(1573) Endovascular Balloon Occlusion of the Aorta in a Frozen Abdomen and Massive Gastrointestinal Bleed

Introduction: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has been demonstrated as a useful adjunct that is a potentially life-saving intervention. This alternative technique has been used to control emergent non-traumatic, non-compressible bleeding and traumatic causes of hemorrhage. This study reports on a survivor with class IV hemorrhagic shock from a spontaneous common hepatic artery rupture treated with zone 1 REBOA placement at bedside in the Surgical Intensive Care Unit (SICU) prior to definitive control using endovascular techniques.

Description: A 28-year-old male was transferred as a trauma activation from an outside hospital as a restrained driver in a high-speed collision. He had a grade 4 liver laceration (segment 4 B) and pancreatic head transection, with an associated duodenal injury. On arrival, the patient underwent angioembolization. The gastroduodenal artery appeared occluded at its origin and multiple attempts at selection were unsuccessful. The patient subsequently required damage control laparotomy and multiple reoperations for management of his intra-abdominal injuries; the abdomen was deemed frozen on hospital day 11.

On hospital day 20, the patient developed massive hematemesis, hematochezia, and hemorrhagic shock. REBOA was placed in the SICU, and a massive transfusion protocol was initiated. A 12 Fr sheath was inserted and an aortic occlusion balloon was inflated in Zone 1. Following transport to the angiography suite, a 7 Fr steerable sheath was used to select the celiac artery axis. Frank rupture of the proper hepatic artery was noted and controlled with detachable coils. The total inflation time was 35 minutes. The starting systolic blood pressure of 40 mmHg improved to 150 mmHg after inflation. The patient recovered and remained neurologically intact, and was discharged for acute rehabilitation.

Discussion: This case demonstrates the novel use of REBOA bedside in the SICU for the management of massive gastrointestinal bleeding. REBOA allowed us to achieve temporary hemodynamic stability prior to definitive control in the angiography suite when the patient’s frozen abdomen precluded open operation for hemorrhage control. The bedside use of REBOA in the SICU prevented exsanguination and death.