Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an effective resuscitative modality to temporize noncompressible truncal hemorrhage. Confirming the proper position of the balloon catheter in the target aortic zone is vital. Currently, there is a need for nonradiographical methods. This would overcome the drawbacks of conventional imaging modalities, such as fluoroscopy. Several studies have suggested ultrasound-guided visualization via subxiphoid, transperitoneal, or transesophageal views as an alternative to conventional imaging methods. However, such views are easily obscured in emergency settings. Herein, we report the case of a 70-year-old patient who was successfully resuscitated by REBOA under the guidance of transsplenic ultrasound. REBOA was safely performed using transsplenic visualization without fluoroscopy.
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emerging adjunct therapy used to occlude the aorta at a site proximal to the hemorrhage until definite repair of the injury can be achieved [
Ultrasound (US) is a ubiquitous tool that offers mobility and expeditiousness in the emergency setting. The use of US as a novel imaging modality during REBOA has been previously described in the studies where subxiphoid, transperitoneal, or transesophageal views were used to confirm the correct intraaortic positioning of the catheter [
A 70-year-old male patient presented in a state of semicoma after a motorcycle crash. Upon arrival, the patient was hemodynamically unstable with a blood pressure of 71/54 mmHg and a pulse rate of 120 beats/minute. A FAST examination showed fluid collection in the splenorenal recess and absence of lung sliding on the left side. Endotracheal intubation and a closed thoracostomy were performed. The hemoglobin level was 6.5 g/dL. Computed tomography revealed severe brain hemorrhage and multiple torso injuries, including a Grade 3 splenic laceration. As the patient’s blood pressure deteriorated, REBOA in the supra-diaphragmatic location (Zone 1) was performed according to the algorithm for REBOA usage in hemorrhagic shock at Dankook University hospital (
A 7-Fr introducer sheath and a 0.025-inch guidewire were inserted in the left common femoral artery using the Seldinger technique. After measuring the distance from the sheath to the xiphoid process, a 7-Fr balloon catheter (Rescue Balloon, Tokai Medical Products, Aichi, Japan) was blindly advanced up to 50 cm along the wire and the balloon was partially inflated with 5 mL of saline. With the patient in the supine position, a curved array probe with a median frequency of 2–4 MHz was positioned at the 10th intercostal space for a posterolateral approach (
The aorta is divided into 3 zones while performing REBOA: Zone 1 is supradiaphragmatic and distal to the left subclavian artery but proximal to the celiac artery; Zone 2 is between the celiac trunk and the renal arteries; and Zone 3 is below the renal artery but proximal to the iliac bifurcation [
Fluoroscopy has been considered the gold standard for imaging-guided REBOA [
The 9–11th intercostal spaces in the left side represent the optimal window for transsplenic imaging. Homogeneous echogenicity and location of the spleen render transsplenic US useful during REBOA. The exact location of the catheter can be determined by correcting the sonographic angle such that the entire length of the aortic lumen runs parallel to the coronal plane. This will ensure that the US beam intersects the spleen perpendicular to the aorta (
To the best of our knowledge, this is the 1st report that demonstrates the applicability of transsplenic US for safe and accurate Zone 1 REBOA. However, this method has some limitations. The sonographic window is compromised by obesity, pneumoperitoneum, subcutaneous emphysema, and tortuous or calcified aorta [
In summary, there is a need for faster, effective portable imaging modalities to replace the current standard methods used during REBOA. This case demonstrates that REBOA can be safely performed using transsplenic visualization without fluoroscopy. Therefore, we recommend transsplenic US-guidance as an option when visualization using other approaches is not possible during REBOA.
Methodology, conceptualization and writing - review & editing: SWC, DHK. Investigation, visualization and writing - original draft: YH. Project administration: DHK.
The authors have no conflicts of interest to declare.
This research did not involve any human or animal experiments.
All relevant data are included in this manuscript.
None.
Algorithm developed by Dankook University Hospital, Level 1 trauma center for REBOA usage in hemorrhagic shock [
* Early transfusion in resuscitation room and no possible aortic injury by chest radiography.
† Door-to incision time less than 30 minutes. REBOA, resuscitative endovascular balloon occlusion of the aorta.
ATLS = advanced trauma life support; FAST = focused assessment with sonography for trauma; SBP = systolic blood pressure.
Time course through resuscitation, surgery, and critical care (hours and minutes).
FFP = fresh frozen plasma; PRC, packed red blood cell; REBOA, resuscitative endovascular balloon occlusion of the aorta; SBP, systolic blood pressure.
The transsplenic method during resuscitative endovascular balloon occlusion of the aorta in Zone 1.
A transverse view of the abdominal aorta using the transsplenic method. (A and B) initially, the inflated balloon was located underneath the diaphragm. (C and D) after advancing the catheter by 5 cm cephalad, the balloon was no longer observed.
Position of the 7-Fr balloon catheter (arrow) in the aortic Zone 1 was reconfirmed by X-ray.
The optimal sonographic window (A) in the sagittal, and (B) coronal computed tomographic images (solid arrows). Perpendicular images are desirable (ii) as inappropriate angles lead to wrong locations for the catheter (i, iii).