Name: complete and partial aortic occlusion for the treatment of hemorrhagic shock in swine
Uploaded: 2018-08-24T14:45:00
Description: Watch this Scientific Journal Video about Complete and Partial Aortic Occlusion for the Treatment of Hemorrhagic Shock in Swine at JoVE.com

We would like to acknowledge Rachel O&#39;Connell,&#160;and Jessica Lee for their assistance with the animal studies. We would also like to acknowledge Maj. General Harold Timboe, MD, MPH, U.S. Army (Ret.), who has been an advisor and mentor for this project.

In conducting research using animals, the investigators adhered to the Animal Welfare Act Regulations and other Federal statutes relating to animals and experiments involving animals and the principles set forth in the current version of the Guide for Care and Use of Laboratory Animals of the National Research Council. This study protocol was approved by the University of Michigan Institutional Animal Care and Use Committee (IACUC). The experiments were conducted in compliance with all regulations and guidelines regardin...

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E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+role+of+REBOA+in+the+control+of+exsanguinating+torso+hemorrhage.">The role of REBOA in the control of exsanguinating torso hemorrhage.</a> Journal of Trauma and Acute Care Surgery. 78 (5), 1054-1058 (2015).</li><li>Manzano Nunez, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+meta-analysis+of+resuscitative+endovascular+balloon+occlusion+of+the+aorta+(REBOA)+or+open+aortic+cross-clamping+by+resuscitative+thoracotomy+in+non-compressible+torso+hemorrhage+patients.">A meta-analysis of resuscitative endovascular balloon occlusion of the aorta (REBOA) or open aortic cross-clamping by resuscitative thoracotomy in non-compressible torso hemorrhage patients.</a> World Journal of Emergency Surgery. 12, 30 (2017).</li><li>Gupta, B. K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+role+of+intra-aortic+balloon+occlusion+in+penetrating+abdominal+trauma.">The role of intra-aortic balloon occlusion in penetrating abdominal trauma.</a> Journal of Trauma. 29 (6), 861-865 (1989).</li><li>Inoue, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Resuscitative+endovascular+balloon+occlusion+of+the+aorta+might+be+dangerous+in+patients+with+severe+torso+trauma:+A+propensity+score+analysis.">Resuscitative endovascular balloon occlusion of the aorta might be dangerous in patients with severe torso trauma: A propensity score analysis.</a> Journal of Trauma and Acute Care Surgery. 80 (4), 559-566 (2016).</li><li>Russo, R. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Extending+the+golden+hour:+Partial+resuscitative+endovascular+balloon+occlusion+of+the+aorta+in+a+highly+lethal+swine+liver+injury+model.">Extending the golden hour: Partial resuscitative endovascular balloon occlusion of the aorta in a highly lethal swine liver injury model.</a> Journal of Trauma and Acute Care Surgery. 80 (3), 378-380 (2016).</li><li>Russo, R. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Partial+Resuscitative+Endovascular+Balloon+Occlusion+of+the+Aorta+in+Swine+Model+of+Hemorrhagic+Shock.">Partial Resuscitative Endovascular Balloon Occlusion of the Aorta in Swine Model of Hemorrhagic Shock.</a> Journal of the American College of Surgeons. 223 (2), 359-368 (2016).</li><li>Williams, T. K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Extending+resuscitative+endovascular+balloon+occlusion+of+the+aorta:+Endovascular+variable+aortic+control+in+a+lethal+model+of+hemorrhagic+shock.">Extending resuscitative endovascular balloon occlusion of the aorta: Endovascular variable aortic control in a lethal model of hemorrhagic shock.</a> The Journal of Trauma and Acute Care Surgery. 81 (2), 294-301 (2016).</li><li>Hannon, J. P., Swindle, M. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hemorrhage+and+hemorrhagic-shock+in+swine:+A+review.">Hemorrhage and hemorrhagic-shock in swine: A review.</a> Swine as Models in Biomedical Research. , 197-245 (1992).</li><li>Garry, B. P., Bivens, H. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Seldinger+technique.">The Seldinger technique.</a> Journal of Cardiothorac Anesthesia. 2 (3), 403 (1988).