Citation Information :
Rezende-Neto JB, Al-Kefeiri G, Strickland M, Prabhudesai V, Rizoli SB, Rotstein O. Three Sequential Balloon Catheters for Vascular Exclusion of the Liver and Aortic Control (one REBOA and two REBOVCs): A Hemorrhage Control Strategy in Suprahepatic Vena Cava Injuries. Panam J Trauma Crit Care Emerg Surg 2018; 7 (2):114-122.
Introduction: We hypothesized that sequential deployment of a resuscitative endovascular balloon occlusion in the aorta REBOA, Pringle maneuver, and two Resuscitative balloon occlusion of the inferior vena cava (REBOVC) would provide hepatic vascular exclusion and hemorrhage control.
Materials and Methods: Hemodynamic monitoring and splenectomy were performed in seven swine. One REBOA device and two REBOVCs were positioned under fluoroscopy in the thoracic aorta, suprahepatic and infrahepatic inferior vena cava (IVC); 35% of the total blood volume was removed. Hepatic vascular exclusion was performed for 15 minutes during shock through sequential deployment of the REBOA in the thoracic aorta, Pringle maneuver, the REBOVC in the infrahepatic IVC, and the REBOVC in the suprahepatic IVC. Hepatic vascular exclusion was reversed in the following sequence: Deflation of the REBOVC in the suprahepatic IVC, followed by the infrahepatic IVC REBOVC, release of the Pringle, and deflation of the REBOA. Subsequently, a 1.5 cm injury was performed in the suprahepatic IVC. Immediately thereafter, hepatic vascular exclusion was performed for 15 minutes followed by reversal of exclusion; suture repair of the injury was performed in two animals.
Results: Hepatic vascular exclusion effectively stopped the bleeding from the suprahepatic IVC injury, significantly increased MAP. The procedure did not aggravate shock assessed by pH, lactate and base excess, and hemodynamics. Reversal of the exclusion led to immediate exsanguination from the suprahepatic IVC injury except after suture repair of the injury.
Conclusion: Sequential deployment of REBOA, Pringle maneuver and two REBOVCs provided vascular exclusion of the liver and effectively temporized the hemorrhage from the suprahepatic IVC.
Clinical Significance: Vascular exclusion of the liver during operative repair is difficult in the setting of massive bleeding. The procedure described herein is less invasive and effectively controls the bleeding.
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