Live Webinar 2 REBOA Laura Moore MD FACS and Elizabeth Benjamin MD PhD FACS Brought to you by the EAST Online Education Section Generously sponsored by an unrestricted educational grant ID: 1010162
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1. EAST Master Class SeriesLive Webinar #2: REBOALaura Moore, MD, FACSandElizabeth Benjamin, MD, PhD, FACSBrought to you by the EAST Online Education Section
2. Generously sponsored by an unrestricted educational grant
3. Start Recording
4. REBOATechniques, Indications, Pitfalls and Incorporating it in to your Trauma ProgramElizabeth Benjamin MD, PhD, FACSAssistant Professor of Clinical SurgeryLAC+USC Medical CenterLaura J. Moore, MD, FACSAssociate Professor of SurgeryChief of Surgical Critical CareMedical Director, Shock Trauma ICU
5. IntroductionHemorrhage remains a leading cause of death in civilian and wartime traumaHemorrhage occurs in two broad categories:Compressible Non compressibleVascular disruption with concomitant hemorrhage is the leading cause of potentially preventable death in trauma patients
6. OBJECTIVESOverview of REBOAClinical indicationsZones of OcclusionTechnical Considerations14 Fr and 7 Fr systemsPotential PitfallsEducational opportunitiesHow to implement REBOA at your center
7. Statement of the ProblemHemodynamically unstable trauma patients with hemorrhage from the abdomen and pelvis have a high mortality rates. Failure to rapidly treat hemorrhage results in cardiovascular collapse and death.
8. Options for Aortic Occlusion1. Resuscitative thoracotomy with application of aortic cross clamp.
9. Options for Aortic OcclusionResuscitative thoracotomy with application of aortic cross clamp.Insertion of catheter into the aorta with inflation of a balloon to occlude lumen of the aorta.
10. What is REBOA? Resuscitative Endovascular BalloonOcclusion of theAorta
11. Similarities and DifferencesResuscitative ThoracotomyREBOAMaximally Invasive Minimally InvasiveHigh potential for blood exposure via accidental puncture to healthcare teamLower risk for blood exposure via accidental puncture to healthcare teamAortic Occlusion via Cross clampingAortic Occlusion via Endovascular BalloonSupports myocardial and cerebral perfusionSupports myocardial and cerebral perfusionAllows access to other mediastinal structures (pericardium, heart, hilum)Allows for selective occlusion (Zone I vs. Zone III)
12. How1. Arterial accesss2. Balloon selection & positioning3. Balloon inflation4. Balloon deflation5. Sheath removal
13. Aortic Occlusion ZonesZone I – Descending thoracic aorta from origin of left subclavian to celiacZones II – Paravisceral aorta between celiac and lowest renal arteryZone III – Infrarenal abdominal aorta to bifurcation
14. Aortic Occlusion ZonesSelect zone of occlusion based upon injury patternZones I and III preferredAvoid occlusion in Zone IIConfirm zone of occlusion on plain x ray or fluoroscopy
15. REBOA Algorithm
16. REBOA - Patient SelectionRefractory hemorrhagic shock due to non-compressible truncal hemorrhagePenetrating abdominal traumaBlunt trauma
17. REBOA - Patient SelectionRefractory hemorrhagic shock due to non-compressible truncal hemorrhagePenetrating abdominal traumaBlunt traumaResuscitative thoracotomy should still remain standard for patients with cardiovascular collapse from intra-thoracic hemorrhage
18. Case Example24 year old male sustained a gunshot wound to the right upper quadrant. On arrival in the ER he was in extremis with a systolic blood pressure of 50 mm Hg and a heart rate of 135. Two large bore peripheral IVs were in place. Abdominal FAST exam was positive. Massive transfusion protocol was initiated. The OR was notified.
19. KUB in ER
20. Case continuedThe patient remained hypotensive with a systolic blood pressure in the 50’s. Given his positive abdominal FAST the decision was made to place a REBOA in Zone 1. The right common femoral artery was accessed percutaneously and a 14 French sheath was placed. The CODA catheter was inserted and the balloon was inflated in Zone 1.
