution in rabbit VX2 thigh tumors. MATERIALS AND METHODS: Fourteen Japanese white rabbits had VX2 tumors implanted in the right femoral muscle 3 weeks before intraarterial infusion. Rabbits were divided into control and CO2 groups (n = 7 each). Fifty milliliters of solution (saline solution and CO2-saturated solution for the control and CO2 groups, respectively) was administered via a 24-gauge catheter in the ipsilateral iliac artery close to the feeding artery of the VX2 tumor. All rabbits were killed for tumor harvest on day 3 after the procedure. Tumor volume was evaluated with in vivo direct caliper measurement and contrast-enhanced computed tomography (CT). Tumor apoptotic changes were examined by DNA fragmentation assay and immunoblot analysis. The tumor growth ratio and apoptotic cell rate were analyzed. RESULTS: Body weight was equally increased in both groups, but the mean tumor growth ratio was significantly decreased in the CO2 group compared with the control group (-9.5% ± 7.9 vs 27.2% ± 6.6 and 4.1% ± 4.4 vs 35.7% ± 4.5 measured by calipers and contrast-enhanced CT, respectively; P < .01). Apoptotic activity in the CO2 group was higher than in the control group (number of apoptotic cells per area, 215.0 ± 58.7 vs 21.8 ± 5.4; adjusted relative density of cleaved caspase-3, 0.23 ± 0.07 vs 0.04 ± 0.01; P < .01). CONCLUSIONS: Intraarterial infusion of CO2-saturated solution inhibits rabbit VX2 thigh tumor growth by activation of apoptotic cell death through cleaved caspase-3 upregulation.

Case Report: Urgent endovascular treatment of subclavian artery injury after blunt trauma.

Subclavian arterial injury is rare and potentially life-threatening, particularly when it leads to arterial occlusion, causing limb ischemia, retrograde thromboembolization and cerebral infarction within hours after injury. Here we report a blunt trauma case with subclavian arterial injury, upper extremity ischemia, and the need for urgent treatment to salvage the limb and prevent cerebral infarction. A 41-year-old man had a left, open, mid-shaft clavicle fracture and left subclavian artery injury accompanied by a weak pulse in the left radial artery, decreased blood pressure of the left arm compared to the right, and left hand numbness. Urgent debridement and irrigation of the open clavicle fracture was followed by angiography for the subclavian artery injury. The left distal subclavian artery had a segmental dissection with a thrombus. Urgent endovascular treatment using a self-expanding nitinol stent successfully restored the blood flow and blood pressure to the left upper extremity. Endovascular treatment is a viable option for cases of subclavian artery injury where there is a risk of extremity ischemia and cerebral infarction.

Successful n-butyl cyanoacrylate embolization of a spontaneous rupture of the internal mammary artery in a patient with myelodysplastic syndrome: report of a case.

Hemomediastinum and hemothorax due to spontaneous internal mammary artery (IMA) rupture is extremely rare, and can be a life-threatening condition. We herein present, to the best of our knowledge, the first case of spontaneous IMA rupture complicating myelodysplastic syndrome, and the first case that was successfully treated by emergency trans-arterial embolization using n-butyl cyanoacrylate.

Iliac leg and abdominal aortic cuff stent-graft for blunt thoracic aortic injury in young patient.

Thoracic endovascular aortic repair for blunt thoracic aortic injury in young adults with small aortic diameter often encounters high difficulty. We report, to our knowledge, the first case of successful treatment using combination of iliac leg and abdominal aortic cuff stent-graft.

Technical and outcome considerations of endovascular treatment for internal iliac artery aneurysms.

PURPOSE: This study was designed to analyze the outcomes of endovascular treatment for internal iliac artery aneurysm (IIAA) at mid-term follow-up. METHODS: We retrospectively analyzed 33 patients (28 males, mean age 77.4 years) who underwent endovascular treatment of 35 IIAAs (mean diameter 39.8 mm) from 2002 to 2012. We attempted to completely and selectively embolize all distal branches with permanent embolic materials, followed by proximal controls either by stent-graft placement (type 1) or coil embolization (type 2). RESULTS: Procedural success rate was 97.1% (n = 34). Complete permanent distal branches embolization was achieved in 27 (79.4%), type 1 in 24 (70.6%), and type 2 in 10 (29.4%) cases. During mean follow-up period of 29.1 months (range, 1.2-92.8), no IIAA-related mortality and stent/stent-graft related complications occurred. Pelvic ischemia occurred and resolved in 8 (25%) patients. Among 32 cases followed by CT, the aneurysm diameter was stable in 18 (56.3%), shrank in 11 (34.4%), and enlarged in 3 (9.4%) cases. In 22 assessed by contrast-enhanced CT, secondary endoleak occurred in 3 (13.6%) cases and 2 required secondary interventions (2/32, 6.3%). Type 1 procedure tends to have better mid-term outcomes. Incomplete permanent distal branches embolization was associated with enlargement and secondary intervention (p = 0.007 and p = 0.042, respectively). The secondary intervention-free rate at 3 years in the complete and incomplete distal embolization group was 100 and 83.3%, respectively (p = 0.128). CONCLUSIONS: Endovascular treatment for IIAA is feasible and safe. Complete permanent distal branches embolization is important to achieve satisfactory mid-term outcomes.

Hybrid management for spontaneous isolated dissection of the iliofemoral artery.

Acute spontaneous and isolated dissection of the iliofemoral artery is an extremely rare entity. Conservative, surgical, and endovascular treatment have been used to treat such cases. To the best of our knowledge we report the first case of using hybrid management to successfully treat isolated external iliac artery dissection extending to the superficial femoral artery. This method could potentially overcome the limitations of endovascular techniques and minimize use of extensive open surgery.