Aortic occlusion balloons are frequently used to control hemorrhage in patients with ruptured abdominal aortic aneurysms who are hemodynamically unstable. However, a new technologic advance is resuscitative endovascular balloon occlusion of the aorta. This technique may be used for traumatic life-threatening hemorrhage below the diaphragm in patients in hemorrhagic shock who are refractory to resuscitation. Resuscitative endovascular balloon occlusion of the aorta does not confer any long-term survival advantage when used in traumatic cardiac arrest patients compared with standard of care. There are insufficient data to make specific recommendations about use of resuscitative endovascular balloon occlusion of the aorta in pediatric or geriatric populations; resuscitative endovascular balloon occlusion of the aorta may have increased risks in these populations, and further study is needed in these patient populations. Physicians should be aware of the complications of the procedure, which may include but are not limited to spinal cord ischemia and ischemia reperfusion injury leading to acute renal failure and multisystem organ failure. In addition, the catheters may cause injury to blood vessels associated with their placement.
Prior to use of this technique, physicians must receive appropriate training. It is recommended that institutions using this technique have specific protocols in place. The ER-REBOA catheter is intended for temporary occlusion of large vessels and blood pressure monitoring, including in patients requiring emergency control of hemorrhage. It involves placement of an endovascular balloon in the aorta to control hemorrhage and augment afterload in traumatic arrest and hemorrhagic shock states.
PREOPERATIVE PREPARATION, ANESTHESIA, AND POSITION
In patients with ruptured abdominal or thoracoabdominal aortic aneurysms who are considered for endovascular repair, preparation is similar to that described in Chapter 152, except that they are prepped from nipples to knees. Access may be achieved while the anesthesia team prepares to intubate the patient. Resuscitative endovascular balloon occlusion of the aorta may be placed in the field or emergency room as a guidewire-free procedure through the femoral artery. It is necessary to have the appropriate access needles and wires available. For both ruptured abdominal aortic aneurysm and resuscitative endovascular balloon occlusion of the aorta, the femoral artery is cannulated either with a micropuncture 21-gauge needle and a 0.018-inch wire or an 18-gauge needle and a 0.035-inch wire. If available, ultrasound-guided access minimizes complications. Additionally, 12-F sheaths are needed for specific kits for ruptured abdominal aortic aneurysm and resuscitative endovascular balloon occlusion of the aorta. For ruptured abdominal aortic aneurysm, it will be useful, if possible, to identify which vertebral body the renal arteries come off from the computed tomography scan. Prior to beginning the procedure, a time-out is performed.
RUPTURED ABDOMINAL AORTIC ANEURYSM
For a ruptured abdominal aortic aneurysm, percutaneous access is achieved expeditiously or, if needed, through a femoral artery cut-down followed by placing a 5-French sheath. After percutaneous ...