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  • 1.
    Bilos, Linda
    et al.
    Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden; Örebro University, Örebro, Sweden.
    Pirouzram, Artai
    Örebro University, School of Medical Sciences. Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University Hospital, Örebro, Sweden.
    Toivola, Asko
    Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden; Örebro University, Örebro, Sweden.
    Vidlund, Mårten
    Örebro University, School of Health Sciences. Department of Cardiothoracic and Vascular Surgery, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Cha, Soon Ok
    Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden; Örebro University, Örebro, Sweden.
    Hörer, Tal
    Örebro University, School of Medical Sciences. Department of Cardiothoracic and Vascular Surgery, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    EndoVascular and Hybrid Trauma Management (EVTM) for Blunt Innominate Artery Injury with Ongoing Extravasation2017In: Cardiovascular and Interventional Radiology, ISSN 0174-1551, E-ISSN 1432-086X, Vol. 40, no 1, p. 130-134Article in journal (Refereed)
    Abstract [en]

    Innominate artery (IA) traumatic injuries are rare but life-threatening, with high mortality and morbidity. Open surgical repair is the treatment of choice but is technically demanding. We describe a case of blunt trauma to the IA with ongoing bleeding, treated successfully by combined (hybrid) endovascular and open surgery. The case demonstrates the immediate usage of modern endovascular and surgical tools as part of endovascular and hybrid trauma management.

  • 2.
    Borger van der Burg, B. L. S.
    et al.
    Department of Surgery, Alrijne Hospital, Leiderdorp, The Netherlands.
    van Dongen, Thijs T. C. F.
    Department of Surgery, Alrijne Hospital, Leiderdorp, The Netherlands; Defense Healthcare Organization, Ministry of Defense, Utrecht, The Netherlands.
    Morrison, J. J.
    R. Adam Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, USA.
    Hedeman Joosten, P. P. A.
    Department of Surgery, Alrijne Hospital, Leiderdorp, The Netherlands.
    DuBose, J. J.
    Division of Vascular Surgery, David Grant Medical Center, Travis AFB, California, USA.
    Hörer, Tal M.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery.
    Hoencamp, R.
    Department of Surgery, Alrijne Hospital, Leiderdorp, The Netherlands; Defense Healthcare Organization, Ministry of Defense, Utrecht, The Netherlands; Division of Surgery, Leiden University Medical Centre, Leiden, The Netherlands.
    A systematic review and meta-analysis of the use of resuscitative endovascular balloon occlusion of the aorta in the management of major exsanguination2018In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 44, no 4, p. 535-550Article, review/survey (Refereed)
    Abstract [en]

    BACKGROUND: Circulatory collapse is a leading cause of mortality among traumatic major exsanguination and in ruptured aortic aneurysm patients. Approximately 40% of patients die before hemorrhage control is achieved. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct designed to sustain the circulation until definitive surgical or endovascular repair. A systematic review was conducted for the current clinical use of REBOA in patients with hemodynamic instability and to discuss its potential role in improving prehospital and in-hospital outcome.

    METHODS: Systematic review and meta-analysis (1900-2017) using MEDLINE, Cochrane, EMBASE, Web of Science and Central and Emcare using the keywords "aortic balloon occlusion", "aortic balloon tamponade", "REBOA", and "Resuscitative Endovascular Balloon Occlusion" in combination with hemorrhage control, hemorrhage, resuscitation, shock, ruptured abdominal or thoracic aorta, endovascular repair, and open repair. Original published studies on human subjects were considered.

    RESULTS: A total of 490 studies were identified; 89 met criteria for inclusion. Of the 1436 patients, overall reported mortality was 49.2% (613/1246) with significant differences (p < 0.001) between clinical indications. Hemodynamic shock was evident in 79.3%, values between clinical indications showed significant difference (p < 0.001). REBOA was favored as treatment in trauma patients in terms of mortality. Pooled analysis demonstrated an increase in mean systolic pressure by almost 50 mmHg following REBOA use.

    CONCLUSION: REBOA has been used in trauma patients and ruptured aortic aneurysm patients with improvement of hemodynamic parameters and outcomes for several decades. Formal, prospective study is warranted to clarify the role of this adjunct in all hemodynamic unstable patients.

  • 3.
    Coccolini, Federico
    et al.
    General and Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, Bergamo, Italy.
    Hörer, Tal M.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Ansaloni, Luca
    General and Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, Bergamo, Italy.
    Splenic trauma: WSES classification and guidelines for adult and pediatric patients2017In: World Journal of Emergency Surgery, ISSN 1749-7922, E-ISSN 1749-7922, Vol. 12, article id 40Article, review/survey (Refereed)
    Abstract [en]

    Spleen injuries are among the most frequent trauma-related injuries. At present, they are classified according to the anatomy of the injury. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic derangement, and the associated injuries. The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology especially considering the modern tools for bleeding management. Thus, the management of splenic trauma should be ultimately multidisciplinary and based on the physiology of the patient, the anatomy of the injury, and the associated lesions. Lastly, as the management of adults and children must be different, children should always be treated in dedicated pediatric trauma centers. In fact, the vast majority of pediatric patients with blunt splenic trauma can be managed non-operatively. This paper presents the World Society of Emergency Surgery (WSES) classification of splenic trauma and the management guidelines.

  • 4.
    Coccolini, Federico
    et al.
    General Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy.
    Hörer, Tal M.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery, , Örebro University Hospital, Örebro, Sweden.
    Catena, Fausto
    Emergency and Trauma Surgery, Parma Maggiore Hospital, Parma, Italy.
    The open abdomen in trauma and non-trauma patients: WSES guidelines2018In: World Journal of Emergency Surgery, ISSN 1749-7922, E-ISSN 1749-7922, Vol. 13, article id 7Article, review/survey (Refereed)
    Abstract [en]

    Damage control resuscitation may lead to postoperative intra-abdominal hypertension or abdominal compartment syndrome. These conditions may result in a vicious, self-perpetuating cycle leading to severe physiologic derangements and multiorgan failure unless interrupted by abdominal (surgical or other) decompression. Further, in some clinical situations, the abdomen cannot be closed due to the visceral edema, the inability to control the compelling source of infection or the necessity to re-explore (as a "planned second-look" laparotomy) or complete previously initiated damage control procedures or in cases of abdominal wall disruption. The open abdomen in trauma and non-trauma patients has been proposed to be effective in preventing or treating deranged physiology in patients with severe injuries or critical illness when no other perceived options exist. Its use, however, remains controversial as it is resource consuming and represents a non-anatomic situation with the potential for severe adverse effects. Its use, therefore, should only be considered in patients who would most benefit from it. Abdominal fascia-to-fascia closure should be done as soon as the patient can physiologically tolerate it. All precautions to minimize complications should be implemented.

  • 5.
    Coccolini, Federico
    et al.
    General and Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, Bergamo, Italy.
    Stahel, Philip F.
    Department of Orthopedic Surgery, Department of Neurosurgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver CO, USA.
    Montori, Giulia
    General and Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, Bergamo, Italy.
    Biffl, Walter
    Acute Care Surgery, The Queen's Medical Center, Honolulu HI, USA.
    Hörer, Tal M.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Dept. of Cardiothoracic and Vascular Surgery & Dept. Of Surgery, Örebro University Hospital, Örebro, Sweden.
    Catena, Fausto
    Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy.
    Kluger, Yoram
    Division of General Surgery Rambam Health Care Campus Haifa, Haifa, Israel.
    Moore, Ernest E.
    Trauma Surgery, Denver Health, Denver CO, USA.
    Peitzman, Andrew B.
    Surgery Department, University of Pittsburgh, Pittsburgh PA, USA.
    Ivatury, Rao
    Virginia Commonwealth University, Richmond VA, USA.
    Coimbra, Raul
    Department of Surgery, UC San Diego Health System, San Diego, USA.
    Fraga, Gustavo Pereira
    Faculdade de Ciências Médicas (FCM) - Unicamp, Campinas SP, Brazil.
    Pereira, Bruno
    Faculdade de Ciências Médicas (FCM) - Unicamp, Campinas SP, Brazil.
    Rizoli, Sandro
    Trauma & Acute Care Service, St Michael's Hospital, Toronto ON, Canada.
    Kirkpatrick, Andrew
    General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary AB, Canada.
    Leppaniemi, Ari
    Abdominal Center, University Hospital Meilahti, Helsinki, Finland.
    Manfredi, Roberto
    General and Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, Bergamo, Italy.
    Magnone, Stefano
    General and Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, Bergamo, Italy.
    Chiara, Osvaldo
    Emergency and Trauma Surgery, Niguarda Hospital, Milan, Italy.
    Solaini, Leonardo
    General and Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, Bergamo, Italy.
    Ceresoli, Marco
    General and Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, Bergamo, Italy.
    Allievi, Niccolò
    General and Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, Bergamo, Italy.
    Arvieux, Catherine
    Digestive and Emergency Surgery, UGA-Université Grenoble Alpes, Grenoble, France.
    Velmahos, George
    Harvard Medical School, Division of Trauma, Emergency Surgery and Surgical Critical Care Massachusetts General Hospital, Boston MA, USA.
    Balogh, Zsolt
    Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle NSW, Australia.
    Naidoo, Noel
    Department of Surgery, University of KwaZulu-Natal, Durban, South Africa.
    Weber, Dieter
    Department of General Surgery, Royal Perth Hospital, Perth, Australia.
    Abu-Zidan, Fikri
    Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates.
    Sartelli, Massimo
    General and Emergency Surgery, Macerata Hospital, Macerata, Italy.
    Ansaloni, Luca
    General and Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, Bergamo, Italy.
    Pelvic trauma: WSES classification and guidelines2017In: World Journal of Emergency Surgery, ISSN 1749-7922, E-ISSN 1749-7922, Vol. 12, no 5Article in journal (Refereed)
    Abstract [en]

    Complex pelvic injuries are among the most dangerous and deadly trauma related lesions. Different classification systems exist, some are based on the mechanism of injury, some on anatomic patterns and some are focusing on the resulting instability requiring operative fixation. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic impairment of pelvic ring function and the associated injuries. The management of pelvic trauma patients aims definitively to restore the homeostasis and the normal physiopathology associated to the mechanical stability of the pelvic ring. Thus the management of pelvic trauma must be multidisciplinary and should be ultimately based on the physiology of the patient and the anatomy of the injury. This paper presents the World Society of Emergency Surgery (WSES) classification of pelvic trauma and the management Guidelines.

  • 6.
    Dogan, Emanuel M.
    et al.
    Örebro University, School of Medical Sciences. Department of Cardiothoracic and Vascular Surgery.
    Beskow, Linus
    Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Calais, Fredrik
    Department of Cardiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Hörer, Tal M.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiology.
    Axelsson, Birger
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery.
    Nilsson, Kristofer F.
    Örebro University, School of Medical Sciences.
    Resuscitative Endovascular Balloon Occlusion of the Aorta in Experimental Cardiopulmonary Resuscitation: Aortic Occlusion Level Matters2019In: Shock, ISSN 1073-2322, E-ISSN 1540-0514, Vol. 52, no 1, p. 67-74Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Aortic occlusion during cardiopulmonary resuscitation (CPR) increases systemic arterial pressures. Correct thoracic placement during the resuscitative endovascular balloon occlusion of the aorta (REBOA) may be important for achieving effective CPR.

    HYPOTHESIS: The positioning of the REBOA in the thoracic aorta during CPR will affect systemic arterial pressures.

    METHODS: Cardiac arrest was induced in 27 anesthetized pigs. After 7 min of CPR with a mechanical compression device, REBOA in the thoracic descending aorta at heart level (zone Ib, REBOA-Ib, n = 9), at diaphragmatic level (zone Ic, REBOA-Ic, n = 9) or no occlusion (control, n = 9) was initiated. The primary outcome was systemic arterial pressures during CPR.

    RESULTS: During CPR, REBOA-Ic increased systolic blood pressure from 86 mmHg (confidence interval [CI] 71-101) to 128 mmHg (CI 107-150, P < 0.001). Simultaneously, mean and diastolic blood pressures increased significantly in REBOA-Ic (P < 0.001 and P = 0.006, respectively), and were higher than in REBOA-Ib (P = 0.04 and P = 0.02, respectively) and control (P = 0.005 and P = 0.003, respectively). REBOA-Ib did not significantly affect systemic blood pressures. Arterial pH decreased more in control than in REBOA-Ib and REBOA-Ic after occlusion (P = 0.004 and P = 0.005, respectively). Arterial lactate concentrations were lower in REBOA-Ic compared with control and REBOA-Ib (P = 0.04 and P < 0.001, respectively).

