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

doi:10.5847/wjem.j.1920-8642.2024.001

Abstract

Abstract:

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 effectiveness prior to operative hemorrhage control remains unknown. Hence, we aimed to estimate the efficacy 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.

Key words: Non-compressible torso hemorrhage, Liver injury, Ischemia-reperfusion injury, Resuscitative endovascular balloon occlusion of the aorta

Yi Shan, Yang Zhao, Chengcheng Li, Jianxin Gao, Guogeng Song, Tanshi Li. Efficacy of partial and complete resuscitative endovascular balloon occlusion of the aorta in the hemorrhagic shock model of liver injury[J]. World Journal of Emergency Medicine, 2024, 15(1): 10-15.

Figures/Tables 4

Table 1.

Figure 1.

Table 2.

Comparison of hemodynamic and laboratory values among the four treatment groups

Parameters	Control		cREBOA			C-pREBOA			S-pREBOA
Parameters	60 min	60 min	120 min	180 min	60 min	120 min	180 min	60 min	120 min	180 min
Hemodynamics
HR, beats/min	152.67±10.02	140.60±20.67	153.75±28.55	144.00±17.26	136.75±12.61	123.67±15.04	150.33±13.58	126.80±11.37	156.33±34.85	147.00±20.30
SBP, mmHg	86.33±17.95	138.40±18.04*	94.00±21.56	100.00±28.55	145.75±6.99*	94.33±26.31	100.33±16.50	134.60±14.01*	103.00±19.70	103.67±13.01
DBP, mmHg	50.33±10.07	104.80±5.45*	49.00±17.57	50.50±18.91	111.50±11.45*	44.67±13.05	50.67±8.51	100.40±13.24*	56.00±15.13	51.67±16.17
MAP, mmHg	65.67±10.50	115.80±8.87*	63.50±19.30	66.75±21.48	123.00±9.49*	61.33±17.79	67.00±11.14	111.20±11.19*	71.33±12.10	69.00±14.00
CVP, mmHg	3.57±2.70	4.80±3.11	4.38±3.20	6.50±2.12	4.75±3.59	3.00±2.65	3.67±1.15	7.30±1.30	6.33±3.79	6.67±4.04
CO, L/min	1.88±0.92	3.36±1.11	4.00±1.46	3.25±0.33	4.15±1.29	4.37±2.87	3.93±2.51	4.74±2.20	3.57±0.67	2.70±1.40
SVR, d·s^-1·cm⁵	3470.0±1833.9	2642.2±1122.8	1182.3±345.1	1462.5±477.6	2430.5±1256.7	1488.0±875.1	1742.7±963.8	2223.2±1427.6	1622.0±342.2	2312.3±1080.0
Laboratory indices
pH	7.44±0.05	7.19±0.09*	7.14±0.07	7.13±0.08#	7.24±0.11*	7.21±0.02	7.30±0.02†	7.14±0.07*	7.19±0.03	7.21±0.03†
Lac, mg/dL	9.97±3.62	14.24±2.02*	17.15±1.49	17.73±1.64	14.45±1.19*	15.33±1.47	14.00±3.40	16.18±1.51*	15.87±2.11	16.27±1.54
Hct, %	25.33±2.08	32.40±2.70*ǃ	34.00±1.41#ǃ	28.00±4.08	27.50±4.43	26.00±2.65	28.67±3.79	25.80±3.42	29.00±3.46	29.33±5.51
LDH, U/L	2252.0±377.6	1752.4±415.2	2225.0±689.0	2168.8±518.2	1303.8±320.2*	1867.7±539.3	2387.3±733.6	1830.2±520.4	2266.0±690.1	3030.3±532.6
ALT, U/L	35.00±10.00	17.80±4.60*	27.00±10.30ǃ	33.25±20.34	20.50±3.00	33.67±10.02	36.33±24.21	23.00±9.90	58.33±19.55	48.33±14.57
Cr, mg/dL	1.70±0.26	2.32±0.31*	2.40±0.24	2.40±0.26	1.95±0.24	2.07±0.15	2.07±0.25	2.34±0.30*	2.37±0.40	2.50±0.61
BUN, mg/dL	11.67±3.06	13.60±3.21	16.75±1.71#	17.75±2.87	10.50±1.92	12.67±1.53	13.67±1.53	11.60±4.22	13.67±2.08	14.33±5.77

Table 2.

