From the Clinical Investigation Facilit (M.A.J., G.L.H., C.A.B., C.A.C., M.S., J.K.G.)y, David Grant USAF Medical Center, Travis Air Force Base, CA; Division of Emergency Medicine, Department of Surgery (M.A.J., G.L.H.), University of Utah Health, Salt Lake City, UT; Department of Surgery (C.A.B., C.A.C., M.S.), University of California Davis Medical Center, Sacramento, CA; and Department of Surgery (L.P.N., T.K.W.), Wake Forest Baptist Medical Center, Winston-Salem, NC.
J Trauma Acute Care Surg. 2020 Feb;88(2):298-304. doi: 10.1097/TA.0000000000002558.
Partial resuscitative endovascular balloon occlusion of the aorta (pREBOA) and intermittent REBOA (iREBOA) are techniques to extend the therapeutic duration of REBOA by balloon titration for distal flow or cyclical balloon inflation/deflation to allow transient distal flow, respectively. We hypothesized that manually titrated pREBOA would reduce blood losses and ischemic burden when compared with iREBOA.
Following 20% blood volume controlled hemorrhage, 10 anesthetized pigs underwent uncontrolled hemorrhage from the right iliac artery and vein. Once in hemorrhagic shock, animals underwent 15 minutes of complete zone 1 REBOA followed by 75 minutes of either pREBOA or iREBOA (n = 5/group). After 90 minutes, definitive hemorrhage control was obtained, animals were resuscitated with the remaining collected blood, and then received 2 hours of critical care.
There were no differences in mortality. Animals randomized to iREBOA spent a larger portion of the time at full occlusion when compared with pREBOA (median, 70 minutes; interquartile range [IQR], 70-80 vs. median, 20 minutes; IQR, 20-40, respectively; p = 0.008). While the average blood pressure during the intervention period was equivalent between groups, this was offset by large fluctuations in blood pressure and significantly more rescue occlusions for hypotension with iREBOA. Despite lower maximum aortic flow rates, the pREBOA group tolerated a greater total amount of distal aortic flow during the intervention period (median, 20.9 L; IQR, 20.1-23.0 vs. median, 9.8 L; IQR, 6.8-10.3; p = 0.03) with equivalent abdominal blood losses. Final plasma lactate and creatinine concentrations were equivalent, although iREBOA animals had increased duodenal edema on histology.
Compared with iREBOA, pREBOA reduced the time spent at full occlusion and the number of precipitous drops in proximal mean arterial pressure while delivering more distal aortic flow but not increasing total blood loss in this highly lethal injury model. Neither technique demonstrated a survival benefit. Further refinement of these techniques is necessary before clinical guidelines are issued.
部分复苏性主动脉球囊阻断术（pREBOA）和间歇性 REBOA（iREBOA）是通过球囊滴定来延长 REBOA 治疗时间的技术，以分别实现远端血流或周期性球囊充气/放气来实现短暂的远端血流。我们假设与 iREBOA 相比，手动滴定的 pREBOA 会减少失血量和缺血负担。
在控制 20%血容量出血后，10 只麻醉猪从右髂动脉和静脉进行不受控制的出血。一旦发生失血性休克，动物接受 15 分钟的完全 1 区 REBOA，然后进行 pREBOA 或 iREBOA（每组 5 只）75 分钟。90 分钟后，获得明确的出血控制，动物用收集的剩余血液复苏，然后接受 2 小时的重症监护。
两组死亡率无差异。与 pREBOA 相比，随机接受 iREBOA 的动物在完全阻断的时间比例更大（中位数，70 分钟；四分位距 [IQR]，70-80 与中位数，20 分钟；IQR，20-40，分别；p = 0.008）。尽管干预期间的平均血压在两组之间相当，但由于 iREBOA 血压波动较大且低血压时需要更多的抢救性阻断，这一结果被抵消。尽管最大主动脉流量较低，但 pREBOA 组在干预期间耐受的远端主动脉总流量更大（中位数，20.9 L；IQR，20.1-23.0 与中位数，9.8 L；IQR，6.8-10.3；p = 0.03），腹部出血量相等。最终的血浆乳酸和肌酐浓度相等，尽管 iREBOA 动物的组织学上有更多的十二指肠水肿。
与 iREBOA 相比，pREBOA 减少了完全阻断的时间和近端平均动脉压急剧下降的次数，同时提供了更多的远端主动脉血流，但在这种高致死性损伤模型中并未增加总失血量。这两种技术都没有显示出生存优势。在发布临床指南之前，需要进一步改进这些技术。