    CONCLUSIONS: Thoracic aortic occlusion in zone Ic during CPR may be more effective in increasing systemic arterial pressures than occlusion in zone Ib. REBOA during CPR was found to be associated with a more favorable acid-base status of circulating blood. If REBOA is used as an adjunct in CPR, it may be of importance to carefully determine the aortic occlusion level.The study was performed following approval of the Regional Animal Ethics Committee in Linköping, Sweden (application ID 418).

  • 7.
    Duchesne, Juan
    et al.
    Tulane Univiversity, New Orleans LA, USA.
    Tatum, Danielle
    Our Lady Lake RMC, Baton Rouge LA, USA.
    Hörer, Tal M.
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Nilsson, Kristofer F.
    Örebro University, School of Medical Sciences.
    McGreevy, David
    Örebro University Hospital, Örebro, Sweden.
    DuBose, Joseph
    R Adams Cowley Shock Trauma, Baltimore MD, USA.
    Brenner, Megan
    University of California, Riverside, Riverside CA, USA.
    IMPACT OF DELTA SYSTOLIC BLOOD PRESSURE AFTER REBOA PLACEMENT IN NON-COMPRESSIBLE TORSO HEMORRHAGE PATIENTS: AN ABOTRAUMA REGISTRY ANALYSIS2019In: Shock, ISSN 1073-2322, E-ISSN 1540-0514, Vol. 51, no 6, p. 159-159Article in journal (Other academic)
  • 8. Fujita, Satoko
    et al.
    Hörer, Tal
    Örebro University, School of Medical Sciences. Department of Cardiothoracic and Vascular Surgery, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Pirouzram, Artai
    Örebro University, School of Medical Sciences.
    Toivola, Asko
    Gruber, Göran
    Larzon, Thomas
    Onyx Embolization as Single Rescue Treatment for Ruptured Abdominal Aortic After EVAR2016In: Innovations (Philadelphia): technology and techniques in cardiothoracic and vascular surgery, ISSN 1556-9845, E-ISSN 1559-0879, Vol. 11, no 5, p. 370-372Article in journal (Refereed)
    Abstract [en]

    A 76-year-old man who had undergone endovascular repair for an infrarenal aortic aneurysm, presented with a late type Ia endoleak 3 years after his operation. Deployment of an aortic cuff did not achieve a better seal at the proximal neck, and the aneurysm developed a rupture. We successfully treated the ruptured aneurysm using transcatheter Onyx embolization only. At 6-month and 1-year follow-ups with contrast-enhanced duplex scanning, no endoleak was seen and sac shrinkage was observed. Onyx is a relatively new liquid embolic agent that is slowly transformed into a solid state by contact with blood. Owing to this unique characteristic, Onyx embolization can be a useful technique for stopping bleeding from an aneurysm in an emergency situation. This is a unique case of the use of an embolization agent in the treatment of aortic aneurysm rupture.

  • 9.
    Gamberini, Emiliano
    et al.
    Anesthesia and Intensive Care Department, AUSL Romagna Trauma Center Maurizio Bufalini Hospital, Cesena, Italy.
    Coccolini, Federico
    General and Emergency Surgery Department, ASST Trauma Center Papa Giovanni XXIII Hospital, Bergamo, Italy.
    Tamagnini, Beatrice
    Emergency Medicine, University of Modena and Reggio Emilia, Modena, Italy.
    Martino, Costanza
    Anesthesia and Intensive Care Department, AUSL Romagna Trauma Center Maurizio Bufalini Hospital, Cesena, Italy.
    Albarello, Vittorio
    Anesthesia and Intensive Care Department, AUSL Romagna Trauma Center Maurizio Bufalini Hospital, Cesena, Italy.
    Benni, Marco
    Anesthesia and Intensive Care Department, AUSL Romagna Trauma Center Maurizio Bufalini Hospital, Cesena, Italy.
    Bisulli, Marcello
    Interventional Radiology Department, AUSL Romagna Trauma Center Maurizio Bufalini Hospital, Cesena, Italy.
    Fabbri, Nicola
    AUSL Romagna Trauma Center Maurizio Bufalini Hospital, General and Emergency Surgery Department, Cesena, Italy.
    Hörer, Tal Martin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Cardiothoracic and Vascular Surgery Department, Örebro University Hospital, Örebro, Sweden.
    Ansaloni, Luca
    General and Emergency Surgery Department, AUSL Romagna Trauma Center Maurizio Bufalini Hospital, Cesena, Italy.
    Coniglio, Carlo
    Anesthesia, Intensive Care and 118 Emergency System Department, AUSL Bologna Trauma Center Maggiore Hospital, Bologna, Italy.
    Barozzi, Marco
    Emergency Medicine Department, AUSL Modena Trauma Center Sant'Agostino Hospital, Modena, Italy.
    Agnoletti, Vanni
    Anesthesia and Intensive Care Department, AUSL Romagna Trauma Center Maurizio Bufalini Hospital, Cesena, Italy.
    Resuscitative Endovascular Balloon Occlusion of the Aorta in trauma: a systematic review of the literature2017In: World Journal of Emergency Surgery, ISSN 1749-7922, E-ISSN 1749-7922, Vol. 12, article id 42Article, review/survey (Refereed)
    Abstract [en]

    Aims: Resuscitative endovascular balloon occlusion of the aorta has been a hot topic in trauma resuscitation during these last years. The aims of this systematic review are to analyze when, how, and where this technique is performed and to evaluate preliminary results.

    Methods: The literature search was performed on online databases in December 2016, without time limits. Studies citing endovascular balloon occlusion of the aorta in trauma were retrieved for evaluation.

    Results: Sixty-one articles met the inclusion criteria and were selected for the systematic review. Overall, they included 1355 treated with aortic endovascular balloon occlusion, and 883 (65%) patients died after the procedure. In most of the included cases, a shock state seemed to be present before the procedure. Time of death and inflation site was not described in the majority of included studies. Procedure-related and shock-related complications are described. Introducer sheath size and comorbidity seems to play the role of risk factors.

    Conclusions: Resuscitative endovascular balloon occlusion of the aorta is increasingly used in trauma victim resuscitation all over the world, to elevate blood pressure and limit fluid infusion, while other procedures aimed to stop the bleeding are performed. High mortality rate is probably due to the severity of the injuries. Time and place of balloon insertion, zone of balloon inflation, and inflation cutoff time are very heterogeneous.

  • 10.
    Hörer, Tal
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Early detection of major surgical postoperative complications evaluated by microdialysis2013Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Major abdominal surgery may be followed by postoperative complications, especially in the elderly and patients with co morbidities as diabetes mellitus and obesity. Some of the most feared complications as anastomotic leakage, abdominal infections, abdominal compartment syndrome (ACS) and intestinal ischemia can lead to sepsis, systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS) with high morbidity and mortality. This thesis evaluates intraperitoneal microdialysis (IPM) as a method for early detection of surgical complications. IPM measures extracellular metabolites as lactate, pyruvate, glycerol and glucose. The lactate/pyruvate (l/p) ratio describes the current relationship between aerobic and anaerobic metabolism. Glycerol is a degradation product of lipolysis from fat and a part of the cell membrane and released when cell injury occurs. In Paper I, evaluation of IPM in patients with and without diabetes mellitus and obesity during 48 hours after abdominal surgery did not show any difference in l/p ratio and glycerol levels compared to a control group. Paper II investigated the first two days after abdominal surgery in patients with major complications using IPM. L/p ratio was higher and glycerol was lower. Paper III used IPM in the immediate postoperative period in patients after endovascular repair for ruptured abdominal aortic aneurysm (rEVAR). Patients who required decompression due to intraabdominal hypertension (IAH) with organ failure had higher l/p ratio and glycerol. Paper IV investigated the effects of Aortic Balloon Occlusion (ABO) and Superior Mesenteric Artery (SMA) occlusion for one hour followed by three hours reperfusion in an animal model. ABO had a pronounced effect on the hemodynamic state. I.p l/p ratio increased during ischemia and decreased on reperfusion while glycerol increased on reperfusion and the effect was less pronounced in the SMA group. In conclusion, IPM monitoring of l/p ratio and glycerol indicates serious postoperative complications at an early stage. The l/p ratio increases or is continuously high while glycerol seems to have a more complex pattern. Diabetes and obesity do not influence the results.

    List of papers
    1. Complications but not obesity or diabetes mellitus have impact on the intraperitoneal lactate/pyruvate ratio measured by microdialysis
    Open this publication in new window or tab >>Complications but not obesity or diabetes mellitus have impact on the intraperitoneal lactate/pyruvate ratio measured by microdialysis
    2010 (English)In: Scandinavian Journal of Gastroenterology, ISSN 1502-7708, Vol. 45, no 1, p. 115-121Article in journal (Refereed) Published
    Abstract [en]

    Objective: Studies have shown a higher risk of postoperative complications in diabetic and obese patients. An increased intraperitoneal lactate/pyruvate ratio as measured by microdialysis has been reported before postoperative complications have been discovered. It is not known whether diabetes or obesity have any influence on the intraperitoneal metabolism (lactate/pyruvate ratio, glucose, glycerol) in relation to major abdominal surgery. The aim of this study was to investigate the postoperative intraperitoneal and subcutaneous carbohydrate and fat metabolism as measured by microdialysis in obese and diabetic patients after major abdominal surgery without postoperative complications.

    Material and methods: Seven obese patients (body mass index > 30 kg/m(2)) and six diabetic but non-obese patients were studied up to 48 h after major abdominal surgery and were compared with 31 non-diabetic, non-obese patients, all without complications. Microdialysis was performed to measure glucose, lactate, pyruvate and glycerol intraperitoneally and subcutaneously. The lactate/pyruvate ratio was calculated.

    Results: The lactate/pyruvate ratio did not differ between the groups. In the diabetic patients, glucose levels were higher intraperitoneally at both Days 1 and 2 compared to controls. Higher glycerol levels were found subcutaneously in obese patients at Day 2. CONCLUSIONS: The lactate/pyruvate ratio does not increase intraperitoneally after non-complicated major abdominal surgery in diabetic and obese patients. Obese patients have increased release of free fatty acids and glycerol subcutaneously, while diabetic patients show higher glucose levels intraperitoneally than controls.

    Keywords
    Diabetes, glucose, glycerol, intraperitoneal microdialysis, lactate/pyruvate ratio, obesity
    National Category
    Gastroenterology and Hepatology Medical and Health Sciences Surgery
    Research subject
    Medicine; Surgery
    Identifiers
    urn:nbn:se:oru:diva-11986 (URN)10.3109/00365520903386713 (DOI)000274344000016 ()19961346 (PubMedID)
    Available from: 2010-10-04 Created: 2010-10-04 Last updated: 2018-04-19Bibliographically approved
    2. Intraperitoneal glycerol levels and lactate/pyruvate ratio: early markers of postoperative complications
    Open this publication in new window or tab >>Intraperitoneal glycerol levels and lactate/pyruvate ratio: early markers of postoperative complications
    2011 (English)In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 46, no 7-8, p. 913-919Article in journal (Refereed) Published
    Abstract [en]

    Objective: We have previously presented microdialysis findings of early intraperitoneal (ip) metabolic disturbances, mainly an increased lactate/pyruvate (l/p) ratio, in surgical patients developing postoperative complications. The aim of the present study was to investigate ip glycerol and l/p ratio after major surgery with and without complications.

    Material and methods :Sixty patients were followed with microdialysis for 48 h after major abdominal surgery, 44 patients without postoperative complications and 16 patients with major surgical complications. Intraperitoneal and subcutaneous (sc) measurements of glycerol, lactate, pyruvate and glucose were performed, and the l/p ratio was calculated.

    Results: Intraperitoneal glycerol was significantly lower in the complication group compared with the control group (64 vs. 94.6 μM; p = 0.0015), while the ip l/p ratio was significantly higher in the complication group compared with the control group (13.7 vs. 11.1; p = 0.0073).

    Conclusions: In this study, ip glycerol levels were lower and ip l/p ratio was higher in the immediate postoperative period in a group of patients with complications. These results might indicate early ip disturbances in fat and carbohydrate metabolism in patients who later developed symptoms of postoperative major complications.

