Partial Zone II Resuscitative Endovascular Balloon Occlusion of the Aorta in Management of Multiple Trauma with Combined Abdominal and Pelvic Injury

Abstract

Introduction: Resuscitative endovascular balloon occlusion of the aorta has been used in various clinical settings to elevate blood pressure in the setting of shock, even if the evidence base is weak with no clear indications. Case presentation: We report a case of traumatic hemorrhagic shock in which this technique was used in an unusual manner, treating obvious arterial abdominal bleeding associated with suspected pelvic arterial bleeding, in a Trauma Center where hybrid angiographic-surgical suite is not available. A 35-year-old man was involved in a traffic accident within 2 trucks. He was transported to the Major Trauma Center of an Integrated Trauma System where emergent laparotomy confirmed massive hepatic rupture and a bleeding control was obtained by large abdominal packing. Trauma team decided to considerate Resuscitative Endovascular Balloon Occlusion of the Aorta, positioning a deflated balloon in zone III to eventually manage a pelvic arterial hemorrhage, while performing Bogota Bag. Suddenly a new abdominal arterial bleeding was noted through Bogota Bag. Because Pringle maneuver was considered too difficult in this case because of liver hilum injury, the balloon was moved cranially with the aim to reach zone I. Introducer sheath displacement occurred at this time, and the balloon was then only partially inflated in zone II, usually considered too dangerous, and immediately the target systolic blood pressure of 90 mmHg was obtained. Transfer the patient into interventional radiology suite was then feasible and embolization of active bleeding by right hepatic artery and superior mesenteric artery branch, missed during first laparotomy, were performed. Balloon was definitely deflated after 50 minutes. The patient was discharged by the hospital 113 days later, fully recovered with long lasting motor rehabilitation program. Discussion: Partial zone II Resuscitative Endovascular Balloon Occlusion of the Aorta in this particular case allowed overcoming procedural mistakes without major complications and with good clinical outcome. Conclusion: Judicious manage of REBOA inflation time and amount, together with multidisciplinary contemporary damage control strategy with clear and effective team leading, is the key to effectively resuscitate multiple trauma shocked patients.