Inappropriate Resuscitative endovascular balloon occlusion of the aorta (REBOA) Catheter Placement in Patient With Unexpected Left Common Iliac Artery Rupture

Article information

Trauma Image Proced. 2019;4(1):10-11
Publication date (electronic) : 2019 May 31
doi : https://doi.org/10.24184/tip.2019.4.1.10
Department of Surgery, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital
Correspondence to: Pil Young Jung, Department of Surgery, Yonsei university Wonju college of medicine, Wonju Severance Christian Hospital, Trauma center, 220-701, 20 Ilsan-ro, Wonju-si, Gangwon-do, South Korea Tel: 82-33-741-0882, Fax: 82-33-741-0574, E-mail: surgery4trauma@yonsei.ac.kr
Received 2019 April 24; Revised 2019 May 16; Accepted 2019 May 16.

Abstract

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is effective method increasingly used in cases of traumatic noncompressible torso hemorrhage. However, it is performed in an emergency situation, and the source of hemorrhage cannot be verified during implementation, which may make it difficult to place the catheter accurately.

In the case reported here, catheter placement was inappropriate.

CASE

A 70-year-old man came to our facility after a car accident. The vital signs were unstable; blood pressure could not be recorded at the time of arrival. Immediately after arrival, cardiac arrest occurred twice, and resuscitation was successful. In the emergency room, he underwent brief sonographic examination, and a massive fluid collection was observed in the splenorenal recess. Resuscitative endovascular balloon occlusion of the aorta (REBOA) was also performed with blind puncture technique during the resuscitation. The balloon was inflated with 25 mL of normal saline, but there was no sense of resistance, which is considered unusual. Placement of the catheter tip was checked with bedside ultrasonography but was not clearly confirmed because of the massive fluid collection. In general, catheter tip placement is confirmed with radiography, fluoroscopy, or ultrasonography [1], but the serious emergency situation precluded these assessments. The patient’s blood pressure recovered to 80/50 mm Hg, and he was moved to the operating room immediately.

During the operation, vascular rupture from aortic bifurcation to the left common iliac artery was confirmed (Fig. 1). The REBOA catheter was found to be misplaced: It had been inserted correctly via the femoral artery, but it exited through the ruptured pore of the iliac artery (Fig. 2). We inserted the catheter back into the aorta urgently and then compressed the injured site to control bleeding; however, cardiac arrest continued. The abdomen was closed, the patient was moved to the intensive care unit, and then he was pronounced dead.

Fig. 1.

Ruptured left common iliac artery.

Fig. 2.

Catheter used in resuscitative endovascular balloon occlusion of the aorta (REBOA) that escaped from the ruptured pore of the iliac artery.

DISCUSSION

Noncompressible torso hemorrhage (NCTH) is associated with a high mortality rate (45%) and is the leading cause of death from trauma [2]. Controlling hemorrhage is therefore a key part of management. REBOA is a technique in which an inflatable balloon is temporarily inserted in aorta to increase cardiac afterload until definitive management can be performed [3]. For this reason, it has been increasingly used in trauma and prehospital care [4].

However, various complications have also been reported, such as vessel injury, distal ischemia, ischemia-reperfusion injury, and cardiovascular complications [5]. Furthermore, extreme caution is required in treating unstable pelvic fractures or potential iliofemoral vascular injuries [6].

I therefore suggest that REBOA be performed by experienced, professional medical personnel and that appropriate patient selection be considered as well.

Notes

Conflict of Interest Statement

None of authors have a conflict of interest

References

1. Daley J, Morrison JJ, Sather J, Hile L. The role of resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct to ACLS in non-traumatic cardiac arrest. Am J Emerg Med 2017;35(5):731–6.
2. Kisat M, Morrison JJ, Hashmi ZG, Efron DT, Rasmussen TE, Haider AH. Epidemiology and outcomes of non- compressible torso hemorrhage. J Surg Res 2013;184(1):414–21.
3. Sadeghi M, Nilsson KF, Larzon T, Pirouzram A, Toivola A, Skoog P, et al. The use of aortic balloon occlusion in traumatic shock: first report from the ABO trauma registry. Eur J Trauma Emerg Surg 2018;44(4):491–501.
4. Zhang J, Watson JD, Drucker C, Kalsi R, Crawford RS, Toursavadkohi SA, et al. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Not Yet Applicable for Widespread Out-of-Hospital Use: A Case of Nonsurvivable Complication from Prolonged REBOA Inflation. Ann Vasc Surg 2019;56:354. e5- e9.
5. 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;13:20.
6. Ozkurtul O, Staab H, Osterhoff G, Ondruschka B, Hoch A, Josten C, et al. Technical limitations of REBOA in a patient with exsanguinating pelvic crush trauma: a case report. Patient Saf Surg 2019;13:25.

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Fig. 1.

Ruptured left common iliac artery.

Fig. 2.

Catheter used in resuscitative endovascular balloon occlusion of the aorta (REBOA) that escaped from the ruptured pore of the iliac artery.