    Place, publisher, year, edition, pages
    Informa Healthcare, 2011
    Keywords
    Glucose, glycerol, intraperitoneal, lactate, lactate/pyruvate ratio, microdialysis, postoperative complications
    National Category
    Gastroenterology and Hepatology
    Identifiers
    urn:nbn:se:oru:diva-15172 (URN)10.3109/00365521.2011.568519 (DOI)000292646800021 ()21443418 (PubMedID)2-s2.0-79960245414 (Scopus ID)
    Projects
    Intraabdominal metabolism/microdialysis
    Available from: 2011-04-04 Created: 2011-04-01 Last updated: 2018-02-20Bibliographically approved
    3. Intra-peritoneal microdialysis and intra-abdominal pressure after endovascular repair of ruptured aortic aneurysms
    Open this publication in new window or tab >>Intra-peritoneal microdialysis and intra-abdominal pressure after endovascular repair of ruptured aortic aneurysms
    Show others...
    2013 (English)In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 45, no 6, p. 596-606Article in journal (Refereed) Published
    Abstract [en]

    Objectives: This study aims to evaluate intra-peritoneal (ip) microdialysis after endovascular aortic repair (EVAR) of ruptured abdominal aortic aneurysm (rAAA) in patients developing intra-abdominal hypertension (IAH), requiring abdominal decompression.

    Design: Prospective study.

    Material and methods: A total of 16 patients with rAAA treated with an emergency EVAR were followed up hourly for intra-abdominal pressure (IAP), urine production and ip lactate, pyruvate, glycerol and glucose by microdialysis, analysed only at the end of the study. Abdominal decompression was performed on clinical criteria, and decompressed (D) and non-decompressed (ND) patients were compared.

    Results: The ip lactate/pyruvate (l/p) ratio was higher in the D group than in the ND group during the first five postoperative hours (mean 20 vs. 12), p = 0.005 and at 1 h prior to decompression compared to the fifth hour in the ND group (24 vs. 13), p = 0.016. Glycerol levels were higher in the D group during the first postoperative hours (mean 274.6 vs. 121.7 mu M), p = 0.022. The IAP was higher only at 1 h prior to decompression in the D group compared to the ND group at the fifth hour (mean 19 vs. 14 mmHg).

    Conclusions: lp l/p ratio and glycerol levels are elevated immediately postoperatively in patients developing IAH leading to organ failure and subsequent abdominal decompression.

    Keywords
    Ruptured aortic aneurysm, Intra-abdominal hypertension, Metabolism, Microdialysis, Lactate, Pyruvate, Glycerol
    National Category
    Medical and Health Sciences
    Research subject
    Medicine
    Identifiers
    urn:nbn:se:oru:diva-30189 (URN)10.1016/j.ejvs.2013.03.002 (DOI)000320745100012 ()
    Available from: 2013-08-13 Created: 2013-08-13 Last updated: 2018-09-11Bibliographically approved
    4. Intraperitoneal metabolic consequences of supra-celiac aortic balloon occlusion versus superior mesenteric artery occlusion: an experimental animal study utilising microdialysis
    Open this publication in new window or tab >>Intraperitoneal metabolic consequences of supra-celiac aortic balloon occlusion versus superior mesenteric artery occlusion: an experimental animal study utilising microdialysis
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    (English)Manuscript (preprint) (Other academic)
    Abstract [en]

    Objective: To investigate the effect of aortic supra-celiac balloon occlusion (ABO) and superior mesenteric artery (SMA) occlusion on abdominal visceral metabolism in an animal model by using intraperitoneal microdialysis (IPM) and laser Doppler flowmetry. Design: Prospective study in pigs

    Material and methods: Nine pigs were subjected to ABO and seven animals were subjected to SMA occlusion for one hour followed by three hours of reperfusion. Seven animals served as controls. Hemodynamic data, arterial blood samples, urinary output and intestinal mucosal blood flow (IBF) were followed hourly. Intraperitoneal (i.p) glucose, glycerol, lactate and pyruvate concentrations and lactate-pyruvate (l/p) ratio were measured by IPM.

    Results: Compared to baseline, ABO reduced IBF by 76% and decreased urinary output. SMA occlusion reduced IBF by 75% without affecting urinary output. ABO increased the i.p l/p ratio from 18 at baseline, peaking at 46 in early reperfusion. SMA occlusion and reperfusion tended to increase the i.p l/p ratio, peaking at 36 in early reperfusion. ABO increased the i.p glycerol concentration from 87 μM at baseline to 579 μM after three hours of reperfusion. SMA occlusion and reperfusion increased the i.p glycerol concentration but to a lesser degree.

    Conclusions: Supra-celiac ABO caused severe hemodynamic, renal and systemic metabolic disturbances compared to SMA occlusion, most likely due to the more extensive ischemiareperfusion injury. The intra-abdominal metabolism, measured by microdialysis, was affected both by ABO and SMA occlusion but the most severe disturbances were caused by ABO. The i.p l/p ratios and the glycerol concentrations increased during ischemia and reperfusion and may serve as markers of these events and indicate anaerobic metabolism and cell damage respectively.

    National Category
    Surgery
    Research subject
    Surgery
    Identifiers
    urn:nbn:se:oru:diva-34962 (URN)
    Available from: 2014-05-05 Created: 2014-05-05 Last updated: 2017-10-17Bibliographically approved
  • 11.
    Hörer, Tal M.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital and University, Örebro, Sweden; Department of General Surgery, Örebro University Hospital and University, Örebro, Sweden.
    Resuscitative endovascular balloon occlusion of the aorta (REBOA) and endovascular resuscitation and trauma management (EVTM): a paradigm shift regarding hemodynamic instability2018In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 44, no 4, p. 487-489Article in journal (Refereed)
  • 12.
    Hörer, Tal M.
    et al.
    Örebro University, School of Medical Sciences. Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Cajander, Per
    Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine and Health, Örebro University Hospital and Örebro University, Örebro, Sweden.
    Jans, Anders
    Department of Surgery, Karlskoga Hospital, Karlskoga, Sweden.
    Nilsson, Kristofer F.
    Örebro University, School of Medical Sciences. Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    A case of partial aortic balloon occlusion in an unstable multi-trauma patient2016In: Trauma, ISSN 1460-4086, E-ISSN 1477-0350, Vol. 18, no 2, p. 150-154Article in journal (Refereed)
    Abstract [en]

    The usage of aortic balloon occlusion or resuscitative endovascular balloon occlusion of the aorta in trauma management for bleeding control is increasing rapidly as an alternative to thoracotomy and aortic clamping. Little is known about the effects of partial occlusion of the aorta as a bridge to definitive treatment, but one of its advantages may be limited visceral organ ischemia. We describe the first known case of partial aortic balloon occlusion in trauma for reaching a targeted systolic blood pressure, which was used as an adjunctive tool in trauma management and as a bridge to definitive treatment.

  • 13.
    Hörer, Tal M
    et al.
    Örebro University Hospital.
    Hammo, Sari
    Örebro University Hospital, Örebro, Sweden.
    Lönn, Lars
    National Hospital, University of Copenhagen, Copenhagen, Denmark.
    Skoog, Per
    Örebro University Hospital, Örebro, Sweden.
    Larzon, Thomas
    Örebro University Hospital.
    Unipuncture double-access method in emergent endovascular procedures.2013In: Innovations (Philadelphia): technology and techniques in cardiothoracic and vascular surgery, ISSN 1556-9845, E-ISSN 1559-0879, Vol. 8, no 3, p. 245-247Article in journal (Refereed)
    Abstract [en]

    We describe a technique to gain an additional endovascular access in acute situations in which a large-bore introducer is already inserted or in situations in which multiple accesses are impaired because of other reasons. Using an existing percutaneous femoral artery access, a second guide wire is inserted into the introducer, which is later withdrawn and applied onto one of the two guide wires. A double-wire access is then achieved. This access can be used, for example, for angiography or embolization catheters. This method might be useful in situations in which a quick and unplanned extra access is needed. It is, for example, applicable in hemodynamically unstable patients in whom percutaneous access can be difficult to obtain or in aortic endovascular procedures when an unplanned access is needed to insert an additional catheter for angiography and embolization.

  • 14.
    Hörer, Tal M.
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Hebron, Dan
    Department of Radiology, Hillel Yaffe Medical Center, Hadera, Israel.
    Swaid, Forat
    Department of General Surgery, Bnai-Zion Medical Center, Haifa, Israel.
    Korin, Alexander
    Trauma Unit, Hillel Yaffe Medical Center, Hadera, Israel.
    Galili, Offer
    Department of Vascular Surgery, Hillel Yaffe Medical Center, Hadera, Israel.
    Alfici, Ricardo
    Surgical Division, Hillel Yaffe Medical Center, Hadera, Israel.
    Kessel, Boris
    Trauma Unit, Hillel Yaffe Medical Center, Hadera, Israel.
    Aorta Balloon Occlusion in Trauma: Three Cases Demonstrating Multidisciplinary Approach Already on Patient's Arrival to the Emergency Room2016In: Cardiovascular and Interventional Radiology, ISSN 0174-1551, E-ISSN 1432-086X, Vol. 39, no 2, p. 284-289Article in journal (Refereed)
    Abstract [en]

    To describe the usage of aortic balloon occlusion (ABO), based on a multidisciplinary approach in severe trauma patients, emphasizing the role of the interventional radiologist in primary trauma care.

    We briefly discuss the relevant literature, the technical aspects of ABO in trauma, and a multidisciplinary approach to the bleeding trauma patient. We describe three severely injured trauma patients for whom ABO was part of initial trauma management.

    Three severely injured multi-trauma patients were treated by ABO as a bridge to surgery and embolization. The procedures were performed by an interventional radiologist in the early stages of trauma management.

    The interventional radiologist and the multidisciplinary team approach can be activated already on severe trauma patient arrival. ABO usage and other endovascular methods are becoming more widely spread, and can be used early in trauma management, without delay, thus justifying the early activation of this multidisciplinary approach.

  • 15.
    Hörer, Tal M.
    et al.
    Örebro University, School of Health and Medical Sciences.
    Norgren, Lars
    Örebro University, School of Health and Medical Sciences.
    Jansson, Kjell
    Region Örebro län, Örebro, Sweden.
    Complications but not obesity or diabetes mellitus have impact on the intraperitoneal lactate/pyruvate ratio measured by microdialysis2010In: Scandinavian Journal of Gastroenterology, ISSN 1502-7708, Vol. 45, no 1, p. 115-121Article in journal (Refereed)
    Abstract [en]

    Objective: Studies have shown a higher risk of postoperative complications in diabetic and obese patients. An increased intraperitoneal lactate/pyruvate ratio as measured by microdialysis has been reported before postoperative complications have been discovered. It is not known whether diabetes or obesity have any influence on the intraperitoneal metabolism (lactate/pyruvate ratio, glucose, glycerol) in relation to major abdominal surgery. The aim of this study was to investigate the postoperative intraperitoneal and subcutaneous carbohydrate and fat metabolism as measured by microdialysis in obese and diabetic patients after major abdominal surgery without postoperative complications.

    Material and methods: Seven obese patients (body mass index > 30 kg/m(2)) and six diabetic but non-obese patients were studied up to 48 h after major abdominal surgery and were compared with 31 non-diabetic, non-obese patients, all without complications. Microdialysis was performed to measure glucose, lactate, pyruvate and glycerol intraperitoneally and subcutaneously. The lactate/pyruvate ratio was calculated.

    Results: The lactate/pyruvate ratio did not differ between the groups. In the diabetic patients, glucose levels were higher intraperitoneally at both Days 1 and 2 compared to controls. Higher glycerol levels were found subcutaneously in obese patients at Day 2. CONCLUSIONS: The lactate/pyruvate ratio does not increase intraperitoneally after non-complicated major abdominal surgery in diabetic and obese patients. Obese patients have increased release of free fatty acids and glycerol subcutaneously, while diabetic patients show higher glucose levels intraperitoneally than controls.

  • 16.
    Hörer, Tal M.
    et al.
    Örebro University, School of Health and Medical Sciences. Department of Surgery.
    Norgren, Lars
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Jansson, Kjell
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Intraperitoneal glycerol levels and lactate/pyruvate ratio: early markers of postoperative complications2011In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 46, no 7-8, p. 913-919Article in journal (Refereed)
    Abstract [en]

    Objective: We have previously presented microdialysis findings of early intraperitoneal (ip) metabolic disturbances, mainly an increased lactate/pyruvate (l/p) ratio, in surgical patients developing postoperative complications. The aim of the present study was to investigate ip glycerol and l/p ratio after major surgery with and without complications.

    Material and methods :Sixty patients were followed with microdialysis for 48 h after major abdominal surgery, 44 patients without postoperative complications and 16 patients with major surgical complications. Intraperitoneal and subcutaneous (sc) measurements of glycerol, lactate, pyruvate and glucose were performed, and the l/p ratio was calculated.

    Results: Intraperitoneal glycerol was significantly lower in the complication group compared with the control group (64 vs. 94.6 μM; p = 0.0015), while the ip l/p ratio was significantly higher in the complication group compared with the control group (13.7 vs. 11.1; p = 0.0073).

