Intra-Operative Combination of Resuscitative Endovascular Balloon Occlusion of the Aorta and a Median Sternotomy in Hemodynamically Unstable Patients' with Penetrating Chest Trauma: Is this feasible?

AbstractBackgroundRecent evidence suggests that REBOA is an effective live saving intervention in patients with severe torso trauma. However, the deployment of REBOA in patients with isolated penetrating intra-thoracic injuries remains controversial. We propose that a median sternotomy be performed in conjunction with REBOA as a feasible and effective means of hemorrhage control in patients suffering from penetrating chest trauma who present hemodynamically unstable. The objective of our study was to present our initial experience with this approach.MethodsA prospectively collected case series of the use of REBOA (10 Fr) in conjunction with a median sternotomy from January, 2015 to December, 2016 at a Level I Trauma Center. We included hemodynamically unstable non-compressible torso hemorrhage patients with penetrating chest trauma that underwent intra-operative REBOA deployment plus median sternotomy.ResultsA total of 68 trauma related emergent thoracic surgeries were performed at our institution during the study period. Of these, seven suffered from penetrating chest trauma and non-compressible torso hemorrhage and underwent REBOA plus median sternotomy. Six out of the seven patients suffered intra-thoracic vascular injuries: 2 subclavian arteries, 2 internal mammary arteries, 2 aortic arch and 5 major central venous injuries. Four patients had an associated lung injury with AIS>3, of which two suffered a pulmonary hilar vessel disruption. REBOA-related complications included one case of upper gastrointestinal bleeding. Six out of the seven patients survived the 30 day follow-up. No adverse neurologic outcomes or deficits were observed in survivors.ConclusionThe combined use of REBOA and median sternotomy could be a feasible and effective alternative to hemorrhage control in patients with non-compressible torso hemorrhage secondary to penetrating chest trauma. These findings challenge the recommendation against the use of REBOA in penetrating intra-thoracic injuries. Future studies with stronger designs and larger sample sizes are required to confirm our results.Level of EvidenceV, therapeutic Background Recent evidence suggests that REBOA is an effective live saving intervention in patients with severe torso trauma. However, the deployment of REBOA in patients with isolated penetrating intra-thoracic injuries remains controversial. We propose that a median sternotomy be performed in conjunction with REBOA as a feasible and effective means of hemorrhage control in patients suffering from penetrating chest trauma who present hemodynamically unstable. The objective of our study was to present our initial experience with this approach. Methods A prospectively collected case series of the use of REBOA (10 Fr) in conjunction with a median sternotomy from January, 2015 to December, 2016 at a Level I Trauma Center. We included hemodynamically unstable non-compressible torso hemorrhage patients with penetrating chest trauma that underwent intra-operative REBOA deployment plus median sternotomy. Results A total of 68 trauma related emergent thoracic surgeries were performed at our institution during the study period. Of these, seven suffered from penetrating chest trauma and non-compressible torso hemorrhage and underwent REBOA plus median sternotomy. Six out of the seven patients suffered intra-thoracic vascular injuries: 2 subclavian arteries, 2 internal mammary arteries, 2 aortic arch and 5 major central venous injuries. Four patients had an associated lung injury with AIS>3, of which two suffered a pulmonary hilar vessel disruption. REBOA-related complications included one case of upper gastrointestinal bleeding. Six out of the seven patients survived the 30 day follow-up. No adverse neurologic outcomes or deficits were observed in survivors. Conclusion The combined use of REBOA and median sternotomy could be a feasible and effective alternative to hemorrhage control in patients with non-compressible torso hemorrhage secondary to penetrating chest trauma. These findings challenge the recommendation against the use of REBOA in penetrating intra-thoracic injuries. Future studies with stronger designs and larger sample sizes are required to confirm our results. Level of Evidence V, therapeutic address correspondence to: Carlos A. Ordoñez MD FACS, ordonezcarlosa@gmail.com, Division of Trauma and Acute Care Surgery, Department of Surgery, Fundacion Valle del Lili and Universidad del Valle, Carrera 98 #18-49, Cali, Colombia. Conflict of interest: The authors have no conflict of interest, no disclosure. Financial Support: None Presented at the 76th Annual Meeting of AAST and Clinical Congress of Acute Care Surgery, September 13–16, 2017 in Baltimore, Maryland. © 2018 Lippincott Williams & Wilkins, Inc.

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