51 – Proximal Balloon Occlusion for Cardiac Arrest

#tbs19 The Big Sick—-  You’ve heard of ECMO for cardiac arrest- utilizing a mechanical pump to aid in perfusion of the coronaries.  What if you can’t do ECMO?  What if your resources are such that simply can’t lug a 10 kilogram machine out into the field?  Well, Jostein Brede may have something for you to consider.  He and several other places worldwide are on the forefront of using a REBOA catheter to occlude the proximal aorta during chest compressions in hopes that coronary perfusion pressure increases.  This would subsequently improve chance of return of spontaneous circulation and overall survivorship.  Maybe this is the band-aid that can be used in austere environments like rural Norway where the temperatures are extreme, the people are sparse, but the physicians are motivated.  12

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. T. 2017;35(5):731-736. doi:10.1016/j.ajem.2017.01.010
Aslanger E, Golcuk E, Oflaz H, et al. Intraaortic balloon occlusion during refractory cardiac arrest. A case report. R. 2009;80(2):281-283. doi:10.1016/j.resuscitation.2008.10.017

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  1. Chris Holthaus says

    Hi Zack,
    Great topic. Barring heterogeneity in time down and co-morbidities, it kind of gives me new hope to wonder if cardiac arrest ROSC/CPC/mortality can be improved via mechanical descending aortic occlusion during arrest (by augmenting afterload for cardiocerebral perfusion and/or avoiding excess epinephrine toxicity?). Some additional thoughts as we watch this unfold are:
    1. Does a significant outcome difference exist between REBOA zone 1 or 3 occlusions during arrest?
    2. If REBOA zone 3 occlusion is equivalent to zone 1, can an external device like the (AAJT) abdominal aortic and junctional tourniquet (faster?/less invasive vs REBOA) theoretically occluding zone 3 achieve equivalent REBOA zone 3 outcomes?
    3. Does a zone 3 occlusion and theoretic preservation of renal and splanchnic perfusion (ie avoidance/less gut ischemia/reperfusion injury) tend to do better than zone 1 for cardiac arrest application?
    Interested to hear everyone’s thoughts on this topic. Exciting times!?!?!?!
    -Chris Holthaus, M.D.
    EM Washington University in St. Louis

    • Chris I am interested in investigating similar, I think the AAJT will be limited by the frequency we encounter obese patients but I think the Junctional Tourniquet may be an excellent adjunct. As much as it pains me to say, a pneumatic garment on the legs could do the same.

      Josh Todd, EMT-P, FP-C
      Austin EMS

    • Jostein R Brede says

      Hi Zack and thank you for the invite.
      Its great to see interest and comments on this!
      There are currently no human studies that compare zone 1 to zone 3 occlusion. There are some preclinical studies, like this https://www.ncbi.nlm.nih.gov/pubmed/29965941 that compares zone 3 to zone 1 in swine with hemorrhage and zone 1 was found superior. A challenge is that most studies use swine with hemorrhage, but this is a different “patient cohort” than (euvolemic) cardiac arrest. This study https://www.ncbi.nlm.nih.gov/pubmed/30067564 compares proximal and distal zone 1 occlusion (zone 1a and 1b) in swine with cardiac arrest. I do believe that the more proximal occlusion (zone 1 rather than 3) will provide better hemodynamic effect during CPR on humans. A comparative clinical study is the only way to find out!
      REBOA might be established swift and safe, given that the resuscitation team is competent in Seldinger technique and ultrasound. I grant that this is not possible in all prehospital services. This study https://www.ncbi.nlm.nih.gov/pubmed/29661286 compare REBOA zone 3 to AAJT, but again, this is swine with hemorrhage and the goal was hemostasis. The AAJT (tourniquet) might be easier to establish, but I believe there are some limitations (severe obesity) and possible side effects to the technique. This paper http://www.jevtm.com/journal/images/v2n3/03_JEVTM_58/03_JEVTM_58.html describes all techniques (including SAAP).
      The concept of REBOA in cardiac arrest is in its infancy and I think there is a lot of questions to be answered in the future!
      Best regards,
      Jostein R Brede, MD
      Trondheim, Norway

  2. Jesper Fjølner says

    Super interesting. How long time do you use to insert the arterial cannula initially?
    Are you using the Prytimes ER REBOA catheter?

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