Anatomical landmarks for safely implementing resuscitative balloon occlusion of the aorta (REBOA) in zone 1 without fluoroscopy

Abstract

Background: Resuscitative balloon occlusion of the aorta (REBOA) can maintain hemodynamic stability during hemorrhagic shock after a following torso injury, although inappropriate balloon placement may induce brain or visceral organ ischemia. External anatomical landmarks [the suprasternal notch (SSN) and xiphoid process (Xi)] are empirically used to implement REBOA in zone 1. We aimed to confirm if these landmarks were useful for determining a balloon catheter length for safe implementation of REBOA in zone 1 without using fluoroscopy.

Method: We selected 25 successive adult blunt trauma cases requiring contrast-enhanced chest/abdominal computed tomography (CT) treated at our emergency department (in an urban area of Kyoto city, Japan) between October 1, 2016 and January 31, 2017. We retrospectively evaluated anonymized CT images. We used three-dimensional multiplanar reconstructions to measure the length along the aorta's central axis, from the bilateral common femoral arteries (FA) to the celiac trunk (CeT) (FA-CeT) and to the origin of the left subclavian artery (LSCA) (FA-LSCA). Volume-rendering reconstruction images were used to measure the external distance from common FAs to SSN (FA-SSN) and to Xi (FA-Xi).

Result: FA-LSCA was significantly longer than FA-SSN. FA-CeT was significantly shorter than FA-Xi.

Discussion: Based on these results, the REBOA balloon catheter should be shorter than FA-SSN, and longer than FA-Xi to avoid placement outside zone 1. The advantages of this method are that it can rapidly and easily predict a safe balloon catheter length, and it reflects each patient's individual torso height.

Conclusion: To safely implement REBOA, the balloon catheter length should be shorter than FA-SSN and longer than FA-Xi. We believe that these anatomical landmarks are good references for safe implementation of REBOA in zone 1 without radiographic guidance.

Keywords: Aortic balloon occlusion (ABO); External landmark; Hemorrhagic shock; Resuscitative balloon occlusion of the aorta (REBOA); Trauma resuscitation.

Conflict of interest statement

Ethics approval and consent to participate

As this study was retrospective anonymized review and no intervention was performed, the ethics committee in our hospital did not require ethical approval.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1

Three-dimensional and volume-rendering images. a Three-dimensional multiplanar reconstructions were used to measure the length from the bilateral common femoral artery (FA) to the origin of the left subclavian artery (LSCA) and to the celiac trunk (CeT). b Volume-rendering images were used to measure the external distances from the common FAs to the suprasternal notch (SSN) and to the xiphoid process (Xi)

Fig. 2

Distributions of the measurements from this study. The box plots indicate that FA–LSCA was significantly longer than FA–SSN, and FA–Xi was significantly longer than FA–CeT on both sides (paired one-tailed t-test, p < 0.01). FA: femoral artery, FA–LSCA: the artery length between common femoral artery and the origin of left subclavian artery, FA–SSN: the external distance from common femoral artery to supra-sternum notch, FA–Xi: The external distance from common femoral artery to the xiphoid process, FA–CeT: the artery length between common femoral artery and celiac trunk, LSCA: left subclavian artery, SSN: suprasternal notch, Xi: xiphoid process, CeT: celiac trunk

Fig. 3

The model for using external anatomical landmarks for predicting a safe balloon catheter length