Effi cacy of partial and complete resuscitative endovascular balloon occlusion of the aorta in the hemorrhagic shock model of liver injury

BACKGROUND:Resuscitative endovascular balloon occlusion of the aorta(REBOA)can temporarily control traumatic bleeding.However,its prolonged use potentially leads to ischemia-reperfusion injury(IRI).Partial REBOA(pREBOA)can alleviate ischemic burden;however,its security and eff ectiveness prior to operative hemorrhage control remains unknown.Hence,we aimed to estimate the effi cacy of pREBOA in a swine model of liver injury using an experimental sliding-chamber ballistic gun.METHODS:Twenty Landrace pigs were randomized into control(no aortic occlusion)(n=5),intervention with complete REBOA(cREBOA)(n=5),continuous pREBOA(C-pREBOA)(n=5),and sequential pREBOA(S-pREBOA)(n=5)groups.In the cREBOA and C-pREBOA groups,the balloon was inflated for 60 min.The hemodynamic and laboratory values were compared at various observation time points.Tissue samples immediately after animal euthanasia from the myocardium,liver,kidneys,and duodenum were collected for histological assessment using hematoxylin and eosin staining.RESULTS:Compared with the control group,the survival rate of the REBOA groups was prominently improved(all P<0.05).The total volume of blood loss was markedly lower in the cREBOA group(493.14±127.31 mL)compared with other groups(P<0.01).The pH was significantly lower at 180 min in the cREBOA and S-pREBOA groups(P<0.05).At 120 min,the S-pREBOA group showed higher alanine aminotransferase(P<0.05)but lower blood urea nitrogen compared with the cREBOA group(P<0.05).CONCLUSION:In this trauma model with liver injury,a 60-minute pREBOA resulted in improved survival rate and was effective in maintaining reliable aortic pressure,despite persistent hemorrhage.Extended tolerance time for aortic occlusion in Zone I for non-compressible torso hemorrhage was feasible with both continuous partial and sequential partial measures,and the significant improvement in the severity of acidosis and distal organ injury was observed in the sequential pREBOA.

Totally Occluded Coarctation of the Aorta in a Young Adult

We report the case of a 20-year-old female patient presenting with a totally occluded coarctation of the aorta. The patient was admitted for the evaluation of resistant grade III high blood pressure. The physical examination revealed a blood pressure gradient between the upper and lower limbs, absent femoral pulses, a diffuse continuous murmur over the chest, and hyperpulsatility of the carotid arteries and sternal notch. A transthoracic echocardiography outlined a narrowing in the caliber of the isthmic aorta without acceleration of flow or gradient. Thoracic CT angiography revealed a complete aortic coarctation with interruption of continuity between segment 3 and the descending aorta.

Application of abdominal aortic balloon occlusion followed by uterine artery embolization for the treatment of pernicious placenta previa complicated with placenta accreta during cesarean section

Objective:This study aimed to investigate the clinical effects of abdominal aortic balloon occlusion followed by uterine artery embolization for the treatment of pernicious placenta previa complicated with placenta accreta during cesarean section.Methods:We performed a retrospective analysis of the clinical data for 623 patients who experienced pernicious placenta previa complicated with placenta accreta and received treatment in our hospital from January 2013 to January 2019.All patients underwent abdominal aortic balloon occlusion before their cesarean section.Seventyeight patients received bilateral uterine artery embolization,and among them,placenta accreta was found at the opening of the cervix in 13 patients.Due to suturing difficulty after the removal of the placenta,gauze packing was used to temporarily compress the hemorrhage.As soon as the uterus was sutured,emergent bilateral uterine artery embolization was performed.Active bleeding was noted in the remaining 65 patients when the lower part of the uterus was pressed after the placenta was removed and the uterus was sutured,therefor,bilateral uterine artery embolization was performed urgently.Results:Of the 623 patients,545 patients underwent only abdominal aortic balloon occlusion and 78 patients underwent additional emergent bilateral uterine artery embolization due to hemorrhaging during or after their cesarean section.No hysterectomies were performed.In the 78 patients,the amount of bleeding was 800-3,200 ml with an average of 1,650 ml during the operation;the volume of blood transfused was 360-1,750 ml(average:960 ml).The fetal fluoroscopy time was 3–8 s(average:5 s).The dose of radiation exposure was(4.2±2.9) m Gy.Fetal appearance,pulse,grimace,activity,and respiration(Apgar) score were normal.No serious complications were observed during or after the operation in the follow-up visits.Conclusion:For patients with pernicious placenta previa complicated with placenta accreta who experience active bleeding after cesarean section and abdominal aortic balloon occlusion,bilateral uterine artery embolization can effectively reduce blood loss and requirement of blood transfusion during the operation,and lowers the risk of hysterectomy.