</li><li>Halaweish, I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Addition+of+low-dose+valproic+acid+to+saline+resuscitation+provides+neuroprotection+and+improves+long-term+outcomes+in+a+large+animal+model+of+combined+traumatic+brain+injury+and+hemorrhagic+shock.">Addition of low-dose valproic acid to saline resuscitation provides neuroprotection and improves long-term outcomes in a large animal model of combined traumatic brain injury and hemorrhagic shock.</a> The Journal of Trauma and Acute Care Surgery. 79 (6), 911-919 (2015).</li><li>Alam, H. B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surviving+blood+loss+without+blood+transfusion+in+a+swine+poly-trauma+model.">Surviving blood loss without blood transfusion in a swine poly-trauma model.</a> Surgery. 146 (2), 325-333 (2009).</li><li>Jin, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Traumatic+brain+injury+and+hemorrhagic+shock:+evaluation+of+different+resuscitation+strategies+in+a+large+animal+model+of+combined+insults.">Traumatic brain injury and hemorrhagic shock: evaluation of different resuscitation strategies in a large animal model of combined insults.</a> Shock. 38 (1), 49-56 (2012).</li><li>Nikolian, V. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Valproic+acid+decreases+brain+lesion+size+and+improves+neurologic+recovery+in+swine+subjected+to+traumatic+brain+injury,+hemorrhagic+shock,+and+polytrauma.">Valproic acid decreases brain lesion size and improves neurologic recovery in swine subjected to traumatic brain injury, hemorrhagic shock, and polytrauma.</a> The Journal of Trauma and Acute Care Surgery. 83 (6), 1066-1073 (2017).</li><li>Langeland, H., Lyng, O., Aadahl, P., Skjaervold, N. K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+coherence+of+macrocirculation,+microcirculation,+and+tissue+metabolic+response+during+nontraumatic+hemorrhagic+shock+in+swine.">The coherence of macrocirculation, microcirculation, and tissue metabolic response during nontraumatic hemorrhagic shock in swine.</a> Physiological Reports. 5 (7), (2017).</li><li>Johnson, M. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+effect+of+resuscitative+endovascular+balloon+occlusion+of+the+aorta,+partial+aortic+occlusion+and+aggressive+blood+transfusion+on+traumatic+brain+injury+in+a+swine+multiple+injuries+model.">The effect of resuscitative endovascular balloon occlusion of the aorta, partial aortic occlusion and aggressive blood transfusion on traumatic brain injury in a swine multiple injuries model.</a> Journal of Trauma Acute Care Surgery. 83 (1), 61-70 (2017).</li><li>Theisen, M. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ventral+recumbency+is+crucial+for+fast+and+safe+orotracheal+intubation+in+laboratory+swine.">Ventral recumbency is crucial for fast and safe orotracheal intubation in laboratory swine.</a> Laboratory Animals. 43 (1), 96-101 (2009).</li><li>Li, Y., Alam, H. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Modulation+of+acetylation:+creating+a+pro-survival+and+anti-inflammatory+phenotype+in+lethal+hemorrhagic+and+septic+shock.">Modulation of acetylation: creating a pro-survival and anti-inflammatory phenotype in lethal hemorrhagic and septic shock.</a> Journal of Biomedicine and Biotechnology. 2011, 523481 (2011).</li><li>Nikolian, V. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Valproic+acid+decreases+brain+lesion+size+and+improves+neurologic+recovery+in+swine+subjected+to+traumatic+brain+injury,+hemorrhagic+shock,+and+polytrauma.">Valproic acid decreases brain lesion size and improves neurologic recovery in swine subjected to traumatic brain injury, hemorrhagic shock, and polytrauma.</a> The Journal of Trauma and Acute Care Surgery. 83 (6), 1066-1073 (2017).</li><li>Dekker, S. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Normal+saline+influences+coagulation+and+endothelial+function+after+traumatic+brain+injury+and+hemorrhagic+shock+in+pigs.">Normal saline influences coagulation and endothelial function after traumatic brain injury and hemorrhagic shock in pigs.</a> Surgery. 156 (3), 556-563 (2014).</li><li>Causey, M. W., McVay, D. P., Miller, S., Beekley, A., Martin, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+efficacy+of+Combat+Gauze+in+extreme+physiologic+conditions.">The efficacy of Combat Gauze in extreme physiologic conditions.