    Conclusions: In this study, ip glycerol levels were lower and ip l/p ratio was higher in the immediate postoperative period in a group of patients with complications. These results might indicate early ip disturbances in fat and carbohydrate metabolism in patients who later developed symptoms of postoperative major complications.

  • 17.
    Hörer, Tal M.
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Sweden.
    Skoog, Per
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Sweden.
    Nilsson, Kristofer F.
    Department of Cardio-Thoracic and Vascular Surgery, Örebro University and Örebro University Hospital, Sweden.
    Oikinomakis, Ioannis
    Department of Surgery Örebro University and Örebro University Hospital, Sweden.
    Larzon, Thomas
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Cardio-Thoracic and Vascular Surgery, Örebro University and Örebro University Hospital, Sweden.
    Norgren, Lars
    Örebro University, School of Health and Medical Sciences. Department of Surgery Örebro University and Örebro University Hospital, Sweden.
    Jansson, Kjell
    Department of Surgery Örebro University and Örebro University Hospital, Sweden.
    Intraperitoneal metabolic consequences of supra-celiac aortic balloon occlusion versus superior mesenteric artery occlusion: an experimental animal study utilising microdialysisManuscript (preprint) (Other academic)
    Abstract [en]

    Objective: To investigate the effect of aortic supra-celiac balloon occlusion (ABO) and superior mesenteric artery (SMA) occlusion on abdominal visceral metabolism in an animal model by using intraperitoneal microdialysis (IPM) and laser Doppler flowmetry. Design: Prospective study in pigs

    Material and methods: Nine pigs were subjected to ABO and seven animals were subjected to SMA occlusion for one hour followed by three hours of reperfusion. Seven animals served as controls. Hemodynamic data, arterial blood samples, urinary output and intestinal mucosal blood flow (IBF) were followed hourly. Intraperitoneal (i.p) glucose, glycerol, lactate and pyruvate concentrations and lactate-pyruvate (l/p) ratio were measured by IPM.

    Results: Compared to baseline, ABO reduced IBF by 76% and decreased urinary output. SMA occlusion reduced IBF by 75% without affecting urinary output. ABO increased the i.p l/p ratio from 18 at baseline, peaking at 46 in early reperfusion. SMA occlusion and reperfusion tended to increase the i.p l/p ratio, peaking at 36 in early reperfusion. ABO increased the i.p glycerol concentration from 87 μM at baseline to 579 μM after three hours of reperfusion. SMA occlusion and reperfusion increased the i.p glycerol concentration but to a lesser degree.

    Conclusions: Supra-celiac ABO caused severe hemodynamic, renal and systemic metabolic disturbances compared to SMA occlusion, most likely due to the more extensive ischemiareperfusion injury. The intra-abdominal metabolism, measured by microdialysis, was affected both by ABO and SMA occlusion but the most severe disturbances were caused by ABO. The i.p l/p ratios and the glycerol concentrations increased during ischemia and reperfusion and may serve as markers of these events and indicate anaerobic metabolism and cell damage respectively.

  • 18.
    Hörer, Tal M.
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital. Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Skoog, Per
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Nilsson, Kristofer F.
    Örebro University Hospital. Örebro University, School of Medical Sciences. Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Oikonomakis, Ioannis
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Larzon, Thomas
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital. Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Norgren, Lars
    Örebro University, School of Health and Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Jansson, Kjell
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Intraperitoneal Metabolic Consequences of Supraceliac Aortic Balloon Occlusion in an Experimental Animal Study Using Microdialysis2014In: Annals of Vascular Surgery, ISSN 0890-5096, E-ISSN 1615-5947, Vol. 28, no 5, p. 1286-1295Article in journal (Refereed)
    Abstract [en]

    Background: To investigate the effects of supraceliac aortic balloon occlusion (ABO) and superior mesenteric artery (SMA) occlusion on abdominal visceral metabolism in an animal model using intraperitoneal microdialysis (IPM) and laser Doppler flowmetry.

    Methods: A total of 9 pigs were subjected to ABO and 7 animals were subjected to SMA occlusion for 1 hour followed by 3 hours of reperfusion. Seven animals served as controls. Hemodynamic data, arterial blood samples, urinary output, and intestinal mucosal blood flow (IBF) were followed hourly. Intraperitoneal (i.p) glucose, glycerol, lactate, and pyruvate concentrations and lactate-to-pyruvate (lip) ratio were measured using IPM.

    Results: Compared with the baseline, ABO reduced IBF by 76% and decreased urinary output. SMA occlusion reduced IBF by 75% without affecting urinary output. ABO increased the i.p lip ratio from 18 at baseline, peaking at 46 in early reperfusion. SMA occlusion and reperfusion tended to increase the i.p lip ratio, peaking at 36 in early reperfusion. ABO increased the i.p glycerol concentration from 87 mu M at baseline to 579 p,M after 3 hours of reperfusion. SMA occlusion and reperfusion increased The i.p glycerol concentration but to a lesser degree.

    Conclusions: Supraceliac ABO caused severe hemodynamic, renal, and systemic metabolic disturbances compared with SMA occlusion, most likely because of the more extensive ischemia-reperfusion injury. The intra-abdominal metabolism, measured by microdialysis, was affected by both ABO and SMA occlusion but the most severe disturbances were caused by ABO. The i.p lip ratios and the glycerol concentrations increased during ischemia and reperfusion and may serve as markers of these events and indicate anaerobic metabolism and cell damages respectively.

  • 19.
    Hörer, Tal M.
    et al.
    Örebro University Hospital. Department of Cardio-Vascular and Thoracic Surgery, Örebro University Hospital, Örebro, Sweden.
    Skoog, Per
    Department of Cardio-Vascular and Thoracic Surgery, Örebro University Hospital, Örebro, Sweden.
    Pirouzram, Artai
    Department of Cardio-Vascular and Thoracic Surgery, Örebro University Hospital, Örebro, Sweden.
    Larzon, Thomas
    Örebro University Hospital. Department of Cardio-Vascular and Thoracic Surgery, Örebro University Hospital, Örebro, Sweden.
    Tissue plasminogen activator-assisted hematoma evacuation to relieve abdominal compartment syndrome after endovascular repair of ruptured abdominal aortic aneurysm2012In: Journal of Endovascular Therapy, ISSN 1526-6028, E-ISSN 1545-1550, Vol. 19, no 2, p. 144-148Article in journal (Refereed)
    Abstract [en]

    Purpose: To describe our experience with a novel technique to decompress abdominal compartment syndrome after endovascular aneurysm repair (EVAR) of ruptured abdominal aortic aneurysm (rAAA).

    Method: From January 2003 to April 2010, 13 patients (12 men; mean age 75 years) treated for rAAA with EVAR underwent tissue plasminogen activator (tPA)-assisted decompression for intra-abdominal hypertension. All of the patients but one had intra-abdominal pressure >20 mmHg, with signs of multiple organ failure or abdominal perfusion pressure <60 mmHg. With computed tomography guidance, a drain was inserted into the retroperitoneal hematoma, and tPA solution was injected to facilitate evacuation of the coagulated hematoma and decrease the abdominal pressure.

    Results: In the 13 patients, the mean intra-abdominal pressure decreased from 23.5 mmHg (range 12-35) to 16 mmHg (range 10-28.5). A mean 1520 mL (range 170-2900) of blood was evacuated. Urine production (mean 130 mL/h, range 50-270) increased in 7 patients at 24 hours after tPA-assisted decompression; among the 5 patients in which urine output did not increase, 3 underwent hemodialysis by the 30-day follow-up. One patient did not respond with clinical improvement and required laparotomy. The 30-day, 90-day, and 1-year mortality was 38% (5/13 patients); none of the deaths was related to the decompression technique.

    Conclusion: tPA-assisted decompression of abdominal compartment syndrome after EVAR can decrease the intra-abdominal pressure and could be useful in preventing multiple organ failure. It is a minimally invasive technique that can be used in selected cases but does not replace laparotomy or retroperitoneal surgical procedures as the gold standard treatments. J Endovasc Thor. 2012;19:144-148

  • 20.
    Hörer, Tal M.
    et al.
    Örebro University, School of Medical Sciences. Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro University, Örebro, Sweden.
    Skoog, Per
    Örebro University, School of Health Sciences. Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro University, Örebro, Sweden.
    Pirouzram, Artai
    Örebro University, School of Medical Sciences. Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro University, Örebro, Sweden.
    Nilsson, Kristofer F.
    Örebro University, School of Medical Sciences. Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro University, Örebro, Sweden.
    Larzon, Thomas
    Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro University, Örebro, Sweden.
    A small case series of aortic balloon occlusion in trauma: lessons learned from its use in ruptured abdominal aortic aneurysms and a brief review2016In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 42, no 5, p. 585-592Article, review/survey (Refereed)
    Abstract [en]

    EndoVascular and Hybrid Trauma Management (EVTM) is an emerging concept for the early treatment of trauma patients using aortic balloon occlusion (ABO), embolization agents and stent grafts to stop ongoing traumatic bleeding. These techniques have previously been implemented successfully in the treatment of ruptured aortic aneurysm.

    We describe our very recent experience of EVTM using ABO in bleeding patients and lessons learned over the last 20 years from the endovascular treatment of ruptured abdominal aortic aneurysms (rAAA). We also briefly describe current knowledge of ABO usage in trauma.

    A small series of educational cases in our hospital is described, where endovascular techniques were used to gain temporary hemorrhage control. The methods used for rAAA and their applicability to EVTM with a multidisciplinary approach are presented.

    Establishing femoral arterial access immediately on arrival at the emergency room and use of an angiography table in the surgical suite may facilitate EVTM at an early stage. ABO may be an effective method for the temporary stabilization of severely hemodynamically unstable patients with hemorrhagic shock, and may be useful as a bridge to definitive treatment of the bleeding patients.

    EVTM, including the usage of ABO, can be initiated on patient arrival and is feasible. Further data need to be collected to investigate proper indications for ABO, best clinical usage, results and potential complications. Accordingly, the ABOTrauma Registry has recently been set up. Existing experiences of EVTM and lessons from the endovascular treatment of rAAA may be useful in trauma management.

  • 21.
    Hörer, Tal M.
    et al.
    Örebro University, School of Medical Sciences. Department of Cardiothoracic and Vascular Surgery, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Skoog, Per
    Örebro University, School of Health Sciences. Department of Cardiothoracic and Vascular Surgery, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Quell, Robin
    Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Nilsson, Kristofer F.
    Örebro University, School of Medical Sciences. Department of Cardiothoracic and Vascular Surgery, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Larzon, Thomas
    Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Souza, Domingos R.
    Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    No-touch technique for radiocephalic arteriovenous fistula - surgical technique and preliminary results2016In: Journal of Vascular Access, ISSN 1129-7298, E-ISSN 1724-6032, Vol. 17, no 1, p. 6-12Article in journal (Refereed)
    Abstract [en]

    Purpose: The radiocephalic arteriovenous fistula (RC-AVF) has significant failure rates due to occlusions and failure to mature. The size and quality of the veins are considerable limiting factors for the procedure. The aim of this pilot study was to describe the No-Touch technique (NTT) to create RC-AVF and present the results up to 1 year of follow-up.

    Methods: Thirty-one consecutive patients who were referred for surgery for a RC-AVF were included (17 men, mean age 63 years, range 35-84) and operated by NTT where the vein and artery were dissected with a tissue cushion around it. Twenty-two patients had small veins or arteries (<= 2 mm), 12 patients had a small cephalic vein (<= 2 mm), and the mean distal cephalic vein diameter was 2.4 mm (range 1.0-4.1 mm).

    Results: Technical surgical success and immediate patency were obtained in all patients. Clinical success was achieved in 23 of the 27 (85%) patients who required hemodialysis. The proportion of primary patency at 30 days and 6 months was 84% and 64%, respectively. Secondary patency at 30 days and 6 months was 97% and 83%, respectively. At 1-year follow-up, primary patency was 54% and secondary patency was 80%. There was no major difference in patency due to preoperative vein diameter.

    Conclusions: The results of this study indicate that NTT can be used for primary radio-cephalic fistula surgery with very good results. This method offers the potential to create a RC-AVF in patients who are not usually considered appropriate for a distal arm fistula due to a small cephalic vein.

