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. 2023 May 12;8(1):e001075.
doi: 10.1136/tsaco-2022-001075. eCollection 2023.

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  1   2   3 , Jens Åström  4 , Anna Stene Hurtsén  1   5 , Tal M Hörer  1   5 , Kristofer F Nilsson  1   5
Affiliations

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 et al. Trauma Surg Acute Care Open. .

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.

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Conflict of interest statement

Competing interests: JÅ has an ongoing collaboration with GE Healthcare regarding workshops in peripheral nerve blocks, but has not received any private payments. The other authors declare no conflicts of interest of the subject matter.

Figures

Figure 1
Figure 1
Study protocol and animal inclusion where nine anesthetized pigs were randomized in a cross-over fashion to ultrasound-guided and fluoroscopy-guided balloon placement of resuscitative endovascular balloon occlusion of the aorta (REBOA) and supraheptic vena cava (REBOVC).
Figure 2
Figure 2
Fluoroscopic and ultrasonic images of resuscitative endovascular balloon occlusion of the supraceliac aorta (REBOA) or of the suprahepatic vena cava (REBOVC) placed either by fluoroscopy guidance or ultrasound guidance in six anesthetized pigs. Three of the animals (row #1–3) had REBOA and REBOVC fluoroscopy-guided placement first (columns 1 and 4) and thereafter ultrasound-guided placement (columns 2 and 5) which was confirmed by fluoroscopy (control fluoroscopy, columns 3 and 6). Three of the animals (row #4–6) had REBOA and REBOVC positioned by ultrasound guidance first which was confirmed by fluoroscopy, and second placement guided by fluoroscopy. Large arrows show the tip of the REBOA/REBOVC catheter. Small arrows show one of the hepatic veins at their confluence with the inferior vena cava. Asterisks show the REBOVC balloon deployed in the inferior vena cava cranially to the confluence of the hepatic veins in the inferior vena cava.
Figure 3
Figure 3
Time to positioning of resuscitative endovascular balloon occlusion of the supraceliac aorta (REBOA) or of the suprahepatic vena cava (REBOVC) either by fluoroscopy guidance or ultrasound guidance in nine anesthetized pigs (n=7–8 per intervention).
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