Application of ultrasound-guided balloon occlusion in cesarean section in 130 cases of sinister placenta previa

Objective:To investigate the clinical utility of ultrasound-guided balloon occlusion in cesarean section in patients with sinister placenta previa.Methods:The Interventional and Ultrasound Departments of the authors’center assisted obstetrics to complete cesarean section in cases of sinister placenta previa.A total of 130 patients with implanted sinister placenta previa were diagnosed using obstetrical ultrasound and magnetic resonance imaging(MRI).Before cesarean section,the balloon was positioned in the bilateral radial or abdominal aorta.Immediately after delivery of the fetus,the balloon was temporarily filled to transiently seal the target vessel.According to the obstetrician’s assessment of hemostasis,the balloon was withdrawn at the appropriate time.Among the 130 patients,there was one case of abdominal aortic occlusion,with 129 cases blocked by the bilateral common iliac artery.Results:All 130 cases were successfully blocked,with an average blocking time of<15 min,while intraoperative blood loss was 800–1500 ml.Conclusion:Ultrasound-guided balloon blocking treatment before cesarean section can mitigate the dangers of placenta previa and significantly reduce blood loss with no exposure to X-ray radiation.Thus,the technique merits serious consideration.

Application of Abdominal Aortic Balloon Occlusion Combined with Tourniquet in Pregnant Women with Severe Placenta Accreta Spectrum

Objective Abdominal aortic balloon occlusion(AABO)is a vascular intervention method that has been widely used in the treatment of severe placenta accreta spectrum(PAS).The aim of this study was to investigate the benefits,potential risks,and characteristics of AABO combined with tourniquet binding of the lower uterine segment(LUS)in treatment of pregnant women with PAS.Methods In this study,64 pregnant women with PAS scores greater than 5 were enrolled as research subjects and divided into two groups.Group A(n=34)underwent normal operative procedures including tourniquet binding of the LUS.Group B(n=30)underwent AABO combined with tourniquet binding of the LUS.General clinical characteristics,ultrasonography PAS score,intraoperative blood loss(IBL),blood loss within 24 h after surgery(24-h BL),postoperative complications,and neonatal data of the two groups were retrospectively reviewed.The influencing factors of IBL for the two groups were analyzed.Results The amounts of IBL,24-h BL,total input red blood cell,and the incidence of disseminated intravascular coagulation were significantly lower in group B than in group A(P<0.05),and this difference was even more significant in the subgroup of placenta percreta(PAS scores≥10).Further multivariate linear analysis showed that the combined therapy of AABO and tourniquet could independently predict lower IBL than normal operative procedures did(P=0.001).Conclusion AABO combined with tourniquet binding of the LUS could improve the outcomes of pregnant women with severe PAS and reduce serious peripartum complications of AABO.

Coarctation of aorta with complete aortic occlusion

Survival to advanced age is exceptional in patients with unrepaired aortic coarctation. We report the case of an 81-year-old man with aortic coarctation and total occlusion who was otherwise asymptomatic. Coarctation was suspected when a femoral-radial pulse delay was noted during his routine physical examination. A 70-mmHg systolic blood.

