A porcine study of ultrasound-guided versus fluoroscopy-guided placement of endovascular balloons in the inferior vena cava (REBOVC) and the aorta (REBOA)

Maria B Wikström; Jens Åström; Anna Stene Hurtsén; Tal M Hörer; Kristofer F Nilsson

doi:10.1136/tsaco-2022-001075

A porcine study of ultrasound-guided versus fluoroscopy-guided placement of endovascular balloons in the inferior vena cava (REBOVC) and the aorta (REBOA)

Trauma Surg Acute Care Open. 2023 May 12;8(1):e001075. doi: 10.1136/tsaco-2022-001075. eCollection 2023.

Authors

Maria B Wikström^{1

2

3}, Jens Åström⁴, Anna Stene Hurtsén^{1

5}, Tal M Hörer^{1

5}, Kristofer F Nilsson^{1

5}

Affiliations

¹ Örebro University School of Medical Sciences, Faculty of Medicine and Health, Örebro, Sweden.
² Centrum för Klinisk Forskning, Region Värmland, Karlstad, Sweden.
³ Emergency Department, Arvika Hospital, Arvika, Sweden.
⁴ Department of Anesthesiology, Falun Hospital, Region Dalarna, Sweden.
⁵ Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.

Abstract

Objectives: In fluoroscopy-free settings, alternative safe and quick methods for placing resuscitative endovascular balloon occlusion of the aorta (REBOA) and resuscitative endovascular balloon occlusion of the inferior vena cava (REBOVC) are needed. Ultrasound is being increasingly used to guide the placement of REBOA in the absence of fluoroscopy. Our hypothesis was that ultrasound could be used to adequately visualize the suprahepatic vena cava and guide REBOVC positioning, without significant time-delay, when compared with fluoroscopic guidance, and compared with the corresponding REBOA placement.

Methods: Nine anesthetized pigs were used to compare ultrasound-guided placement of supraceliac REBOA and suprahepatic REBOVC with corresponding fluoroscopic guidance, in terms of correct placement and speed. Accuracy was controlled by fluoroscopy. Four intervention groups: (1) fluoroscopy REBOA, (2) fluoroscopy REBOVC, (3) ultrasound REBOA and (4) ultrasound REBOVC. The aim was to carry out the four interventions in all animals. Randomization was performed to either fluoroscopic or ultrasound guidance being used first. The time required to position the balloons in the supraceliac aorta or in the suprahepatic inferior vena cava was recorded and compared between the four intervention groups.

Results: Ultrasound-guided REBOA and REBOVC placement was completed in eight animals, respectively. All eight had correctly positioned REBOA and REBOVC on fluoroscopic verification. Fluoroscopy-guided REBOA placement was slightly faster (median 14 s, IQR 13-17 s) than ultrasound-guided REBOA (median 22 s, IQR 21-25 s, p=0.024). The corresponding comparisons of the REBOVC groups were not statistically significant, with fluoroscopy-guided REBOVC taking 19 s, median (IQR 11-22 s) and ultrasound-guided REBOVC taking 28 s, median (IQR 20-34 s, p=0.19).

Conclusion: Ultrasound adequately and quickly guide the placement of supraceliac REBOA and suprahepatic REBOVC in a porcine laboratory model, however, safety issues must be considered before use in trauma patients.

Level of evidence: Prospective, experimental, animal study. Basic science study.

Keywords: multiple trauma; shock, hemorrhagic; ultrasonography; veins.