在失血性休克的大型动物模型中，主动脉完全复苏性血管内球囊阻断后进行渐进性球囊放气会导致血流急剧变化和快速再灌注。
Incremental balloon deflation following complete resuscitative endovascular balloon occlusion of the aorta results in steep inflection of flow and rapid reperfusion in a large animal model of hemorrhagic shock.
作者信息
Davidson Anders J, Russo Rachel M, Ferencz Sarah-Ashley E, Cannon Jeremy W, Rasmussen Todd E, Neff Lucas P, Johnson M Austin, Williams Timothy K
机构信息
From the Department of Surgery (A.J.D., R.M.R., S.-A.E.F., L.P.N.), UC Davis Medical Center, Sacramento, California; Department of General Surgery (A.J.D., R.M.R., L.P.N.), David Grant Medical Center, Travis Air Force Base, California; Division of Traumatology, Surgical Critical Care and Emergency Surgery (J.W.C.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; The Norman M. Rich Department of Surgery (J.W.C., T.E.R., L.P.N.), the Uniformed Services University of the Health Sciences, Bethesda, Maryland; Department of Emergency Medicine (A.M.J.), UC Davis Medical Center, Sacramento, California; and Heart, Lung and Vascular Center (T.K.W.), David Grant Medical Center, Travis Air Force Base, California.
出版信息
J Trauma Acute Care Surg. 2017 Jul;83(1):139-143. doi: 10.1097/TA.0000000000001502.
INTRODUCTION
To avoid potential cardiovascular collapse after resuscitative endovascular balloon occlusion of the aorta (REBOA), current guidelines recommend methodically deflating the balloon for 5 minutes to gradually reperfuse distal tissue beds. However, anecdotal evidence suggests that this approach may still result in unpredictable aortic flow rates and hemodynamic instability. We sought to characterize aortic flow dynamics following REBOA as the balloon is deflated in accordance with current practice guidelines.
METHODS
Eight Yorkshire-cross swine were splenectomized, instrumented, and subjected to rapid 25% total blood volume hemorrhage. After 30 minutes of shock, animals received 60 minutes of Zone 1 REBOA with a low-profile REBOA catheter. During subsequent resuscitation with shed blood, the aortic occlusion balloon was gradually deflated in stepwise fashion at the rate of 0.5 mL every 30 seconds until completely deflated. Aortic flow rate and proximal mean arterial pressure (MAP) were measured continuously over the period of balloon deflation.
RESULTS
Graded balloon deflation resulted in variable initial return of aortic flow (median, 78 seconds; interquartile range [IQR], 68-105 seconds). A rapid increase in aortic flow during a single-balloon deflation step was observed in all animals (median, 819 mL/min; IQR, 664-1241 mL/min) and corresponded with an immediate decrease in proximal MAP (median, 30 mm Hg; IQR, 14.5-37 mm Hg). Total balloon volume and time to return of flow demonstrated no correlation (r = 0.016).
CONCLUSION
This study is the first to characterize aortic flow during balloon deflation following REBOA. A steep inflection point occurs during balloon deflation that results in an abrupt increase in aortic flow and a concomitant decrease in MAP. Furthermore, the onset of distal aortic flow was inconsistent across study animals and did not correlate with initial balloon volume or relative deflation volume. Future studies to define the factors that affect aortic flow during balloon deflation are needed to facilitate controlled reperfusion following REBOA.
引言
为避免复苏性血管内主动脉球囊阻断术（REBOA）后出现潜在的心血管崩溃，当前指南建议有步骤地将球囊放气5分钟，以逐步恢复远端组织床的灌注。然而，轶事证据表明，这种方法仍可能导致不可预测的主动脉血流速度和血流动力学不稳定。我们试图在按照当前实践指南放气球囊时，描述REBOA后的主动脉血流动力学特征。
方法
八只约克夏杂交猪接受脾切除、仪器植入，并经历快速失血量达总血容量25%的出血过程。休克30分钟后，动物使用低轮廓REBOA导管接受60分钟的1区REBOA。在随后用自体血进行复苏期间，主动脉阻断球囊以每30秒0.5 mL的速率逐步放气，直至完全放气。在球囊放气期间持续测量主动脉血流速度和近端平均动脉压（MAP）。
结果
分级球囊放气导致主动脉血流的初始恢复时间各异（中位数为78秒；四分位间距[IQR]为68 - 105秒）。在所有动物中均观察到在单个球囊放气步骤期间主动脉血流迅速增加（中位数为819 mL/分钟；IQR为664 - 1241 mL/分钟），且与近端MAP立即下降相对应（中位数为30 mmHg；IQR为14.5 - 37 mmHg）。球囊总体积与血流恢复时间无相关性（r = 0.016）。
结论
本研究首次描述了REBOA后球囊放气期间的主动脉血流情况。球囊放气期间会出现一个陡峭的转折点，导致主动脉血流突然增加，同时MAP下降。此外，研究动物的远端主动脉血流起始时间不一致，且与初始球囊体积或相对放气体积无关。需要进一步研究以确定影响球囊放气期间主动脉血流的因素，以便在REBOA后促进可控的再灌注。
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