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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)
Örebro University, School of Medical Sciences. Centrum för Klinisk Forskning, Region Värmland, Karlstad, Sweden; Emergency Department, Arvika Hospital, Arvika, Sweden.ORCID iD: 0000-0001-8864-7068
Department of Anesthesiology, Falun Hospital, Region Dalarna, Sweden.
Örebro University, School of Medical Sciences. Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.ORCID iD: 0000-0003-0646-2508
Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.ORCID iD: 0000-0003-3912-4732
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2023 (English)In: Trauma surgery & acute care open, E-ISSN 2397-5776, Vol. 8, no 1, article id e001075Article in journal (Refereed) Published
Abstract [en]

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.

Place, publisher, year, edition, pages
BMJ Publishing Group Ltd, 2023. Vol. 8, no 1, article id e001075
Keywords [en]
multiple trauma, shock, hemorrhagic, ultrasonography, veins
National Category
Anesthesiology and Intensive Care
Identifiers
URN: urn:nbn:se:oru:diva-105987DOI: 10.1136/tsaco-2022-001075ISI: 000991834800005PubMedID: 37205275Scopus ID: 2-s2.0-85159958333OAI: oai:DiVA.org:oru-105987DiVA, id: diva2:1758088
Available from: 2023-05-22 Created: 2023-05-22 Last updated: 2024-04-17Bibliographically approved
In thesis
1. Resuscitative Endovascular Balloon Occlusion of the Inferior Vena Cava (REBOVC): Experimental and clinical studies
Open this publication in new window or tab >>Resuscitative Endovascular Balloon Occlusion of the Inferior Vena Cava (REBOVC): Experimental and clinical studies
2024 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

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.

Place, publisher, year, edition, pages
Örebro: Örebro University, 2024. p. 117
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 291
Keywords
Retrohepatic inferior vena cava, trauma, injury, hemorrhagic shock, endovascular, REBOVC
National Category
Surgery
Identifiers
urn:nbn:se:oru:diva-112004 (URN)9789175295541 (ISBN)9789175295558 (ISBN)
Public defence
2024-05-17, Örebro universitet, Campus USÖ, Tidefeltssalen, Södra Grev Rosengatan 32, Örebro, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2024-02-27 Created: 2024-02-27 Last updated: 2024-04-18Bibliographically approved

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Wikström, Maria BHurtsén, Anna SteneHörer, Tal M.Nilsson, Kristofer F.

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