Long-Term Results of Balloon Angioplasty for Native Coarctation of the Aorta in the Surgical Specialty Teaching Hospital/Cardiac Center/Hawler

Background: Coarctation of aorta is a common congenital cardiac malformation;controversy has surrounded the use of balloon angioplasty for native coarctation of aorta as the primary treatment for patients with various ages with coarctation. Aim: This study aimed to assess the long term outcome of balloon angioplasty especially concerning aneurysm formation. Patients and Methods: A case series (case follow-up) study was carried out on a total of 50 patients (31 male and 19 female) with native coarctation of aorta aged 1 - 21 years of age who were treated with balloon angioplasty for more than 1 year at the time of follow up evaluation in surgical specialty hospital/cardiac center in Erbil Iraq. They were recalled and subjected to detail clinical examination, body weight, height, blood pressure measurements. Radiographic, Echo Doppler data, CT angiography were obtained. CT angiography was done for 34 patients. Full echocardiographic evaluation was done in follow up visits. Results: There was a significant reduction in the peak instantaneous pressure gradient across the coarctated area by Doppler echocardiogram gradient before balloon angioplasty and at the follow up visit from 56.92 ± 14.6 mmHg to 30.68 ± 16.89, P = 0.00. Six cases of total 50 patients had evidence of diastolic runoff pattern by Doppler Echcardiogram. While the only 6 of total 34 cases had the report of CT angiography that documented aneurysm formation (12%). Conclusions: Balloon angioplasty of native aortic coarctation can be performed safely and effectively with good immediate outcome. Furthermore, it offers satisfactory long-term results with low incidence of persisting restenosis, hypertension and aneurysm formation.

The balloon occlusion and thrombus aspiration catheter mediated-distal coronary perfusion technique(BI-RESCUE)for treatment of coronary artery perforation

Coronary artery perforation(CAP)remains an infrequent but potentially lifethreatening complication during percutaneous coronary intervention(PCI).Although the prevalence of CAP is about 0.2%−0.9%in relatively low risk PCI,the incidence could up to 9%in complex clinical scenarios such as severe coronary calcification,chronic total occlusions and rotational atherectomy.[1]Despite the new techniques and equipment had lower morbidity and mortality,up to 17%of acute CAP cases would evolve to tamponade and subsequent death.

Management of adults with coarctation of aorta

Coarctation of the aorta(CoA)is a relatively common congenital cardiac defect often causing few symptoms and therefore can be challenging to diagnose.The hallmark finding on physical examination is upper extremity hypertension,and for this reason,CoA should be considered in any young hypertensive patient,justifying measurement of lower extremity blood pressure at least once in these individuals.The presence of a significant pressure gradient between the arms and legs is highly suggestive of the diagnosis.Early diagnosis and treatment are important as long-term data consistently demonstrate that patients with CoA have a reduced life expectancy and increased risk of cardiovascular complications.Surgical repair has traditionally been the mainstay of therapy for correction,although advances in endovascular technology with covered stents or stent grafts permit nonsurgical approaches for the management of older children and adults with native CoA and complications.Persistent hypertension and vascular dysfunction can lead to an increased risk of coronary disease,which,remains the greatest cause of long-term mortality.Thus,blood pressure control and periodic reassessment with transthoracic echocardiography and threedimensional imaging(computed tomography or cardiac magnetic resonance)for should be performed regularly as cardiovascular complications may occur decades after the intervention.

Effect of bFGF on expression of MMPs mRNA on the rat thoracic aorta after ballon injury and cultured VSMCS

Background:Extracellular matrix (ECM) plays a very important role in the development ofrestenosis after PTCA The MMPs,enymes specialized in degradation of ECM,probably partciptesin extracelular matrix remodeling after balloon injury,but the factors that regulates MMPs activity arenot completely understood Basic fibroblast growth factor (bFGF),as a mitogen for a variety of cellstypes,influences metabolism of ECM.However,if effects on MMPs are not known.Methodsand Results:24 male Wistar rats were divided randomly into control group,balloon-injuried group andbFGF-treated group.The rats of control group were not treated.The rats in balloon-injuried group weredamaged by balloon and the thoracic aortas were harvested after two weeks.In the bFGF-treated grorp,balloon injury and the injuried vessels were collected after two weeks.The northern blot was used toinvestigate the MMP1,MMP2 and MMP9 mRNA expression of vesss.At the same time,the effectsof differet dose bFGF (0ng/ml,40ng/ml,80ng/ml and 120ng/ml) on the MMPs expression of culturedVSMCs were examined The results showed the bFGF can selectively increase the expression ofMMP1 and MMP9 mRNA without effect on the MMP2 on the injuried rat thoracic aorta,and dosedependently increase the MMP1 mRNA expression of cultured VSMCs without MMP2 and MMP9expression Conclusion:bFGF selectively increased MMPs mRNA expression on both injuried ratthoracic aorta and cultured VSMCs.This effect may be related to the degradation of ECM,remodelingof vessel after injuty.