  • 22.
    Hörer, Tal
    et al.
    Örebro University, School of Health and Medical Sciences.
    Skoog, Per
    Liljegren, Göran
    Venös obstruktion och stas sekundär till mesenteriell torsion2010In: Svensk kirurgi, ISSN 0346-847X, Vol. 68, no 4, p. 206-207Article in journal (Other academic)
    Abstract [sv]

    Isolerad rotation av tunntarmsmesenteriet med venös stas av vena mesenterica superior som följd, är sällsynt men kan ha dödliga konsekvenser. Vanliga orsaker till mesenteriell ischemi är emboli i arteria mesenterica superior (50 %) eller trombos (25 %), nonoklusivischemi (25 %) och trombosi vena mesenterica superior (5 %)1,4. Mortaliteten vid mesenteriell ischemi är hög, delvis då tillståndet är svårdiagnoserat, speciellt hos gamla och sjuka patienter 2–3,5–7. Vi beskriver här ett ovanligt fall med rotation av mesenterieroten och tunntarmsstas och vill med detta illustrera diagnostikproblemet med tarmischemi, speciellt hos de äldre patienterna.

  • 23.
    Hörer, Tal
    et al.
    Örebro University Hospital. School of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Skoog, Per
    Örebro University Hospital, Örebro, Sweden; School of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Norgren, Lars
    School of Health and Medical Sciences, Örebro University, Örebro, Sweden; Örebro University Hospital, Örebro, Sweden.
    Magnuson, A.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital, Örebro, Sweden.
    Berggren, Lars
    School of Health and Medical Sciences, Örebro University, Örebro, Sweden; Örebro University Hospital, Örebro, Sweden.
    Jansson, Karl
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital, Örebro, Sweden.
    Larzon, Thomas
    School of Health and Medical Sciences, Örebro University, Örebro, Sweden; Örebro University Hospital, Örebro, Sweden.
    Intra-peritoneal microdialysis and intra-abdominal pressure after endovascular repair of ruptured aortic aneurysms2013In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 45, no 6, p. 596-606Article in journal (Refereed)
    Abstract [en]

    Objectives: This study aims to evaluate intra-peritoneal (ip) microdialysis after endovascular aortic repair (EVAR) of ruptured abdominal aortic aneurysm (rAAA) in patients developing intra-abdominal hypertension (IAH), requiring abdominal decompression.

    Design: Prospective study.

    Material and methods: A total of 16 patients with rAAA treated with an emergency EVAR were followed up hourly for intra-abdominal pressure (IAP), urine production and ip lactate, pyruvate, glycerol and glucose by microdialysis, analysed only at the end of the study. Abdominal decompression was performed on clinical criteria, and decompressed (D) and non-decompressed (ND) patients were compared.

    Results: The ip lactate/pyruvate (l/p) ratio was higher in the D group than in the ND group during the first five postoperative hours (mean 20 vs. 12), p = 0.005 and at 1 h prior to decompression compared to the fifth hour in the ND group (24 vs. 13), p = 0.016. Glycerol levels were higher in the D group during the first postoperative hours (mean 274.6 vs. 121.7 mu M), p = 0.022. The IAP was higher only at 1 h prior to decompression in the D group compared to the ND group at the fifth hour (mean 19 vs. 14 mmHg).

    Conclusions: lp l/p ratio and glycerol levels are elevated immediately postoperatively in patients developing IAH leading to organ failure and subsequent abdominal decompression.

  • 24.
    Hörer, Tal
    et al.
    Örebro University Hospital. Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Toivola, Asko
    Endovascular Repair of a Ruptured Aortic Extra-anatomic Bypass Pseudoaneurysm After Previous Coarctation Surgery2015In: Innovations (Philadelphia): technology and techniques in cardiothoracic and vascular surgery, ISSN 1556-9845, E-ISSN 1559-0879, Vol. 10, no 5, p. 370-372Article in journal (Refereed)
    Abstract [en]

    We present a short case of a total endovascular repair of a ruptured thoracic pseudoaneurysm after previous coarctation aortic conduit bypass surgery. A 67-year-old man with two previous coarctation repairs many years ago was admitted with chest pain, dyspnea, and hemoptysis. Computed tomography showed a rupture in the distal anastomosis of the thoracic extra-anatomic graft. Successful treatment was achieved by placement of an endovascular stent graft between the old graft and the native aorta and with a vascular plug occlusion of the native aorta.

  • 25.
    Hörer, Tal
    et al.
    Örebro University, School of Health and Medical Sciences.
    Toivola, Asko
    Larzon, Thomas
    Embolisation with Onyx in iatrogenic bleeding of the gluteal region2011In: Innovations (Philadelphia): technology and techniques in cardiothoracic and vascular surgery, ISSN 1556-9845, E-ISSN 1559-0879, Vol. 6, no 4, p. 267-270Article in journal (Refereed)
    Abstract [en]

    Purpose: We report a unique method using transcatheter Onyx embolization in a bleeding due to morphineinjection in the gluteal region.Case report: A 47 year-old man with a rare blood type presented a painful glutealhematoma due to iatrogenic injury. A Computed Tomographic Angiography (CTA) verified bleedingfrom a suspected branch of the deep femoral artery. Due to the unbearable pain, the hematoma wasevacuated by means of CT guided puncture and the insertion of a pigtail catheter combined with theinjection of a human plasminogen activation agent (t-PA). The initial result was positive. In order tostop the bleeding, angiographic embolization with Onyx was successfully used.Conclusions:Onyx can be used insmall vessel bleedings and might offer the advantage of selective embolization in cases where theaccess to the bleeding vessel is challenging or time consuming.

  • 26.
    Hörer, Tal
    et al.
    Örebro University, School of Health and Medical Sciences.
    Vidlund, Mårten
    Lindell, Peter
    Jansson, Kjell
    A rare case of pacemaker electrode perforation of the heart with intra-abdominal migration2010In: Clinical Cardiology, ISSN 0160-9289, E-ISSN 1932-8737, Vol. 33, no 8, p. E20-E20Article in journal (Refereed)
  • 27.
    Larzon, Thomas
    et al.
    Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Hörer, Tal
    Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Plugging and sealing technique by Onyx to prevent type II endoleak in ruptured abdominal aortic aneurysm.2013In: Vascular, ISSN 1708-5381, E-ISSN 1708-539X, Vol. 21, no 2, p. 87-91Article in journal (Refereed)
    Abstract [en]

    Control of back bleeding from the hypogastric artery into the aneurysm after endovascular aneurysm repair (EVAR) of a ruptured aorto-iliac aneurysm may be necessary in order to avoid a type II endoleak. It is an emergency situation and selective catheterization and embolization of the hypogastric artery may be time-consuming and more importantly, it has to be performed before complete exclusion of the aneurysm has been established. We describe a plugging and sealing technique that embolizes the hypogastric artery after the exclusion of a ruptured aorto-iliac aneurysm using the embolizing agent Onyx. The mortality rate of the 16 patients treated in our institute with this technique was 25% (4/16) at 30-day and 31% (5/16) at 90-day follow up. One patient had a type II endoleak at one-year follow-up. The EVAR procedure can focus completely on controlling the acute life-threatening situation, with the embolization performed at the end of the procedure.

  • 28.
    Manzano-Nunez, Ramiro
    et al.
    Clinical Research Center, Fundacion Valle del Lili, Cali, Colombia; Division of Trauma and Acute Care Surgery, Department of Surgery, Fundacion Valle del Lili, Cali, Colombia.
    Herrera-Escobar, Juan Pablo
    Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Harvard T.H Chan School of Public Health, Boston MA, USA.
    DuBose, Joseph
    R Adams Cowley Shock Trauma Center, Baltimore MD, USA.
    Hörer, Tal M.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden; Department of General Surgery, Örebro University Hospital, Örebro, Sweden.
    Galvagno, Samuel
    Department of Anesthesiology, R Adams Cowley Shock Trauma Center, Baltimore MD, USA.
    Orlas, Claudia Patricia
    Clinical Research Center, Fundacion Valle del Lili, Cali, Colombia; Division of Trauma and Acute Care Surgery, Department of Surgery, Fundacion Valle del Lili, Cali, Colombia.
    Parra, Michael W.
    Department of Trauma Critical Care, Broward General Level I Trauma Center, Fort Lauderdale FL, USA.
    Coccolini, Federico
    Department of General, Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy.
    Sartelli, Massimo
    Department of Surgery, Macerata Hospital, Macerata, Italy.
    Falla-Martinez, Juan Camilo
    Clinical Research Center, Fundacion Valle del Lili, Cali, Colombia.
    García, Alberto Federico
    Division of Trauma and Acute Care Surgery, Department of Surgery, Fundacion Valle del Lili, Cali, Colombia.
    Chica, Julian
    Clinical Research Center, Fundacion Valle del Lili, Cali, Colombia; Division of Trauma and Acute Care Surgery, Department of Surgery, Fundacion Valle del Lili, Cali, Colombia.
    Naranjo, Maria Paula
    Clinical Research Center, Fundacion Valle del Lili, Cali, Colombia.
    Sanchez, Alvaro Ignacio
    Clinical Research Center, Fundacion Valle del Lili, Cali, Colombia; Division of Trauma and Acute Care Surgery, Department of Surgery, Fundacion Valle del Lili, Cali, Colombia.
    Salazar, Camilo Jose
    School of Medicine, Universidad ICESI, Cali, Colombia.
    Calderón-Tapia, Luis Eduardo
    Clinical Research Center, Fundacion Valle del Lili, Cali, Colombia.
    Lopez-Castilla, Valeria
    School of Medicine, Universidad ICESI, Cali, Colombia.
    Ferrada, Paula
    Surgical and Trauma Intensive Care Unit, VCU Health System, Virginia Commonwealth University, Richmond VA, USA.
    Moore, Ernest E.
    Department of Surgery, Trauma Research Center, University of Colorado, Denver CO, USA.
    Ordonez, Carlos A.
    Division of Trauma and Acute Care Surgery, Department of Surgery, Fundacion Valle del Lili, Cali, Colombia.
    Could resuscitative endovascular balloon occlusion of the aorta improve survival among severely injured patients with post-intubation hypotension?2018In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 44, no 4, p. 527-533Article in journal (Refereed)
    Abstract [en]

    Current literature shows the association of post-intubation hypotension and increased odds of mortality in critically ill non-trauma and trauma populations. However, there is a lack of research on potential interventions that can prevent or ameliorate the consequences of endotracheal intubation and thus improve the prognosis of trauma patients with post-intubation hypotension. This review paper hypothesizes that the deployment of REBOA among trauma patients with PIH, by its physiologic effects, will reduce the odds of mortality in this population. The objective of this paper is to review the current literature on REBOA and post-intubation hypotension, and, furthermore, to provide a rational hypothesis on the potential role of REBOA in severely injured patients with post-intubation hypotension.

  • 29.
    Manzano-Nunez, Ramiro
    et al.
    Clinical Research Center, Fundacion Valle del Lili, Cali, Colombia; Division of Trauma and Acute Care Surgery, Department of Surgery, Fundacion Valle del Lili, Cali, Colombia.
    Orlas, Claudia P.
    Clinical Research Center, Fundacion Valle del Lili, Cali, Colombia; Division of Trauma and Acute Care Surgery, Department of Surgery, Fundacion Valle del Lili, Cali, Colombia.
    Herrera-Escobar, Juan P.
    Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School & Harvard T.H. Chan School of Public Health. Boston MA, USA.
    Galvagno, Samuel
    R Adams Cowley Shock Trauma Center, Baltimore MD, USA.
    DuBose, Joseph
    R Adams Cowley Shock Trauma Center, Baltimore MD, USA.
    Melendez, Juan J.
    Trauma and Acute Care Surgery Fellowship, Department of Surgery, Universidad del Valle, Cali, Colombia.
    Serna, Jose J.
    Trauma and Acute Care Surgery Fellowship, Department of Surgery, Universidad del Valle, Cali, Colombia.
    Salcedo, Alexander
    Trauma and Acute Care Surgery Fellowship, Department of Surgery, Universidad del Valle, Cali, Colombia.
    Peña, Camilo A.
    Trauma and Acute Care Surgery Fellowship, Department of Surgery, Universidad del Valle, Cali, Colombia.
    Angamarca, Edison
    Trauma and Acute Care Surgery Fellowship, Department of Surgery, Universidad del Valle, Cali, Colombia.
    Hörer, Tal M.
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Salazar, Camilo J.
    School of Medicine, ICESI University, Cali, Colombia.
    Lopez-Castilla, Valeria
    School of Medicine, ICESI University, Cali, Colombia.
    Ruiz-Yucuma, Juan
    School of Medicine, ICESI University, Cali, Colombia.
    Rodriguez, Fernando
    Division of Trauma and Acute Care Surgery, Department of Surgery, Fundacion Valle del Lili, Cali, Colombia.
    Parra, Michael W.
    Department of Trauma Critical Care, Broward General Level I Trauma Center. Fort Lauderdale FL, USA.
    Ordoñez, Carlos A.
    Division of Trauma and Acute Care Surgery, Department of Surgery, Fundacion Valle del Lili, Cali, Colombia; Trauma and Acute Care Surgery Fellowship, Department of Surgery, Universidad del Valle, Cali, Colombia.
    A meta-analysis of the incidence of complications associated with groin access after the use of resuscitative endovascular balloon occlusion of the aorta in trauma patients.2018In: Journal of Trauma and Acute Care Surgery, ISSN 2163-0755, E-ISSN 2163-0763, Vol. 85, no 3, p. 626-634Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Serious complications related to groin access have been reported with the use of resuscitative endovascular balloon occlusion of the aorta (REBOA). We performed a systematic review and meta-analysis to estimate the incidence of complications related to groin access from the use of REBOA in adult trauma patients.

