Page 75 - JSOM Summer 2023

Ultrasound Localization of Resuscitative Endovascular
Balloon Occlusion of the Aorta in a Human Cadaver Model

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Tyler R. Lopachin, MD *; Christopher D. Treager, MD ; Eric F. Sulava, MD ; Sean M. Stuart, MD ;
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Megan L. Bohan, BS ; Michael Boboc, BS ; Pravina Fernandez ; William D. Bianchi, DO ;
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Andrew J. McGowan, MD ; Emily E. Friedrich, PhD 10
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ABSTRACT
Objective: Resuscitative endovascular balloon occlusion of the REBOA is indicated for traumatic life-threatening hemorrhage
aorta (REBOA) is a method of gaining proximal control of below the diaphragm in patients in hemorrhagic shock who are
noncompressible torso hemorrhage (NCTH). Catheter place- unresponsive to resuscitation. Placement of a REBOA cath-
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ment is traditionally confirmed with fluoroscopy, but few eter occurs after accessing the common femoral artery with
studies have evaluated whether ultrasound (US) can be used. an introducer sheath and subsequent insertion of the catheter.
Methods: Using a pressurized human cadaver model, a certi- For control of severe intra-abdominal or retroperitoneal hem-
fied REBOA placer was shown one of four randomized cards orrhage, the balloon catheter may be inflated in Zone 1. To
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that instructed them to place the REBOA either correctly or control severe pelvic, junctional, or proximal lower extremity
incorrectly in Zone 1 (the distal thoracic aorta extending from hemorrhage, the balloon catheter may be inflated in Zone 3. 7,9
the celiac artery to the left subclavian artery) or Zone 3 (in the
distal abdominal aorta, from the aortic bifurcation to the low- Historically, this procedure was performed exclusively by vas-
est renal artery). Once the REBOA was placed, 10 US-trained cular surgeons under fluoroscopic guidance. 9,10 However, ad-
locators were asked to confirm balloon placement via US. The vances in training, technique, and catheter design have pushed
participants were given 3 minutes to determine whether the this technology from the operating room into the hands of
catheter had been correctly placed, repeating this 20 times frontline providers in the pre-hospital setting, forward-
on two cadavers. Results: Overall, US exhibited an average deployed military surgical units, and the emergency depart-
sensitivity of 83%, specificity of 76%, and accuracy of 80%. ment. 10–13 Although it is possible to estimate placement without
For Zone 1, US showed a sensitivity of 78% and specificity imaging based on external and intravascular landmarks, con-
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of 83%, and for Zone 3, a sensitivity of 88% and specificity firmation of proper placement is paramount; balloon malposi-
of 76%. In addition, US exhibited a likelihood positive ratio tioning can be catastrophic, with possible resultant myocardial
(LR+) of 3.73 and a likelihood negative ratio (LR–) of 0.22 damage, occlusion of renal or cerebral blood flow, worsening
for either position, with similar numbers for Zone 1 (+4.57, of hemorrhage, or arterial damage. 15
–0.26) and Zone 3 (+3.16, –0.16). Conclusion: Ultrasound
could prove to be a useful tool for confirming placement of a A review of the Aortic Occlusion for Resuscitation in Trauma
REBOA catheter, especially in austere environments. and Acute Care Surgery (AORTA) registry revealed a lack of
standardized approach for placement verification. Most clini-
Keywords: trauma; ultrasound; REBOA cians in this registry verify placement via radiography (52%)
or C-arm fluoroscopy (13%), while 26% of clinicians place
them blindly. The current Joint Trauma System Clinical Prac-
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tice Guideline recommends the use of either plain film radiog-
Introduction
raphy, fluoroscopy, or US for REBOA placement confirmation,
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Hemorrhage remains a leading cause of traumatic deaths, both yet does not clarify whether these techniques are equivalent.
in the military and in civilian sectors. NCTH is a clinical Catheter placement confirmed with fluoroscopy can be cum-
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challenge to control and a leading cause of traumatic hem- bersome and is often not available in emergency departments
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orrhage death. Attempts at controlling NCTH were first or austere locations. Ultrasound, by comparison, is almost uni-
described during the Korean War and have since led to the versally available and feasible for determining placement, 17,18
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development of a procedure called REBOA. With this tech- but few studies have evaluated the accuracy or reliability of
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nique, an intravascular balloon is used to occlude the aorta US in REBOA placement confirmation in Zones 1 and 3. 19,20
proximal to the site of injury to reduce intra-abdominopelvic
hemorrhage as a temporizing measure until definitive surgical With such a time-sensitive and critical procedure being per-
repair can be achieved. formed in resource-limited environments, a fast, reliable, and
*Correspondence to tlopachin1@gmail.com
1 LT Tyler R. Lopachin, MC, USN, LT Christopher D. Treager, MC, USN, LCDR Eric F. Sulava, MC, USN, and CDR Sean M. Stuart, MC,
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USN, are affiliated with the Department of Emergency Medicine, Navy Medical Readiness Training Command, Portsmouth, VA, and the Combat
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Trauma Research Group, Navy Medical Readiness Training Command, Portsmouth. Megan L. Bohan, Michael Boboc, and Pravina Fernandez
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are affiliated with the Combat Trauma Research Group, Navy Medical Readiness Training Command, Portsmouth, and General Dynamics In-
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formation Technology, Falls Church, VA. LCDR William D. Bianchi, MC, USN, and LCDR Andrew J. McGowan, MC, USN, are affiliated with
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the Combat Trauma Research Group, Navy Medical Readiness Training Command, Portsmouth. Dr Emily E. Friedrich is affiliated with the
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Combat Trauma Research Group, Navy Medical Readiness Training Command, Portsmouth, and General Dynamics Information Technology,
Falls Church.
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