Intra-abdominal aortic balloon occlusion in the management of placenta percreta

Background:Massive bleeding is the main concern for the management of placenta percreta(PP).Intra-abdominal aortic balloon occlusion(IABO)is one method for pelvic devascularization,but the efficacy of IABO is uncertain.This study aims to investigate the outcomes of IABO in PP patients.Methods:We retrospectively reviewed the clinical data of PP cases from six tertiary centers in China between January 2011 and December 2015.PP cases with/without the use of IABO were analyzed.Propensity score matching analysis was performed to reduce the effect of selection bias.Postpartum hemorrhage(PPH)and the rate of hysterectomy,as well as neonatal outcomes,were analyzed.Results:One hundred and thirty-two matched pairs of patients were included in the final analysis.Compared with the control group,maternal outcomes,including PPH(68.9%vs.87.9%,χ^(2)=13.984,P<0.001),hysterectomy(8.3%vs.65.2%,χ^(2)=91.672,P<0.001),and repeated surgery(1.5%vs.12.1%,χ^(2)=11.686,P=0.001)were significantly reduced in the IABO group.For neonatal outcomes,Apgar scores at 1 minute(8.67±1.79vs.8.53±1.68,t=-0.638,P=0.947)and 5 minutes(9.43±1.55vs.9.53±1.26,t=0.566,P=0.293)were not significantly different between the two groups.Conclusions:IABO can significantly reduce blood loss,hysterectomies,and repeated surgeries.This procedure has not shown harmful effects on neonatal outcomes.

Percutaneous balloon angioplasty of coarctation of the aorta in children: 12-year follow-up results

Objective To evaluate the efficiency of percutaneous balloon angioplasty of coarctation ot the aorta in children and discuss its risk factors that can lead to poor long-term results. Mehods From September 1987 to August 1999, 24 patients underwent 27 balloon angioplasty procedures for native or recurrent coarctation of the aorta at our institution. There were 19 patients with discrete (membranous) coarctation, 4 patients with long-segment and aortic arch hypoplasia, and 1 patient with postoperative recurrence. The balloon diameter was chosen not to exceed the diameter of the aorta proximal to the stenotic site ( 11.06 + 2.80 mm vs 11.78 + 3.18 mm), with the chosen diameter two to four times that of the stenotic segment (2.57 + 0.68 times). The patients have been followed up for half to twelve years (mean 6.2 + 2.8 years). Satisfactory result was defined as a reduction in the pressure gradient across the site of coarctation to ≤20 mm Hg.Results The systolic pressure gradient across the coarctation site decreased from 48.17 + 14.68 mm Hg to 14.96 + 13.12 mm Hg ( P ＜ 0.01 ) and the diameter of the coarctation site increased from 4.66 + 2.43 mm to 8.80 + 3.32 mm ( P ＜ 0.01 ). Immediate satisfactory results were obtained in 19 patients (79％). Of the 5 patients with unsatisfactory results, 4 had aortic arch hypoplasia and 1 had membranous coarctation. Of the 19 patients with satisfactory results, 18 patients had membranous coarctation and 1 patient had recurrent postoperative coarctation. No aneurysm and other complications had occurred in any patients at the follow-ups.Conclusion Percutaneous balloon angioplasty is an effective treatment altemative to surgery in most patients with recurrent postoperative or native membranous coarctation of the aorta. It should not be recommended for the coarctation of aortic arch hypoplasia.