    METHODS: We identified articles in MEDLINE and EMBASE. We reviewed all studies that involved adult trauma patients that underwent the placement of a REBOA and included only those that reported the incidence of complications related to groin access. A meta-analysis of proportions was performed RESULTS: We 13 studies with a total of 424 patients. REBOA was inserted most commonly by trauma surgeons or emergency room physicians. Information regarding puncture technique was reported in 12 studies and was available for a total of 414 patients. Percutaneous access and surgical cutdown were performed in 304 (73.4%) and 110 (26.5%) patients respectively. Overall, complications related to groin access occurred in 5.6% of patients (n=24/424). Lower limb amputation was required in 2.1% of patients (9/424), of which three cases (3/424 [0.7%]) were directly related to the vascular puncture from the REBOA insertion. A meta-analysis which used the logit transformation showed a 5% (95% CI 3%-9%) incidence of complications without significant heterogeneity (LR test: χ2 = 0.73, p=0.2, Tau-square=0.2). In a second meta-analysis, we used the Freeman-Turkey double arcsine transformation and found an incidence of complications of 4% (95% CI 2%-7%) with low heterogeneity (I2 = 16.3%).

    CONCLUSION: We found that the incidence of complications related to groin access was of four to five percent based on a meta-analysis of 13 studies published worldwide. Currently, there are no benchmarks or quality measures as a reference to compare, and thus, further work is required to identify these benchmarks and improve the practice of REBOA in trauma surgery.

    LEVEL OF EVIDENCE: Systematic Review and Meta-analysis, Level III.

  • 30.
    McGreevy, D. T.
    et al.
    Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Dogan, S.
    Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Oscarsson, V.
    Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Vergari, M.
    Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Eliasson, K.
    Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Hörer, Tal M.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery.
    Nilsson, K. F.
    Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Norgren, L.
    Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Metabolic Response to Claudication in Peripheral Arterial Disease: a Microdialysis pilot study2019In: Annals of Vascular Surgery, ISSN 0890-5096, E-ISSN 1615-5947, Vol. 58, p. 134-141Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: In a pilot study investigate the possible use of microdialysis in the calf muscle to assess the metabolic response to intermittent claudication (IC). In addition, evaluate the simultaneous systemic inflammatory reaction.

    METHODS: With one microdialysis catheter in the gastrocnemic muscle and one subcutaneously in the pectoral region (as a reference), and a peripheral venous catheter, dialysate and venous blood sampling was performed before, during and after walking on a treadmill to maximal tolerable claudication (controls 10 minutes).

    RESULTS: A total of 9 participants were recruited, six patients with IC and three healthy controls. At baseline, IC and control subjects did not differ in metabolic findings (glucose, lactate, pyruvate, glycerol) in the gastrocnemic muscle. Subcutaneous glucose concentration was higher in controls. After physical exertion, gastrocnemic and subcutaneous glycerol, lactate and pyruvate concentrations increased in IC subjects. Plasma concentrations of Tumor Necrosis Factor--α (TNF- α), Interleucin-6 (IL-6), Interleucin-1ß (IL-1ß), Hepatocyte Growth Factor (HGF) and Vascular Endothelial Growth Factor (VEGF) were higher in IC subjects at baseline, and TNF-α, (IL-6) and Interleukin-18 (IL-18) increased after walking as did IL-6 and (IL-1ß) in controls. The muscle catheters did not show any signs of causing harm.

    CONCLUSIONS: Microdialysis can be used to study the ongoing metabolic response during walking and claudication. Our results suggest both an acute local and a systemic inflammatory reaction during development of claudication pain.

  • 31. McGreevy, David
    et al.
    Dogan, Emanuel
    Örebro University, School of Medical Sciences. Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University Hospital, Örebro, Sweden.
    Toivola, Asko
    Bilos, Linda
    Pirouzram, Artai
    Örebro University, School of Medical Sciences. Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University Hospital, Örebro, Sweden.
    Nilsson, Kristofer F.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Hörer, Tal
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Endovascular Resuscitation with Aortic Balloon Occlusion in Non-Trauma Cases: First use of ER-REBOA in Europe2017In: Journal of Endovascular Resuscitation and Trauma Management, ISSN 2002-7567, no 1, p. 42-49Article in journal (Refereed)
    Abstract [en]

    Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is currently evolving and being used worldwide for trauma management. Smaller sheath devices for REBOA and new advances in endovascular resuscitation methods suggest the potential for the procedure to be utilized in hemodynamically unstable non-trau-matic patients.

    Methods: We describe five adult patients that underwent hemodynamic control using the 7 Fr sheath ER-REBOA™ catheters for non-traumatic hemorrhagic instability at Örebro University Hospital between February 2017 and June 2017.

    Results: The ER-REBOA™ catheter was inserted and used successfully for temporary blood pressure stabilization as part of an endovascular resuscitation process.

    Conclusion: The ER-REBOA™ catheter for endovascular resuscitation may be an additional method for temporary hemodynamic stabilization in the treatment of non-traumatic patients. Furthermore, the ER-REBOA™ catheter may be a potential addition to advanced cardiac life support in the management of non-traumatic cardiac arrest.

  • 32.
    Nilsson, Carolina
    et al.
    Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University Hospital and Örebro University, Örebro, Sweden.
    Bilos, Linda
    Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University Hospital and Örebro University, Örebro, Sweden.
    Hörer, Tal M.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Pirouzram, Artai
    Örebro University, School of Medical Sciences. Department of Cardiothoracic and Vascular Surgery, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Use of Resuscitative Endovascular Balloon Occlusion of the Aorta in a Multidisciplinary Approach2017In: Innovations (Philadelphia): technology and techniques in cardiothoracic and vascular surgery, ISSN 1556-9845, E-ISSN 1559-0879, Vol. 12, no 4, p. E1-E2Article in journal (Refereed)
    Abstract [en]

    The usage of resuscitative endovascular balloon occlusion of the aorta, also known as aortic balloon occlusion, is an emerging method for bleeding control as a bridge to definitive treatment in trauma management. We describe a trauma case where resuscitative endovascular balloon occlusion of the aorta was used as part of the EndoVascular hybrid Trauma and bleeding Management concept to facilitate transient hemorrhage control and thereby to permit damage control surgery. The case is an illustration of the adoption of a multidisciplinary approach.

  • 33.
    Pirouzram, Artai
    et al.
    Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Hörer, Tal Martin
    Örebro University, School of Medical Sciences. Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Larzon, Thomas
    Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Conduit-Free Retroperitoneal Access to the Iliac Artery in Endovascular Aortic Repair in Patients With Improper Access Vessels2016In: Innovations (Philadelphia): technology and techniques in cardiothoracic and vascular surgery, ISSN 1556-9845, E-ISSN 1559-0879, Vol. 11, no 2, p. 150-153Article in journal (Refereed)
    Abstract [en]

    Successful endovascular aortic repair is highly dependent on the quality of the iliac access vessels. Patients with poor access vessels can be turned down from endovascular aortic repair or thoracic endovascular aortic repair by the treating physician. Perioperative complications such as failure to deliver the device or iliac rupture can be addressed to improper access vessels. In this article, we describe a novel technique to access the common iliac artery when access vessels are poor in diameter or quality. This sutureless conduit-free access technique can be used in TEVAR or EVAR and requires less surgical exposure of the iliac arteries.

  • 34.
    Reva, V. A.
    et al.
    Department of War Surgery, Kirov Military Medical Academy, Saint-Petersburg, Russian Federation.
    Matsumura, Y.
    R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore MD, United States; Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.
    Hörer, Tal M.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Sveklov, D. A.
    Department of War Surgery, Kirov Military Medical Academy, Saint-Petersburg, Russian Federation.
    Denisov, A. V.
    Department of War Surgery, Kirov Military Medical Academy, Saint-Petersburg, Russian Federation.
    Telickiy, S. Y.
    Department of War Surgery, Kirov Military Medical Academy, Saint-Petersburg, Russian Federation.
    Seleznev, A. B.
    Department of War Surgery, Kirov Military Medical Academy, Saint-Petersburg, Russian Federation.
    Bozhedomova, E. R.
    Department of War Surgery, Kirov Military Medical Academy, Saint-Petersburg, Russian Federation.
    Matsumoto, J.
    Departments of Emergency and Critical Care Medicine, Saint-Marianna University School of Medicine, Sugao Kawasaki, Japan; Department of Radiology, National Hospital Organization Disaster Medical Center, Tachikawa, Japan.
    Samokhvalov, I. M.
    Department of War Surgery, Kirov Military Medical Academy, Saint-Petersburg, Russian Federation.
    Morrison, J. J.
    Department of Vascular Surgery, South Glasgow University Hospital, Glasgow, United Kingdom; The Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, United Kingdom.
    Resuscitative endovascular balloon occlusion of the aorta: what is the optimum occlusion time in an ovine model of hemorrhagic shock?2018In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 44, no 4, p. 511-518Article in journal (Refereed)
    Abstract [en]

    The aim of this study is to evaluate the early survival and organ damage following 30 and 60 min of thoracic resuscitative endovascular balloon occlusion of the aorta (REBOA) in an ovine model of severe hemorrhagic shock.

    Eighteen sheep were induced into shock by undergoing a 35 % controlled exsanguination over 30 min. Animals were randomized into three groups: 60-min REBOA 30 min after the bleeding (60-REBOA), 30-min REBOA 60 min after the bleeding (30-REBOA) and no-REBOA control (n-REBOA). Resuscitation with crystalloids and whole blood was initiated 20 and 80 min after the induction of shock. Animals were observed for 24 h with serial potassium and lactate measurements. Autopsy was performed to evaluate organ damage.

    Two animals of the n-REBOA group died within 90 min of shock induction; no hemorrhagic deaths were observed in the REBOA groups. Twenty-four-hour survival for the 60-, 30-, and n-REBOA groups was 0/6, 5/6, and 4/6 (P = 0.002). In 60-REBOA, potassium and lactate were increased at 270-min time point: from 4.3 to 5.1 mEq/l and from 3.7 to 5.1 mmol/L, respectively. Both these values were significantly higher than in the n-REBOA group (P = 0.029 for potassium and P = 0.039 for lactate). Autopsy revealed acute tubular necrosis in all died REBOA group animals.

    In this ovine model of severe hemorrhagic shock, REBOA can be used to prevent early death from hemorrhage; however, 60 min of occlusion results in significant metabolic derangement and organ damage that offsets this gain.

  • 35.
    Reva, Viktor A.
    et al.
    General and Emergency Surgery, Kirov Academy of Military Medicine, Saint Petersburg, Russia.
    Hörer, Tal M.
    Örebro University Hospital. Örebro University, School of Medical Sciences. Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Makhnovskiy, Andrey I.
    General and Emergency Surgery, Kirov Academy of Military Medicine, Saint Petersburg, Russia.
    Sokhranov, Mikhail V.
    General and Emergency Surgery, Kirov Academy of Military Medicine, Saint Petersburg, Russia.
    Samokhvalov, Igor M.
    Department of War Surgery, Military Medical Academy, Saint Petersburg, Russia.
    DuBose, Joseph J.
    Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, Houston, United States.
    Field and en route resuscitative endovascular occlusion of the aorta: A feasible military reality?2017In: Journal of Trauma and Acute Care Surgery, ISSN 2163-0755, E-ISSN 2163-0763, Vol. 83, no 1, p. S170-S176Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Severe non-compressible torso hemorrhage (NCTH) remains a leading cause of potentially preventable death in modern military conflicts. Resuscitative endovascular occlusion of the aorta (REBOA) has demonstrated potential as an effective adjunct to the treatment of NCTH in the civilian early hospital and even pre-hospital settings - but the application of this technology for military pre-hospital use has not been well described. We aimed to assess the feasibility of both field and en route pre-hospital REBOA in the military exercise setting simulating a modern armed conflict.