</a> The Journal of Surgical Research. 177 (2), 301-305 (2012).</li><li>Frankel, D. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Physiologic+response+to+hemorrhagic+shock+depends+on+rate+and+means+of+hemorrhage.">Physiologic response to hemorrhagic shock depends on rate and means of hemorrhage.</a> The Journal of Surgical Research. 143 (2), 276-280 (2007).</li><li>Morrison, J. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+inflammatory+sequelae+of+aortic+balloon+occlusion+in+hemorrhagic+shock.">The inflammatory sequelae of aortic balloon occlusion in hemorrhagic shock.</a> The Journal of Surgical Research. 191 (2), 423-431 (2014).</li><li>White, J. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+porcine+model+for+evaluating+the+management+of+noncompressible+torso+hemorrhage.">A porcine model for evaluating the management of noncompressible torso hemorrhage.</a> Journal of Trauma. 71, S131-S138 (2011).</li><li>Alam, H. B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Putting+life+on+hold-for+how+long?+Profound+hypothermic+cardiopulmonary+bypass+in+a+Swine+model+of+complex+vascular+injuries.">Putting life on hold-for how long? Profound hypothermic cardiopulmonary bypass in a Swine model of complex vascular injuries.</a> Journal of Trauma. 64 (4), 912-922 (2008).</li><li>Bebarta, V. S., Daheshia, M., Ross, J. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+significance+of+splenectomy+in+experimental+swine+models+of+controlled+hemorrhagic+shock.">The significance of splenectomy in experimental swine models of controlled hemorrhagic shock.</a> The Journal of Trauma and Acute Care Surgery. 75 (5), 920 (2013).</li><li>Georgoff, P. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Alterations+in+the+human+proteome+following+administration+of+valproic+acid.">Alterations in the human proteome following administration of valproic acid.</a> Journal of Trauma and Acute Care Surgery. 81 (6), 1020-1027 (2016).</li><li>Dekker, S. 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In this protocol, we highlighted a hemorrhagic shock model in swine. This model has been shown to be both reliable and reproducible16,17,18,19. Models similar to this have been employed in several scientific studies investigating the effects of hemorrhagic shock on animal physiology16,20. Furthermore, this model has also been used for t...

Hemorrhage continues to be the dominant cause of preventable deaths in patients undergoing traumatic events, accounting for 90% of trauma-related deaths in the military setting and 40% of post-traumatic deaths in the civilian population1,2. Although direct pressure can treat compressible hemorrhage, non-compressible torso hemorrhage remains difficult to treat and can be lethal without prompt hemostatic control. The historical approach of resuscitative thoracotomy or laparotomy with aortic cross-clamping has proved to be extremely invasive3,4. This intervention also requires a complex selection algorithm to determine the candidacy of patients that have undergone traumatic insults5.
In recent years, there has been a resurgence of interest in a previously described approach&#8212;resuscitative endovascular balloon occlusion of the aorta (REBOA)6,7,8. Although REBOA has conferred a short-term survival advantages in hemorrhage, a prolonged complete occlusion of the aorta during balloon inflation poses serious concerns that include irreversible end-organ ischemia9,10. In an attempt to overcome this potential morbidity, alternative endovascular strategies to manage hemorrhage are being devised. One such strategy that has seen a growing attention is a partial occlusion of the aorta11,12. The idea of partial aortic balloon occlusion affords the perfusion of vascular beds distal to the site of occlusion, improved physiologic proximal aortic MAPs, and a gradual afterload reduction following the balloon deflation. These changes in parameters are desired modifications to the physiological characteristics of a bleeding animal. Prior to this method&#39;s translation to humans, complete and partial aortic balloon occlusion catheters have been heavily tested in swine models of hemorrhagic shock11,12,13.