Management of life-threatening celiac-hepatic arterial hemorrhage after pancreaticoduodenectomy： usefulness of temporary balloon occlusion

When a large visceral artery is ruptured, uncontrolled bleeding may lead to hemodynamic collapse. Use of endovascular occlusion balloon catheter may provide rapid control of hemorrhage and facilitate definitive therapy. We reported two patients with massive hemorrhage from ruptured celiac-hepatic artery after pancreaticoduodenectomy, who were initially treated percutaneously by temporary selective balloon occlusion. They became critically hemodynamic unstable during the angiographic procedure. Through an 8Fr sheath, a 6Fr compliant latex occlusion balloon was placed proximal to the celiac trunk and inflated, and upon patient stabilization surgical revision and stent-graft placement were successfully performed in the two patients, respectively. Temporary selective balloon occlusion provides fast and effective bleeding control for patient with critically uncontrollable visceral arterial hemorrhage, permitting subsequent use of conventional techniques for management of the arterial bleeding source.

Pre-hospital application of REBOA for life-threatening hemorrhage

Dear Editor,Most battlefield casualties occur prior to the arrival of medical facilities.Uncontrollable hemorrhage accounts for more than 90%of those potentially survivable battlefield casualties[1].In both military and civilian conditions,non-compressible torso hemorrhage always caused rapid exsanguination and high mortality rates before definitive treatment[2].More than half of the deaths due to non-compressible torso hemorrhage occur before hospital care can be provided[2].Therefore,early and rapid pre-hospital hemorrhage control is essential to reduce mortality.

Balloon-occluded retrograde transvenous obliteration for treatment of congenital intrahepatic portosystemic venous shunt:A case report

Congenital intrahepatic portosystemic venous shunt(CPSVS), a rare vascular malformation, has been described in both children and adults and can lead to severe neurophysiological complications. However, a standard therapeutic protocol for CPSVS has not been elucidated. With the advantage of minimally invasive techniques,transcatheter embolization has been used to treat CPSVS. The condition is challenging to manage, especially in patients with large or multiple shunts, through which rapid blood flow can cause ectopic embolism. Here, we describe a case of CPSVS with a large shunt that was successfully treated with balloon-occluded retrograde transvenous obliteration with interlocking detachable coils.

Primary balloon angioplasty for chronic occlusion of intracranial internal carotid artery: A case report

Chronic occlusion of large intracranial arteries is the main cause of ischemic stroke in China.Patients with symptomatic intracranial artery occlusion and hemodynamic impairment are at high risk of recurrent stroke.Chronic occlusion of the intracranial segment of the internal carotid artery is a common type of intracranial artery occlusion.Medical management is regarded as the standard treatment for this disease.With the development of endovascular treatment,some patients with chronic cerebral artery occlusion have achieved satisfactory results with endovascular therapy.We reported a patient with symptomatic chronic occlusion of the ophthalmic segment of the internal carotid artery.Simple balloon angioplasty was performed,and the occluded ophthalmic segment of the internal carotid artery was successfully recanalized without perioperative complications.At 4 months followup,the internal carotid artery remained patent and perfusion of the right cerebral hemisphere improved dramatically.In addition,we briefly reviewed the relevant literature.

Approach to traumatic cardiac arrest in the emergency department: a narrative literature review for emergency providers

BACKGROUND:Traumatic cardiac arrest(TCA)is a major contributor to mortality and morbidity in all age groups and poses a significant burden on the healthcare system.Although there have been advances in treatment modalities,survival rates for TCA patients remain low.This narrative literature review critically examines the indications and eff ectiveness of current therapeutic approaches in treating TCA.METHODS:We performed a literature search in the PubMed and Scopus databases for studies published before December 31,2022.The search was refi ned by combining search terms,examining relevant study references,and restricting publications to the English language.Following the search,943 articles were retrieved,and two independent reviewers conducted a screening process.RESULTS:A review of various studies on pre-and intra-arrest prognostic factors showed that survival rates were higher when patients had an initial shockable rhythm.There were conflicting results regarding other prognostic factors,such as witnessed arrest,bystander cardiopulmonary resuscitation(CPR),and the use of prehospital or in-hospital epinephrine.Emergency thoracotomy was found to result in more favorable outcomes in cases of penetrating trauma than in those with blunt trauma.Resuscitative endovascular balloon occlusion of the aorta(REBOA)provides an advantage to emergency thoracotomy in terms of occupational safety for the operator as an alternative in managing hemorrhagic shock.When implemented in the setting of aortic occlusion,emergency thoracotomy and REBOA resulted in comparable mortality rates.Veno-venous extracorporeal life support(V-V ECLS)and veno-arterial extracorporeal life support(V-A ECLS)are viable options for treating respiratory failure and cardiogenic shock,respectively.In the context of traumatic injuries,V-V ECLS has been associated with higher rates of survival to discharge than V-A ECLS.CONCLUSION:TCA remains a signifi cant challenge for emergency medical services due to its high morbidity and mortality rates.Pre-and intra-arrest prognostic factors can help identify patients who are likely to benefit from aggressive and resource-intensive resuscitation measures.Further research is needed to enhance guidelines for the clinical use of established and emerging therapeutic approaches that can help optimize treatment effi cacy and ameliorate survival outcomes.