    METHODS: Two adult male Sus Scrofa underwent simulated junctional combat injury in the context of a planned military training exercise. Both underwent zone I REBOA in conjunction with standard tactical combat casualty care (TCCC) interventions - one during point of injury care and the other during en route flight care. Animals were sequentially evacuated to two separate Forward Surgical Teams (FSTs) by rotary wing platform where the balloon position was confirmed by chest X-Ray. Animals then underwent different damage control thoracic and abdominal procedures before euthanasia.

    RESULTS: The first swine underwent immediate successful REBOA at the point of injury 7:30 minutes after the injury. It required 6 minutes total from initiation of procedure to effective aortic occlusion. Total occlusion time was 60 minutes. In the second animal, the REBOA placement procedure was initiated immediately after take-off (17:40 minutes after the injury). Although the movements and vibration of flight were not significant impediments, we only succeeded to put a 6-Fr sheath into a femoral artery during the 14 minutes flight due to lighting and visualization challenges. After the sheath had been upsized in the FST, the REBOA catheter was primarily placed in zone I followed by its replacement to zone III. Both animals survived to study completion and the termination of training. No complications were observed in either animal.

    CONCLUSION: Our study demonstrates the potential feasibility of REBOA for use during tactical field and en route (flight) care of combat casualties. Further study is needed to determine the optimal training and utilization protocols required to facilitate the effective incorporation of REBOA into military pre-hospital care capabilities.

  • 36.
    Sadeghi, Mitra
    et al.
    Örebro University, School of Medical Sciences. Department of Vascular Surgery, Västmanlands Hospital, Västerås, Sweden.
    Hörer, Tal M.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery.
    Forsman, Daniel
    Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Dogan, Emanuel M.
    Örebro University, School of Medical Sciences. Orebro Univ, Fac Med & Hlth, Dept Cardiothorac & Vasc Surg, Orebro, Sweden..
    Jansson, Kjell
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Kindler, Csaba
    Department of Pathology, Västmanlands Hospital Västerås, Västerås, Sweden.
    Skoog, Per
    Department of Vascular Surgery and Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital and Academy, Gothenburg, Sweden.
    Nilsson, Kristofer F.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery.
    Blood pressure targeting by partial REBOA is possible in severe hemorrhagic shock in pigs and produces less circulatory, metabolic and inflammatory sequelae than total REBOA2018In: Injury, ISSN 0020-1383, E-ISSN 1879-0267, Vol. 49, no 12, p. 2132-2141Article in journal (Refereed)
    Abstract [en]

    Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an effective adjunct in exsanguinating torso hemorrhage, but causes ischemic injury to distal organs. The aim was to investigate whether blood pressure targeting by partial REBOA (pREBOA) is possible in porcine severe hemorrhagic shock and to compare pREBOA and total REBOA (tREBOA) regarding hemodynamic, metabolic and inflammatory effects.

    Methods: Eighteen anesthetized pigs were exposed to induced controlled hemorrhage to a systolic blood pressure (SBP) of 50 mmHg and randomized into three groups of thoracic REBOA: 30 min of pREBOA (target SBP 80-100 mmHg), tREBOA, and control. They were then resuscitated by autologous transfusion and monitored for 3 h. Hemodynamics, blood gases, mesenteric blood flow, intraperitoneal metabolites, organ damage markers, histopathology from the small bowel, and inflammatory markers were analyzed.

    Results: Severe hemorrhagic shock was induced in all groups. In pREBOA the targeted blood pressure was reached. The mesenteric blood flow was sustained in pREBOA, while it was completely obstructed in tREBOA. Arterial pH was lower, and lactate and troponin levels were significantly higher in tREBOA than in pREBOA and controls during the reperfusion period. Intraperitoneal metabolites, the cytokine response and histological analyses from the small bowel were most affected in the tREBOA compared to the pREBOA and control groups.

    Conclusion: Partial REBOA allows blood pressure titration while maintaining perfusion to distal organs, and reduces the ischemic burden in a state of severe hemorrhagic shock. Partial REBOA may lower the risks of post-resuscitation metabolic and inflammatory impacts, and organ dysfunction. (C) 2018 Published by Elsevier Ltd.

  • 37.
    Sadeghi, Mitra
    et al.
    Örebro University, School of Medical Sciences. Västmanlands Hospital, Västerås, Sweden; Department of Vascular Surgery, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Nilsson, Kristofer F.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery.
    Larzon, Thomas
    Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Pirouzram, Artai
    Örebro University, School of Medical Sciences. Department of Cardiothoracic and Vascular Surgery.
    Toivola, Asko
    Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Skoog, Per
    Department of Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Idoguchi, Koji
    Senshu Trauma and Critical Care Center, Rinku General Medical Center, Izumisano, Japan.
    Kon, Yuri
    Emergency and Critical Care Center, Hachinohe City Hospital, Hachinohe, Japan.
    Ishida, Tokiya
    Emergency and Critical Care Center, Ohta Nishinouchi Hospital, Koriyama, Japan.
    Matsumara, Y.
    Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan; R Adams Cowley Shock Trauma Center, University of Maryland, College Park MD, United States.
    Matsumoto, Junichi
    Department of Emergency and Critical Care Medicine, St Marianna University School of Medicine, Kawasaki, Japan.
    Reva, Viktor A.
    Department of War Surgery, Kirov Military Medical Academy, Saint Petersburg, Russian Federation; Dzhanelidze Research Institute of Emergency Medicine, Saint Petersburg, Russian Federation.
    Maszkowski, M.
    Västmanlands Hospital, Västerås, Sweden; Department of Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Bersztel, Adam
    Västmanlands Hospital, Västerås, Sweden; Department of Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Caragounis, Eva Corina
    Department of Surgery, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden.
    Falkenberg, Mårten P.
    Department of Radiology, Örebro University Hospital, Örebro, Sweden.
    Handolin, Lauri E.
    Department of Orthopedics and Traumatology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.
    Kessel, Boris J.
    Department of Surgery, Hillel Yaffe Medical Centre, Hadera, Israel.
    Hebron, Dan
    Department of Surgery, Hillel Yaffe Medical Centre, Hadera, Israel.
    Coccolini, Federico
    Department of Surgery, Papa Giovanni XXIII Hospital, Bergamo, Italy.
    Ansaloni, Luca
    Department of Surgery, Papa Giovanni XXIII Hospital, Bergamo, Italy.
    Madurska, Marta J.
    Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, United Kingdom.
    Morrison, Jonathan James
    Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, United Kingdom.
    Hörer, Tal Martin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery.
    The use of aortic balloon occlusion in traumatic shock: first report from the ABO trauma registry2018In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 44, no 4, p. 491-501Article in journal (Refereed)
    Abstract [en]

    PURPOSE: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a technique for temporary stabilization of patients with non-compressible torso hemorrhage. This technique has been increasingly used worldwide during the past decade. Despite the good outcomes of translational studies, clinical studies are divided. The aim of this multicenter-international study was to capture REBOA-specific data and outcomes.

    METHODS: REBOA practicing centers were invited to join this online register, which was established in September 2014. REBOA cases were reported, both retrospective and prospective. Demographics, injury patterns, hemodynamic variables, REBOA-specific data, complications and 30-days mortality were reported.

    RESULTS: Ninety-six cases from 6 different countries were reported between 2011 and 2016. Mean age was 52 ± 22 years and 88% of the cases were blunt trauma with a median injury severity score (ISS) of 41 (IQR 29-50). In the majority of the cases, Zone I REBOA was used. Median systolic blood pressure before balloon inflation was 60 mmHg (IQR 40-80), which increased to 100 mmHg (IQR 80-128) after inflation. Continuous occlusion was applied in 52% of the patients, and 48% received non-continuous occlusion. Occlusion time longer than 60 min was reported as 38 and 14% in the non-continuous and continuous groups, respectively. Complications, such as extremity compartment syndrome (n = 3), were only noted in the continuous occlusion group. The 30-day mortality for non-continuous REBOA was 48%, and 64% for continuous occlusion.

    CONCLUSIONS: This observational multicenter study presents results regarding continuous and non-continuous REBOA with favorable outcomes. However, further prospective studies are needed to be able to draw conclusions on morbidity and mortality.

  • 38.
    Seilitz, Jenny
    et al.
    Örebro University, School of Medical Sciences. Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University Hospital, Örebro, Sweden.
    Hörer, Tal M.
    Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University Hospital, Örebro, Sweden.
    Skoog, Per
    Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University Hospital, Örebro, Sweden; Department of Vascular Surgery and Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital and Academy, Gothenburg, Sweden.
    Sadeghi, Mitra
    Örebro University, School of Medical Sciences. Department of Vascular Surgery, Västmanland's Hospital, Västerås, Sweden .
    Jansson, Kjell
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Axelsson, Birger
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery.
    Nilsson, Kristofer F.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery.
    Splanchnic Circulation and Intraabdominal Metabolism in Two Porcine Models of Low Cardiac Output2019In: Journal of Cardiovascular Translational Research, ISSN 1937-5387, E-ISSN 1937-5395, Vol. 12, no 3, p. 240-249Article in journal (Refereed)
    Abstract [en]

    The impact of acute cardiac dysfunction on the gastrointestinal tract was investigated in anesthetized and instrumented pigs by sequential reductions of cardiac output (CO). Using a cardiac tamponade (n = 6) or partial inferior caval vein balloon inflation (n = 6), CO was controllably reduced for 1 h each to 75% (CO75%), 50% (CO50%), and 35% (CO35%) of the baseline value. Cardiac output in controls (n = 6) was not manipulated and maintained. Mean arterial pressure, superior mesenteric arterial blood flow, and intestinal mucosal perfusion started to decrease at CO50% in the intervention groups. The decrease in superior mesenteric arterial blood flow was non-linear and exaggerated at CO35%. Systemic, venous mesenteric, and intraperitoneal lactate concentrations increased in the intervention groups from CO50%. Global and mesenteric oxygen uptake decreased at CO35%. In conclusion, gastrointestinal metabolism became increasingly anaerobic when CO was reduced by 50%. Anaerobic gastrointestinal metabolism in low CO can be detected using intraperitoneal microdialysis.

  • 39.
    Skoog, P.
    et al.
    Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Hörer, Tal M.
    Örebro University Hospital. Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Nilsson, Kristofer F.
    Örebro University Hospital. Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Norgren, L.
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Larzon, Thomas
    Örebro University Hospital. Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Jansson, Kjell
    Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Abdominal Hypertension and Decompression: The Effect on Peritoneal Metabolism in an Experimental Porcine Study2014In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 47, no 4, p. 402-410Article in journal (Refereed)
    Abstract [en]

    Objective: The aim of this study was to investigate the abdominal metabolic response and circulatory changes after decompression of intra-abdominal hypertension in a porcine model.

    Methods: This was an experimental study with controls. Three-month-old domestic pigs of both sexes were anesthetized and ventilated. Nine animals had a pneumoperitoneum-induced IAH of 30 mmHg for 6 hours. Twelve animals had the same IAN for 4 hours followed by decompression, and were monitored for another 2 hours. Hemodynamics, including laser Doppler-measured mucosal blood flow, urine output, and arterial blood samples were analyzed every hour along with glucose, glycerol, lactate and pyruvate concentrations, and lactate-pyruvate (l/p) ratio, measured by microdialysis.

    Results: Laser Doppler-measured mucosal blood flow and urine output decreased with the induction of IAH and showed a statistically significant resolution after decompression. Both groups developed distinct metabolic changes intraperitoneally on induction of IAH, including an increased l/p ratio, as signs of organ hypoperfusion. In the decompression group the intraperitoneal l/p ratio normalized during the second decompression hour, indicating partially restored perfusion.

    Conclusion: Decompression after 4 hours of IAH results in an improved intestinal blood flow and a normalized intraperitoneal lip ratio.

  • 40.
    Skoog, Per
    et al.
    Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Hörer, Tal M.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Nilsson, Kristofer. F.
    Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Norgren, Lars
    Dept Surg, Orebro Univ Hosp, Orebro, Sweden.
    Larzon, Thomas
    Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Jansson, Kjell
    Dept Surg, Orebro Univ Hosp, Orebro, Sweden.
    Abdominal Hypertension and Decompression: The Effect on Peritoneal Metabolism in an Experimental Porcine Study2014Manuscript (preprint) (Other academic)
    Abstract [en]

    Objective: This study aims to investigate the abdominal metabolic response and circulatory changes after decompression of intra-abdominal hypertension in a porcine model. Design: Prospective study with controls. Setting: University hospital research laboratory.

    Subjects: Three-months old domestic pigs of both sexes. Interventions: The animals were anesthetised and ventilated. Nine animals had a pneumoperitoneum-induced intra-abdominal hypertension of 30 mmHg for six hours. Twelve animals had corresponding intra-abdominal hypertension for four hours followed by decompression and were monitored for another two hours.