Figure 2.

References 20

1	Zhang HY, Guo Y, Huang XY, Li Y, Zhang LY. An online survey of non-compressible torso hemorrhage: training is needed. World J Emerg Med. 2022; 13(4):297-300. doi: 10.5847/wjem.j.1920-8642.2022.069 pmid: 35837559
2	Hong C, Olsen BD, Hammond PT. A review of treatments for non-compressible torso hemorrhage (NCTH) and internal bleeding. Biomaterials. 2022; 283:121432. doi: 10.1016/j.biomaterials.2022.121432
3	Li YL, Wang JY, Han W, Sun T, Lyu K, Xu SX. Resuscitative endovascular balloon occlusion of the aorta in the treatment of severe hemorrhagic shock caused by upper gastrointestinal bleeding. World J Emerg Med. 2023; 14(3):247-9.
4	Thrailkill MA, Gladin KH, Thorpe CR, Roberts TR, Choi JH, Chung KK, et al. Resuscitative endovascular balloon occlusion of the aorta (REBOA): update and insights into current practices and future directions for research and implementation. Scand J Trauma Resusc Emerg Med. 2021; 29(1):8. doi: 10.1186/s13049-020-00807-9
5	Morrison JJ, Ross JD, Markov NP, Scott DJ, Spencer JR, Rasmussen TE. The inflammatory sequelae of aortic balloon occlusion in hemorrhagic shock. J Surg Res. 2014; 191(2):423-31. doi: 10.1016/j.jss.2014.04.012 pmid: 24836421
6	Li YS, Dubick MA, Yang ZS, Barr JL, Gremmer BJ, Lucas ML, et al. Distal organ inflammation and injury after resuscitative endovascular balloon occlusion of the aorta in a porcine model of severe hemorrhagic shock. PLoS One. 2020; 15(11):e0242450. doi: 10.1371/journal.pone.0242450
7	Russo RM, Neff LP, Lamb CM, Cannon JW, Galante JM, Clement NF, et al. Partial resuscitative endovascular balloon occlusion of the aorta in swine model of hemorrhagic shock. J Am Coll Surg. 2016; 223(2):359-68. doi: 10.1016/j.jamcollsurg.2016.04.037
8	Madurska MJ, McLenithan A, Scalea TM, Kundi R, White JM, Morrison JJ, et al. A feasibility study of partial REBOA data in a high-volume trauma center. Eur J Trauma Emerg Surg. 2022; 48(1):299-305. doi: 10.1007/s00068-020-01561-4
9	Gao J, Shan Y, Sun R, Zhong Z, Zhao Y, Li T. Establishment of a high-velocity fragment-induced penetrating liver injury model in Landrace pigs. Zhonghua Wei Zhong Bing Ji Jiu Yi Xue. 2022; 34(9):958-63.
10	Ribeiro Junior MAF, Feng CYD, Nguyen ATM, Rodrigues VC, Bechara GEK, de-Moura RR, et al. The complications associated with resuscitative endovascular balloon occlusion of the aorta (REBOA). World J Emerg Surg. 2018; 13(1):20. doi: 10.1186/s13017-018-0181-6
11	Rappold JF, Bochicchio GV. Surgical adjuncts to noncompressible torso hemorrhage as tools for patient blood management. Transfusion. 2016; 56(Suppl 2):S203-7.
12	Huang L, Liu GL, Kaye AD, Liu H. Advances in topical hemostatic agent therapies: a comprehensive update. Adv Ther. 2020; 37(10):4132-48. doi: 10.1007/s12325-020-01467-y pmid: 32813165
13	Vulliamy P, Thaventhiran AJ, Davenport RA. What’s new for trauma haemorrhage management? Br J Hosp Med (Lond). 2019; 80(5):268-73. doi: 10.12968/hmed.2019.80.5.268 pmid: 31059346
14	Moore LJ, Brenner M, Kozar RA, Pasley J, Wade CE, Baraniuk MS, et al. Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage. J Trauma Acute Care Surg. 2015; 79(4): 523-30;discussion530. doi: 10.1097/TA.0000000000000809 pmid: 26402524
15	Bukur M, Gorman E, DiMaggio C, Frangos S, Morrison JJ, Scalea TM, et al. Temporal changes in REBOA utilization practices are associated with increased survival: an analysis of the AORTA registry. Shock. 2021; 55(1):24-32. doi: 10.1097/SHK.0000000000001586
16	Hoehn MR, Teeter WA, Morrison JJ, Gamble WB, Hu P, Stein DM, et al. Aortic branch vessel flow during resuscitative endovascular balloon occlusion of the aorta. J Trauma Acute Care Surg. 2019; 86(1):79-85. doi: 10.1097/TA.0000000000002075 pmid: 30252777
17	Hoareau GL, Tibbits EM, Beyer CA, Simon MA, DeSoucy ES, Faulconer ER, et al. Resuscitative endovascular balloon occlusion of the aorta: review of the literature and applications to veterinary emergency and critical care. Front Vet Sci. 2019; 6:197. doi: 10.3389/fvets.2019.00197 pmid: 31275952
18	Sadeghi M, Hörer TM, Forsman D, Dogan EM, Jansson K, Kindler C, et al. Blood pressure targeting by partial REBOA is possible in severe hemorrhagic shock in pigs and produces less circulatory, metabolic and inflammatory sequelae than total REBOA. Injury. 2018; 49:2132-41. doi: S0020-1383(18)30556-4 pmid: 30301556
19	Matsumura Y, Matsumoto J, Kondo H, Idoguchi K, Funabiki T, DIRECT-IABO investigators. Partial occlusion, conversion from thoracotomy, undelayed but shorter occlusion: resuscitative endovascular balloon occlusion of the aorta strategy in Japan. Eur J Emerg Med. 2018; 25(5):348-54. doi: 10.1097/MEJ.0000000000000466 pmid: 28328730
20	Matsumura Y, Higashi A, Izawa Y, Hishikawa S, Kondo H, Reva V, et al. Distal pressure monitoring and titration with percent balloon volume: feasible management of partial resuscitative endovascular balloon occlusion of the aorta (P-REBOA). Eur J Trauma Emerg Surg. 2021; 47(4):1023-9. doi: 10.1007/s00068-019-01257-4

