Can contrast-enhanced ultrasonography improve Zone III REBOA placement for prehospital care?

BACKGROUND: Torso hemorrhage is the primary cause of potentially preventable mortality in trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been advocated as an adjunct to bridge patients to definitive hemorrhage control. The primary aim of this studywas to assesswhether contrast-enhanced ultrasonography can improve the accuracy of REBOAplacement in the infrarenal aorta (Zone III). METHODS: A fluoroscopy-free ''enhanced'' Zone III REBOA technique was developed using a porcine cadaver model. A ''standard'' over-thewire Seldinger technique was used, which was enhanced with the addition of a microbubble contrast medium to inflate the balloon, observed with ultrasonography. Following this, attending-and resident-level physicianswere randomized into two groups. They were taught either the enhanced with ultrasonography guidance (GroupA) or the standardmeasuring length of catheter insertion (Group B) technique as part of a human cadaver trauma skills course. Outcomes assessed included time (seconds) from insertion to inflation, accuracy, and missed targets. All results were benchmarked against three endovascular experts. RESULTS: Therewere 20 participants who performed REBOAwith GroupA(51 [31]) being significantly faster than Group B (90 [63]) (p = 0.003) and more accurate (p = 0.023) with no missed targets. Group B had five missed targets, the most common error being inflation within Zone II. CONCLUSION: For Zone III REBOA, contrast-enhanced ultrasonography technique is faster and more accurate than the standard technique. This may have value in time-critical and austere environments. Clinical studies are now required to evaluate this approach further. J Trauma Acute Care Surg. 2016;80: 89-94.