Teeter William A, Matsumoto Junichi, Idoguchi Koji, Kon Yuri, Orita Tomohiko, Funabiki Tomohiro, Brenner Megan L, Matsumura Yosuke
From the R Adams Cowley Shock Trauma Center (W.A.T., M.L.B., Y.M.), University of Maryland, Baltimore, Maryland; Department of Emergency and Critical Care Medicine (J.M.), St. Marianna University School of Medicine, Kawasaki, Japan; Senshu Trauma & Critical Care Center (K.I.), Rinku General Medical Center, Osaka, Japan; Division of Radiology, Emergency and Critical Care Center (Y.K.), Hachinohe City Hospital, Hachinohe, Japan; Emergency and Critical Care Center (T.O., T.F.), Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan; and Department of Emergency and Critical Care Medicine (Y.M.), Chiba University Graduate School of Medicine, Chiba, Japan.
J Trauma Acute Care Surg. 2016 Dec;81(6):1039-1045. doi: 10.1097/TA.0000000000001143.
Large arterial sheaths currently used for resuscitative endovascular balloon occlusion of the aorta (REBOA) may be associated with severe complications. Smaller diameter catheters compatible with 7Fr sheaths may improve the safety profile.
A retrospective review of patients receiving REBOA through a 7Fr sheath for refractory traumatic hemorrhagic shock was performed from January 2014 to June 2015 at five tertiary-care hospitals in Japan. Demographics were collected including method of arterial access; outcomes included mortality and REBOA-related access complications.
Thirty-three patients underwent REBOA at Zone 1 (level of the diaphragm). Most patients were male (70%), with a mean age (+SD) 50 ± 18 years, mean BMI 23 ± 4, and a median [IQR] ISS of 38 [34, 52]. Ninety-four percent of patients presented after sustaining injuries from blunt mechanisms. Twenty-four percent underwent CPR before arrival, and an additional 15% received CPR after admission. Percutaneous arterial access without ultrasound or fluoroscopy was achieved in all patients. Systolic blood pressure increased significantly following balloon occlusion (mean 62 ± 36 to 106 ± 40 mm Hg, p < 0.001). Median total duration of complete initial occlusion was 26 [range 10-35] minutes. Sixteen patients (49%) survived beyond 24 hours, and 14 patients (42%) survived beyond 30 days. Twenty-four-hour and 30-day survival were 48% and 42%, respectively. Of the patients surviving 24 hours (n = 16), median duration of sheath placement was 28 [range 18-45] hours with all removed using manual pressure to achieve hemostasis. Of 33 REBOAs, 20 were performed by Emergency Medicine practitioners, 10 by Emergency Medicine practitioners with endovascular training, and 3 by Interventional Radiologists. No complication related to sheath insertion or removal was identified during the follow-up period, including dissection, pseudoaneurysm, retroperitoneal hematoma, leg ischemia, or distal embolism.
7Fr REBOA catheters can significantly elevate systolic blood pressure with no access-related complications. Our results suggest that a 7Fr introducer device for REBOA may be a safe and effective alternative to large-bore sheaths, and may remain in place during the post-procedure resuscitative phase without sequelae.
Therapeutic/care management, level V.
目前用于主动脉复苏性血管内球囊阻断术（REBOA）的大型动脉鞘可能与严重并发症相关。与7Fr鞘兼容的较小直径导管可能会改善安全性。
对2014年1月至2015年6月期间在日本五家三级医疗医院通过7Fr鞘接受REBOA治疗难治性创伤性失血性休克的患者进行回顾性研究。收集人口统计学数据，包括动脉入路方法；结果包括死亡率和与REBOA相关的入路并发症。
33例患者在1区（膈肌水平）接受了REBOA治疗。大多数患者为男性（70%），平均年龄（+标准差）50±18岁，平均BMI 23±4，损伤严重度评分（ISS）中位数[四分位间距]为38[34,52]。94%的患者因钝性机制受伤后就诊。24%的患者在到达前接受了心肺复苏（CPR），另有15%的患者在入院后接受了CPR。所有患者均在无超声或透视引导下经皮实现动脉入路。球囊阻断后收缩压显著升高（平均从62±36 mmHg升至106±40 mmHg，p<0.001）。初始完全阻断的总中位持续时间为26[范围10 - 35]分钟。16例患者（49%）存活超过24小时，14例患者（42%）存活超过30天。24小时和30天生存率分别为48%和42%。在存活24小时的患者（n = 16）中，鞘管放置的中位持续时间为28[范围18 - 45]小时，所有鞘管均通过手动压迫移除以实现止血。在33例REBOA治疗中，20例由急诊科医生实施，10例由接受血管内培训的急诊科医生实施，3例由介入放射科医生实施。随访期间未发现与鞘管插入或移除相关的并发症，包括夹层、假性动脉瘤、腹膜后血肿、下肢缺血或远端栓塞。
7Fr REBOA导管可显著提高收缩压，且无入路相关并发症。我们的结果表明，用于REBOA的7Fr导入装置可能是大口径鞘管的一种安全有效的替代方案，并且在术后复苏阶段可留置而无后遗症。
治疗/护理管理，V级。