Parameters	Control (n=5)	cREBOA (n=5)	C-pREBOA (n=5)	S-pREBOA (n=5)	P-value
Weight, kg	53.80±7.39	53.80±5.81	54.84±3.42	53.6±4.93	0.98
Sex (male: female)	2:3	4:1	4:1	3:2	0.74
Total volume of blood loss, mL	1136.30±270.07	493.14±127.31	882.88±202.49	852.11±68.57	<0.01
Shock index	1.37±0.06	1.34±0.05	1.34±0.02	1.35±0.05	0.77
Time to death, min	57.60±32.69	161.00±42.49	129.60±73.56	145.00±50.50	0.03

[1]	Rashed Alremeithi, Quincy K. Tran, Megan T. Quintana, Soroush Shahamatdar, Ali Pourmand. Approach to traumatic cardiac arrest in the emergency department: a narrative literature review for emergency providers [J]. World Journal of Emergency Medicine, 2024, 15(1): 3-9.
[2]	Mei-jia Shen, Li-chao Sun, Xiao-yu Liu, Meng-chen Xiong, Shan Li, A-ling Tang, Guo-qiang Zhang. Trichostatin A improves the inflammatory response and liver injury in septic mice through the FoxO3a/autophagy signaling pathway [J]. World Journal of Emergency Medicine, 2022, 13(3): 182-188.
[3]	Guo-ming Zhang, Yu Wang, Tian-de Li, Xiao-yan Li, Shao-ping Su, Yuan-yuan Sun, Xiu-hua Liu. Post-conditioning with gradually increased reperfusion provides better cardioprotection in rats [J]. World Journal of Emergency Medicine, 2014, 5(2): 128-134.
[4]	Shi-hui Zhou, Yan-fei Sun, Gang Wang. Effects of hyperbaric oxygen on intestinal mucosa apoptosis caused by ischemia-reperfusion injury in rats [J]. World Journal of Emergency Medicine, 2012, 3(2): 135-140.
[5]	Hai-bin Ni, Zheng Zhang, Hai-dong Qin. Protective effect of glutamine in critical patients with acute liver injury [J]. World Journal of Emergency Medicine, 2011, 2(3): 210-215.