    Measurements and Main Results: Hemodynamics, urine output and arterial blood samples were analysed. Laserdoppler measured mucosal blood flow and urine output decreased with pressure induction and showed a statistically significant restitution after decompression. Glucose, glycerol, lactate and pyruvate concentrations and lactate-pyruvate (l/p) ratio were measured by microdialysis. Both groups developed distinct metabolic changes intraperitoneally at pressure induction including an increased l/p ratio as signs of organ hypoperfusion. In the decompression group the intraperitoneal l/p ratio normalised during the second decompression hour, indicating partially restored perfusion.

    Conclusions: Decompression after four hours of intra-abdominal hypertension results in restoration of intestinal blood flow and normalised intraperitoneal metabolism.

  • 41.
    Skoog, Per
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Hörer, Tal M.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Nilsson, Kristofer F.
    Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Ågren, Göran
    Department of Surgery Örebro University Hospital, Örebro, Sweden.
    Norgren, Lars
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Department of Surgery Örebro University Hospital, Örebro, Sweden.
    Janson, Kjell
    Department of Surgery Örebro University Hospital, Örebro, Sweden.
    Intra-abdominal hypertension: exploration of early changes in intra-abdominal metabolism in a porcine modelManuscript (preprint) (Other academic)
    Abstract [en]

    Objective: To investigate the early effects of intra-abdominal hypertension on intraabdominal metabolism and intestinal mucosal blood flow.

    Design: Prospective animal study.

    Setting: University hospital research laboratory.

    Subjects: Three-month old domestic pigs of both sexes.

    Interventions: The animals were anesthetized and ventilated. Fifteen animals were subjected to intra-abdominal hypertension of 30 mmHg for four hours by carbon dioxide insufflation. Seven animals served as controls.

    Measurements and Main Results: Hemodynamic data, arterial blood samples and urine output were analyzed. Intraluminal laserdoppler flowmetry measured intestinal mucosal blood flow. Glucose, glycerol, lactate and pyruvate concentrations and lactate-pyruvate (l/p) ratio were measured intraperitoneally and intramurally in the small intestine and rectum by microdialysis. Intra-abdominal hypertension lowered the abdominal perfusion pressure by 12- 18 mmHg, reduced the intestinal mucosal blood flow by 45-63% and decreased urine output by 50-80%. While controls remained stable, glycerol concentrations increased at all locations at elevated intra-abdominal pressure, .pyruvate concentrations decreased and the l/p ratio increased intraperitoneally and intramurally in the small intestine. Glucose and lactate concentrations at all locations were only slightly affected or unchanged in both groups.

    Conclusions: Intra-abdominal hypertension negatively influences intestinal blood flow and diuresis and causes early metabolic changes, indicating a discrete shift towards anaerobic metabolism. Metabolic changes, measured by intra-abdominal microdialysis, preferably by an intraperitoneal catheter, might be used as early markers of impaired visceral organ function in intra-abdominal hypertension and abdominal compartment syndrome.

  • 42.
    Skoog, Per
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Deparment of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Hörer, Tal M.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Deparment of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Region Örebro County, Örebro, Sweden.
    Ågren, Göran
    Deparment of Surgery, Örebro University Hospital, Örebro, Sweden.
    Jansson, Kjell
    Örebro University Hospital. Deparment of Surgery, Örebro University Hospital, Region Örebro County, Örebro, Sweden.
    Norgren, Lars
    Örebro University, School of Humanities, Education and Social Sciences. Deparment of Surgery, Örebro University Hospital, Örebro, Sweden.
    Intra-Abdominal Metabolism and Blood Flow During Abdominal Hypertension: A Porcine Pilot Study Under Intravenous Anaesthesia2013In: Archives Of Clinical Experimental Surgery, ISSN 2146-8133, Vol. 2, no 3, p. 176-185Article in journal (Refereed)
    Abstract [en]

    Objective: To study the splanchnic metabolism and intestinal circulation in a porcine model with increased abdominal pressure.

    Methods: In an experimental porcine study, performed under intravenous anaesthesia, five animals were subjected to gradually increasing intra-abdominal pressure (15 mmHg, 25 mmHg, and 35 mmHg) with pneumoperitoneum. Microdialysis and laser Doppler were the main outcome methods for monitoring the metabolic and circulatory changes.

    Results: During stable anaesthesia and gradually increasing intra-abdominal pressure obtained by CO2-pneumoperitoneum, blood flow (microcirculation) was deprived and moderate signs of impaired splanchnic metabolism were recorded.

    Conclusions: The model appears usable for studies of splanchnic metabolic consequences of intra-abdominal hypertension.

  • 43.
    Skoog, Per
    et al.
    Dept Cardiothorac & Vasc Surg, Örebro University Hospital, Örebro, Sweden.
    Hörer, Tal
    Örebro University Hospital. Dept Cardiothorac & Vasc Surg, Örebro University Hospital, Örebro, Sweden.
    Nilsson, Kristofer F.
    Örebro University Hospital. Dept Cardiothorac & Vasc Surg, Örebro University Hospital, Örebro, Sweden.
    Agren, Goran
    Dept Surg, Örebro University Hospital, Örebro, Sweden.
    Norgren, Lars
    Dept Surg, Örebro University Hospital, Örebro, Sweden.
    Jansson, Kjell
    Örebro University Hospital. Dept Surg, Örebro University Hospital, Örebro, Sweden.
    Intra-abdominal Hypertension: An Experimental Study of Early Effects on Intra-abdominal Metabolism2015In: Annals of Vascular Surgery, ISSN 0890-5096, E-ISSN 1615-5947, Vol. 29, no 1, p. 128-137Article in journal (Refereed)
    Abstract [en]

    Background: The main aim of this experimental study was to investigate the early effects of intra-abdominal hypertension (IAH) on intra-abdominal metabolism and intestinal mucosal blood flow to evaluate whether metabolites can serve as markers for organ dysfunction during IAH. Methods: A swine model was used, and the animals were anesthetized and ventilated. Fifteen animals were subjected to IAH of 30 mm Hg for 4 hr by carbon dioxide insufflation. Seven animals served as controls. Hemodynamic data, arterial blood samples, and urine output were analyzed. Intraluminal laser Doppler flowmetry measured intestinal mucosal blood flow. Glucose, glycerol, lactate, and pyruvate concentrations and lactate-to-pyruvate (l/p) ratio were measured intraperitoneally and intramurally in the small intestine and rectum using microdialysis. Results: IAH lowered the abdominal perfusion pressure by 12-18 mm Hg, reduced the intestinal mucosal blood flow by 45-63%, and decreased urine output by 50-80%. In the intervention group, glycerol concentrations increased at all locations, pyruvate concentrations decreased, and the l/p ratio increased intraperitoneally and intramurally in the small intestine. Control animals remained metabolically stable. Glucose and lactate concentrations were only slightly affected or unchanged in both the groups. Conclusions: IAH reduces intestinal blood flow and urinary output and causes early metabolic changes, indicating a discrete shift toward anaerobic metabolism. Intraperitoneal microdialysis may be useful in the early detection of impaired organ dysfunction with metabolic consequences in IAH and abdominal compartment syndrome.

  • 44.
    van der Burg, B. L. S. Borger
    et al.
    Department of Surgery, Alrijne Hospital, Leiderdorp, the Netherlands.
    Kessel, B.
    Department of Trauma, Hillel Yaffe Medical Center, Hadera, Israel.
    DuBose, J. J.
    R Adam Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, USA.
    Hörer, Tal M.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery.
    Hoencamp, R.
    Department of Surgery, Alrijne Hospital, Leiderdorp, the Netherlands; Defense Healthcare Organization, Ministry of Defense, Utrecht, the Netherlands; Leiden University Medical Centre, Leiden, the Netherlands.
    Consensus on resuscitative endovascular balloon occlusion of the Aorta: A first consensus paper using a Delphi method2019In: Injury, ISSN 0020-1383, E-ISSN 1879-0267, Vol. 50, no 6, p. 1186-1191Article in journal (Refereed)
    Abstract [en]

    Background: To further strengthen the evidence base on the use of Resuscitative Endovascular Balloon occlusion of the Aorta (REBOA) we performed a Delphi consensus. The aim of this paper is to establish consensus on the indications and contraindications for the use of REBOA in trauma and non-trauma patients based on the existing evidence and expertise.

    Study Design: A literature review facilitated the design of a three-round Delphi questionnaire. Delphi panelists were identified by the investigators. Consensus was reached when at least 70% of the panelists responded to the survey and more than 70% of respondents reached agreement or disagreement.

    Results: Panel members reached consensus on potential indications, contra-indications and settings for use of REBOA (excluding the pre hospital environment), physiological parameters for patient selection and indications for early femoral access. Panel members failed to reach consensus on the use of REBOA in patients in extremis (no pulse, no blood pressure) and the use of REBOA in patients with two major bleeding sites.

    Conclusions: Consensus was reached on indications, contra indications, physiological parameters for patient selection for REBOA and early femoral access. The panel did not reach consensus on the use of REBOA in patients in pre-hospital settings, patients in extremis (no pulse, no blood pressure) and in patients with 2 or more major bleeding sites. Further research should focus on the indications of REBOA in pre hospital settings, patients in near cardiac arrest and REBOA inflation times.

  • 45.
    van der Burg, Boudewijn L. S. Borger
    et al.
    Department of Surgery, Alrijne Hospital, Leiderdorp, The Netherlands.
    Hörer, Tal M.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery.
    Eefting, D.
    Department of Surgery, Haaglanden Medical Centre, The Hague, The Netherlands; Leiden University Medical Centre, Leiden, The Netherlands.
    van Dongen, T. T. C. F.
    Department of Surgery, Alrijne Hospital, Leiderdorp, The Netherlands; Defense Healthcare Organization, Ministry of Defense, Utrecht, The Netherlands.
    Hamming, J. F.
    Leiden University Medical Centre, Leiden, The Netherlands.
    DuBose, J. J.
    R Adam Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, USA.
    Bowyer, M.
    Department of Surgery, Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center, Bethesda, USA.
    Hoencamp, R.
    Department of Surgery, Alrijne Hospital, Leiderdorp, The Netherlands; Leiden University Medical Centre, Leiden, The Netherlands; Defense Healthcare Organization, Ministry of Defense, Utrecht, The Netherlands.
    Vascular access training for REBOA placement: a feasibility study in a live tissue-simulator hybrid porcine model2019In: Journal of the Royal Army Medical Corps, ISSN 0035-8665, E-ISSN 2052-0468, Vol. 165, no 3, p. 147-151Article in journal (Refereed)
    Abstract [en]

    Background: The use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in patients with severe haemorrhagic shock is increasing. Obtaining vascular access is a necessary prerequisite for REBOA placement in these situations.

    Methods: During the EVTM workshop (September 2017, Orebro, Sweden), 21 individuals participated in this study, 16 participants and five instructors. A formalised curriculum was constructed including basic anatomy of the femoral region and basic training in access materials for REBOA placement in zone 1. Key skills: (1) preparation of endovascular toolkit, (2) achieving vascular access in the model and (3) bleeding control with REBOA. Scoring ranged from 0 to 5 for non-anatomical skills. Identification of anatomical structures was either sufficient (score=1) or insufficient (score=0). Five consultants performed a second identical procedure as a post test.

    Results: Consultants had significantly better overall technical skills in comparison with residents (p=0.005), while understanding of surgical anatomy showed no difference. Procedure times differed significantly (p<0.01), with residents having a median procedure time of 3 min and 24 s, consultants 2:33 and instructors 1:09.

    Conclusion: This comprehensive training model using a live tissue-simulator hybrid porcine model can be used for femoral access and REBOA placement training in medical personnel with different prior training levels. Higher levels of training are associated with faster procedure times. Further research in open and percutaneous access training is necessary to simulate real-life situations. This training method can be used in a multistep training programme, in combination with realistic moulage and perfused cadaver models.

  • 46.
    Wikström, Maria
    et al.
    Örebro University, School of Medical Sciences. Department of Surgery.
    Krantz, Johannes
    Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Hörer, Tal M.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery.
    Nilsson, Kristofer F.
    Örebro University, School of Medical Sciences. Department of Cardiothoracic and Vascular Surgery.
    Resuscitative endovascular balloon occlusion of the inferior vena cava is made hemodynamically possible by concomitant endovascular balloon occlusion of the aorta: a porcine study2019In: Journal of Trauma and Acute Care Surgery, ISSN 2163-0755, E-ISSN 2163-0763Article in journal (Refereed)
    Abstract [en]

    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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