Balloon test occlusion of internal carotid artery: Angiographic findings predictive of results

AIM: To reveal angiographic findings to predict the re-sult of balloon test occlusion(BTO).METHODS: The cerebral angiograms of 42 consecu-tive patients who underwent cerebral angiography in-cluding both the Matas and Allcock maneuvers and BTO were retrospectively analyzed. Visualization of the an-terior cerebral artery(ACA) and the middle cerebral ar-tery(MCA) by the cross flow on the tested side during the Matas or Allcock maneuver was graded on a 5-point scale. Circle of Willis(COW) anatomy with respect to the presence/absence of a collateral path to reach the tested internal carotid artery(ICA) was classified intofour categories. A univariate logistic analysis was used to analyze the associations between each angiographic finding and the BTO result. Sensitivity, specificity, accu-racy, positive predictive value, and negative predictive value for each finding were calculated. RESULTS: Five patients(12%) were BTO-positive and the remaining 37 patients(88%) were BTO-negative. Visualizations of the ACA and MCA as well as the COW anatomy were significantly associated with the BTO re-sult(P = 0.0051 for ACA, P = 0.0002 for MCA, and P < 0.0001 for COW anatomy). In particular, good MCA vi-sualization and the presence of an anterior connection(collateral path to the tested ICA from the contralateral ICA via the anterior communicating artery) in the COW were highly predictive for negative BTO(negative pre-dictive value = 100% for both).

Intravascular ultrasound-guided “extended” reverse controlled antegrade and retrograde subintimal tracking technique using a cutting balloon for recanalizing chronic coronary total occlusion with a side branch

Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) represents the most technically challenging procedure in contemporary interventional cardiology.[1] Blunt lesions and presence of proximal side branch are considered to be strong predictors of reduced technical success.[ 2,3] For such lesions, the antegrade approach may not be feasible or desirable, and the retrograde approach can be used as the initial crossing strategy. However, when treating the blunt CTO with a large side branch proximal to the occlusion, the side branch might be occluded after stent implantation if the retrograde guidewire passed the occluded segment through the subintimal space and re-entered into the true lumen at the opposite side of the side branch.[4] We reported a useful method to solve the above issue which utilizes intravascular ultrasound (IVUS) to guide “extended” reverse controlled antegrade and retrograde subintimal tracking (CART) technique with a cutting balloon.

Cerebral Angiography Induced Prolonged Focal Seizure and Hemiparesis during Carotid Artery Balloon Test Occlusion

The frequency of neurologic complications of cerebral angiography is 0.3%-2.3%, and the frequency of the persistent neurologic deficits that remain over 7-10 days is 0.4%-0.5%. On the other hand, all neurologic complications of balloon test occlusion (BTO) have been reported in 0%-8.3% and especially in 1.6%-1.7% of symptomatic neurologic complications. There are a few reports concerning a seizure related to cerebral angiography and BTO. We report a case of prolonged seizures and left hemiparesis during and after BTO of the right internal carotid artery. The patient showed repeated focal seizures and prolonged left hemiparesis lasting for approximately 2 months. Computed tomography and magnetic resonance imaging demonstrated no abnormal findings. Suspected mechanisms of seizure were a cerebral blood flow change induced by BTO and neurotoxicity of accumulated contrast medium. A combination of prolonged focal seizures and subsequent hemiparesis is a rare complication of BTO, which should be taken into consideration during BTO.