LAUSR

more targeted aortic occlusion (AO) in the distal aorta for pelvic, junctional, or extremity hemorrhage. Summary: This study describes the current largest single-institution experience with REBOA in the United States. The use of REBOA at an urban tertiary care facility for severe traumatic hemorrhage, traumatic arrest (AR), or nontraumatic hemorrhage (NTH) was investigated from February 1, 2013 to January 31, 2017, among 90 patients who were not responsive or were transiently responsive to resuscitation measures, or were in arrest, from presumed hemorrhage below the diaphragm. Possible causes were trauma or nontrauma-related hemorrhage. Patients with ruptured aortic aneurysms were excluded. The main outcome was in-hospital mortality. Approximately 20% of the procedures were performed by endovascular trained vascular surgeons while the rest by acute care surgeons without formal endovascular training. Seventeen percent were malpositioned as noted by some type of imaging and required more proximal positioning. Of the 90 patients in the study (15 women and 75 men; mean [SD] age, 41.5 [17.4] years), 29 underwent REBOA for severe traumatic hemorrhage, 50 for AR, and 11 for NTH. For the patients with severe traumatic hemorrhage and AR, the median age was 36.2 years (interquartile range, 25.3-55.5 years), mean (SD) admission Glasgow Coma Scale score was 6 (5), and median Injury Severity Score was 39 (interquartile range, 10-75). The distal thoracic aorta was occluded in 73 patients (81%), and in all patients with AR. A total of 17 patients (19%) had distal abdominal AO. Mean (SD) systolic blood pressure improved in patients with severe traumatic hemorrhage, from 68 (28) mmHg prior to AO, to 131 (12) mmHg after AO (P < 0.001). Percutaneous access was used in 30 patients (33%), including 13 patients with AR (26%), and groin cutdown in 60 patients (67%), including 37 patients with AR (74%). Overall 30-day mortality was 62% (n 1⁄4 56): 11 (39%) in patients with severe traumatic hemorrhage and 45 (90%) in patients with AR. Of the patients with AR, 29 (58%) had return of spontaneous circulation and 11 of those patients (38%) survived to the operating room. All patients who survived AR gained full neurologic recovery. No aortoiliac injury or limb loss occurred from REBOA use per se but rather from severe preplacement extremity injury. Eleven patients underwent REBOA for NTH; 7 (64%) were in arrest. Overall in-hospital mortality for patients with NTH was 36% (n 1⁄4 4). Only patient died of bowel necrosis after an inflation time of longer than 2 hours. No procedural complications occurred in this group but at the time of removal three access site repairs were required in addition to 9 patients who required thrombectomy, 6 of whom were cannulated with 12 French sheaths. Comments: Others are learning from our experience with the care of a ruptured abdominal aortic aneurysm. This experience confirms in another cohort of patients the utility of aortic balloon occlusion for control of significant abdominal arterial bleeding with some risk of malposition without immediate imaging. Access site repair or extremity thrombectomy is not uncommon, may be the price for a survival advantage, but most be considered to prevent delayed morbidity or mortality.