21. Zone 1 REBOA
22. Operative DetailsMassive hemoperitoneumGrade V right renal injury with active arterial hemorrhage from the hilum -> right nephrectomy performedBullet lodged in the vertebral body with ongoing hemorrhage -> patient underwent angioembolization of lumbar arteryRight groin cutdown performed, sheath removed, common femoral artery repaired
23. Hospital CourseAdmitted to STICU post opTaken back in 24 hours for abdominal closureDischarged to rehab facility on post operative day 12
24. Zone 3 REBOA
25. REBOA Placement Technique 14F System7F System
26. REBOA TechniqueFemoral Arterial Access7F Sheath PlacementWire exchangeUpsize sheath 14F14F System7F SystemFloat REBOAWireless
27. 14F SystemArterial AccessSheath IntroducerMeasure CatheterStiff WireUpsize SheathREBOA InsertionInflate Balloon
28. 14F SystemArterial AccessSheath IntroducerMeasure CatheterStiff WireUpsize SheathREBOA InsertionInflate Balloon
29. 14F SystemArterial AccessSheath IntroducerMeasure CatheterStiff WireUpsize SheathREBOA InsertionInflate Balloon
30. 14F SystemArterial AccessSheath IntroducerMeasure CatheterStiff WireUpsize SheathREBOA InsertionInflate Balloon
31. 14F SystemArterial AccessSheath IntroducerMeasure CatheterStiff WireUpsize SheathREBOA InsertionInflate Balloon
32. 14F SystemArterial AccessSheath IntroducerMeasure CatheterStiff WireUpsize SheathREBOA InsertionInflate Balloon
33. 14F SystemArterial AccessSheath IntroducerMeasure CatheterStiff WireUpsize SheathREBOA InsertionInflate Balloon
34. 14F SystemArterial AccessSheath IntroducerMeasure CatheterStiff WireUpsize SheathREBOA InsertionInflate Balloon
35. 7F SystemArterial Access7F Sheath PlacementWireless Catheter Insertion
36. 7F SystemArterial AccessSheath IntroducerMeasure CatheterStiff WireUpsize SheathREBOA InsertionInflate Balloon
37. 7F SystemArterial AccessSheath IntroducerMeasure CatheterStiff WireUpsize SheathREBOA InsertionInflate Balloon
38. 7F SystemArterial AccessSheath IntroducerMeasure CatheterStiff WireUpsize SheathREBOA InsertionInflate Balloon
39. Catheter MeasurementExternal landmarksX-ray verificationFluoroscopy
40. Catheter MeasurementExternal landmarksX-ray verificationFluoroscopyCadaver based studyMid-Sternum as external landmark100% Balloon deployed in landing zone (I)
41. LAC+USCREBOA Patient SelectionRefractory hemorrhagic shockFailed aggressive ED resuscitationAnticipated operative interventionAnticipated occlusion time <30minLiberal thoracotomy for cardiac arrest
42. REBOA Patient SelectionSignificant Intra-Abdominal Injury Burden
43. Cardiac ArrestExtremity TraumaAbdominal TraumaThoracic TraumaThoracotomyThoracotomyTourniquetREBOAOngoing Resuscitation
44. Cardiac ArrestExtremity TraumaAbdominal TraumaThoracic TraumaThoracotomyThoracotomyTourniquetREBOAHypotension refractory to resuscitationTemporary maneuverImminent operative interventionDelay hypovolemic cardiac arrestOngoing Resuscitation
45. Pelvic BleedingCandidate for Zone 3 Occlusion
46. Severe Pelvic Fracture (PXR)Hypotension+/- REBOAOperating RoomInterventional RadiologyRefractory HypotensionVolume ResponsiveResuscitation
47. REBOA Indication SummaryHemodynamic InstabilityAbdominal or Pelvic TraumaBridge to operative interventionNot used in cardiac arrest
48. REBOA Program: Key ElementsIdentify hospital resourcesInterventions/ComplicationsClear understanding of patient selectionSurgeon drivenTraining programInitial trainingSkill maintenancePatient Safety/Quality Improvement
49. REBOA TrainingCentralized TrainingStandardized approachCertificate upon completionHospital credentialingInternal Institution-Specific TrainingTraining tailored to specific needs of participants and hospital resourcesAvailability of refresher training
50. REBOA TrainingLAC+USCDidactic SessionsLiterature reviewProcedure indicationsPotential pitfallsCatheter System FamiliarityPerfused Cadaver SessionsCase Analysis
51. REBOA TrainingLAC+USC FTDLArterial and Venous PerfusionPerfusion Pump and Drainage
52. CODA Placement: 14F catheter
53. ER REBOA: 7 Fr Catheter
54. Zone 3 Positioning
55. Distal Aortic Disruption
56. Hemodynamic Response
57. Potential PitfallsCatheter PlacementPatient selectionNo benefit to patientDelay in treatmentZone 2 inflationIntestinal ischemiaVascular injuryArterial dissection/transectionThrombosis
58. Potential PitfallsCatheter RemovalHematomaComplicated arterial repairArterial dissection or thrombosisEmbolic eventLimb loss
59. Complications: Sheath Removal
60. Series of 24 REBOA cases from Japan (single center, over 6 years)Reported 3 lower extremity amputations from REBOA insertion10 French Sheath usedProcedure performed by ER doctors or SurgeonsSHOULD WE ABANDON REBOA???
61. Presented at 2016 MHSRSPurpose: Evaluate vascular related complications related to REBOA insertion at the Texas Trauma InstituteMethods: Retrospective review Operative details, outcomes*14 Fr Sheath & CODA balloon used in all cases
62. RESULTSTotal number of patients33Median Age47 (IQR 26.5-62.5)% male79% blunt mechanism88% percutaneous access of CFA55
63. VASCULAR COMPLICATIONSNo amputations attributed to REBOA21 of 33 patients survived to sheath removal13 (62%) underwent primary repair of CFA8 patients required additional vascular interventions3 thrombectomy alone2 thrombectomy + repair of dissection flaps + patch angioplasty1 thrombectomy + patch angioplasty1 thrombectomy + interposition graft + prophylactic fasciotomy1 thrombectomy + repair of dissection flap
64. Basic Endovascular Skills for Trauma
65. BEST CourseCurrently offered in Baltimore and HoustonACS verified courseFor more information about BEST contact:Baltimore: BEST@umm.eduHouston: laura.j.moore@uth.tmc.edu
66. Questions?laura.j.moore@uth.tmc.eduElizabeth.Benjamin@med.usc.edu
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