Swine have been used in studies entailing hemorrhagic shock for many years. Most of the current understanding of the pathophysiology of hemorrhagic shock is derived from studies that have utilized animal models, including swine. Their physiology and homeostatic responses in the setting of pathologic volume depletion following hemorrhage, especially those pertaining to blood clotting and cardiovascular responses, have been well-documented and are like those in humans14. Swine models of hemorrhagic shock also provide opportunities to investigate treatment strategies for hemorrhagic shock and other traumatic injuries.
In this study, we demonstrate a clinically realistic model of hemorrhagic shock in swine to evaluate endovascular treatment strategies, including complete and partial aortic balloon occlusion. We hypothesize that a partial occlusion of the aorta results in a better physiologic and laboratory profile compared to a complete occlusion of the aorta in swine undergoing a controlled fixed-volume hemorrhage.
We aimed to compare the physiologic effects of partial and complete aortic occlusion as a treatment for hemorrhagic shock in a swine model. Partial aortic occlusion was achieved using a selective aortic balloon occlusion in trauma (SABOT) catheter (Figure 1). The SABOT catheter is a two-balloon system that allows intra-luminal blood flow, thereby providing a partial aortic flow to the vascular beds distal to the occlusion. Complete aortic occlusion was achieved using a single-balloon aortic occlusion catheter (e.g.,CODA) (Figure 1). Treatment groups were randomized to undergo resuscitative aortic occlusion either with the complete or with the partial aortic balloon occlusion catheters (n = 2/group).
The major steps of the model include the induction of anesthesia and intubation, the maintenance of anesthesia, instrumentation, 35% TBV hemorrhage (20 min total; half over the first 7 min, and half over the remaining 13 min), aortic balloon occlusion and whole-blood resuscitation (60 min of occlusion; 20% whole-blood resuscitation during the last 20 min of the occlusion), critical care monitoring (240 min) with hemodynamic observation, and euthanasia with tissue harvesting. Figure 2 demonstrates the model utilized in this experiment.

<table>
	<tbody>
		<tr>
			<td>Yorkshire-Landrace Swine</td>
			<td>Michigan State University Veterinary Farm</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Anesthesia: Telazol</td>
			<td>Pfizer</td>
			<td></td>
			<td>Dose: 2-8 mg/kg; IM</td>
		</tr>
		<tr>
			<td>Anti-cholinergic: Atropine</td>
			<td>Pfizer</td>
			<td></td>
			<td>Dose: 1mg, IM</td>
		</tr>
		<tr>
			<td>Anesthesia: Isoflurane</td>
			<td>Baxter</td>
			<td></td>
			<td>Dose: 1-5%, INH</td>
		</tr>
		<tr>
			<td>Betadine</td>
			<td>Humco</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Alcohol 70%</td>
			<td>Humco</td>
			<td>NDC 0395-4202-28</td>
			<td></td>
		</tr>
		<tr>
