The effect of an endovascular Heaney maneuver to achieve total hepatic isolation on survival, hemodynamic stability, retrohepatic bleeding, and collateral flow in a porcine model

Abstract

Purpose: Combining resuscitative endovascular balloon occlusion of the aorta (REBOA) and the inferior vena cava (REBOVC) with open surgery is a new hybrid approach for treating retrohepatic vena caval injuries. We compared endovascular total hepatic isolation with supraceliac REBOA ± suprahepatic REBOVC and no occlusion in experimental retrohepatic vena cava bleeding regarding survival, bleeding volume, hemodynamic stability, and arterial collateral blood flow.

Methods: Twenty-five anesthetized pigs (n = 6-7/group) were randomized to REBOA; REBOA + REBOVC; REBOA + infra and suprahepatic REBOVC + portal vein occlusion (endovascular Heaney maneuver, four-balloon-occlusion, 4BO) or no occlusion. After balloon inflation, free bleeding was initiated from an open sheath in the retrohepatic vena cava. Bleeding volume, right internal thoracic artery (RITA) blood flow, hemodynamics, and arterial blood variables were measured until death or up to 90 min.

Results: The REBOA group had a longer median survival time (63 min) compared with the 4BO (24 min, P = 0.02) and no occlusion (30 min, P = 0.02) groups, not versus the REBOA + REBOVC group (49 min, P > 0.05). The first 15 min accumulated bleeding was comparable in all groups (P > 0.05); Thereafter, bleeding volume was higher in the REBOA group versus the 4BO group (P < 0.05), not versus the other groups. RITA blood flow and MAP were higher in the REBOA group versus the other groups after 10 min of bleeding (P < 0.05).

Conclusions: Endovascular Heaney maneuver was not beneficial for survival or hemodynamic stability in this porcine model, whereas supraceliac REBOA was. Anatomical differences in thoracoabdominal collaterals between pigs and humans must be considered when interpreting these results.

Keywords: REBOA; REBOVC; Retrohepatic inferior vena cava; Trauma.

Fig. 1

An illustration (A) and an x-ray (B) of the endovascular Heaney maneuver (four balloon occlusion) theoretically creating total hepatic isolation

Fig. 2

Survival (A) and accumulated bleeding volume (B) in anesthetized pigs randomized to either supraceliac resuscitative endovascular balloon occlusion of the aorta (REBOA, N = 6); REBOA + suprahepatic resuscitative endovascular balloon occlusion of the inferior vena cava (REBOVC, N = 6); REBOA + supra and infrahepatic REBOVC + endovascular portal vein balloon occlusion (four balloon occlusion, N = 6); or no occlusion (N = 7), started between time − 5 min and 0 min and subjected to free retrohepatic inferior vena cava bleeding (after time 0 min). Data are expressed as means with a 95% confidence interval. * indicates P < 0.05 between the REBOA group and the four balloon occlusion group at the respective time points

Fig. 3

Blood flow in right internal thoracic artery (RITA, A), mean arterial systemic pressure (MAP, B), and cardiac output (C) in anesthetized pigs randomized to either supraceliac resuscitative endovascular balloon occlusion of the aorta (REBOA, N = 6); REBOA + suprahepatic resuscitative endovascular balloon occlusion of the inferior vena cava (REBOVC, N = 6); REBOA + supra and infrahepatic REBOVC + endovascular portal vein balloon occlusion (four balloon occlusion, N = 6); or no occlusion (N = 7) started between time − 5 min and 0 min and subjected to free retrohepatic inferior vena cava bleeding (after time 0 min). Data are expressed as means with a 95% confidence interval. *, #, and ¤ indicate P < 0.05 between the REBOA group and four balloon occlusion, REBOA + suprahepatic REBOVC group, and no occlusion group, respectively, at 10 min after start of bleeding. & indicates P < 0.05 between the four balloon occlusion group and no occlusion group, at 10 min after start of bleeding

Fig. 4

Illustration of the human arterial (A) and venous (B) collateral pathways between thorax and abdomen