			<td>Datex-Aespire Anesthesia Machine</td>
			<td>GE Healthcare</td>
			<td>7900</td>
			<td></td>
		</tr>
		<tr>
			<td>Endotracheal tube</td>
			<td>DEE Veterinary</td>
			<td>20170518</td>
			<td>Appropriate size for animal (6.5 or 7.0F)</td>
		</tr>
		<tr>
			<td>Laryngoscope</td>
			<td>Miller</td>
			<td>85-0045</td>
			<td></td>
		</tr>
		<tr>
			<td>Stylet</td>
			<td>Hudson RCI</td>
			<td>5-151--1</td>
			<td></td>
		</tr>
		<tr>
			<td>Jelco 20G IV Catheter</td>
			<td>Smiths Medical</td>
			<td>4054</td>
			<td></td>
		</tr>
		<tr>
			<td>Operating Room Monitor (Vital Signs Monitor)</td>
			<td>SurgiVet Advisor</td>
			<td>V9201</td>
			<td>May require at least 2</td>
		</tr>
		<tr>
			<td>Surgical Gowns</td>
			<td>Kimberly Clark</td>
			<td>90142</td>
			<td>Use appropriate size for surgeon.</td>
		</tr>
		<tr>
			<td>Sterile surgical gloves</td>
			<td>Cardinal Health (Allegiance)</td>
			<td>22537-570</td>
			<td>Use appropriate size for surgeon.</td>
		</tr>
		<tr>
			<td>Cautery Pencil</td>
			<td>Medline</td>
			<td>ESPB 2000</td>
			<td></td>
		</tr>
		<tr>
			<td>Suction tubing</td>
			<td>Medline</td>
			<td>DYND50251</td>
			<td></td>
		</tr>
		<tr>
			<td>Sunction tip: Yankauer</td>
			<td>Medline</td>
			<td>DYND50130</td>
			<td></td>
		</tr>
		<tr>
			<td>Bovie Aaron 1250 Electrocautery Unit</td>
			<td>Bovie Medical Co. FL</td>
			<td>BOV-A1250U</td>
			<td></td>
		</tr>
		<tr>
			<td>Salpel Blade - Size #10</td>
			<td>Cardinal Health (Allegiance)</td>
			<td>32295-010</td>
			<td></td>
		</tr>
		<tr>
			<td>Scalpel Handle</td>
			<td>Martin</td>
			<td>10-295-11</td>
			<td></td>
		</tr>
		<tr>
			<td>Debakey Forceps</td>
			<td>Roboz</td>
			<td>RS-7562</td>
			<td></td>
		</tr>
		<tr>
			<td>Weitlander Retractor</td>
			<td>Roboz</td>
			<td>RS-8612</td>
			<td></td>
		</tr>
		<tr>
			<td>Mayo Scissors</td>
			<td>Roboz</td>
			<td>RS-76870SC</td>
			<td></td>
		</tr>
		<tr>
			<td>Army-navy Retractor</td>
			<td>Teleflex</td>
			<td>164715</td>
			<td></td>
		</tr>
		<tr>
			<td>Mixter Right-angle Forceps</td>
			<td>Teleflex</td>
			<td>175073</td>
			<td></td>
		</tr>
		<tr>
			<td>5F (1.7 mm) 11 cm Insertion Sheath with 0.35&#34; Guidewire</td>
			<td>Boston Scientific</td>
			<td>16035-05B</td>
			<td></td>
		</tr>
		<tr>
			<td>8F (2.7 mm) 11 cm Insertion Sheath with 0.35&#39;&#39; Guidewire</td>
			<td>Boston Scientific</td>
			<td>16035-08B</td>
			<td></td>
		</tr>
		<tr>
			<td>20G angled Introducer Needle</td>
			<td>Arrow</td>
			<td>AK-09903-S</td>
			<td></td>
		</tr>
		<tr>
			<td>14F (4.78 mm) 13 cm Insertion Sheath with 10F dilator</td>
			<td>Cook Medical</td>
			<td>G08024</td>
			<td></td>
		</tr>
		<tr>
			<td>2-0 Silk 18&#39;&#39; 45 cm</td>
			<td>Ethicon</td>
			<td>A185H</td>
			<td></td>
		</tr>
		<tr>
			<td>3-0 Vicryl 36&#39;&#39; 90 cm</td>
			<td>Ethicon</td>
			<td>J344H</td>
			<td></td>
		</tr>
		<tr>
			<td>3-0 Nylon 18&#39;&#39; 45 cm</td>
			<td>Ethicon</td>
			<td>663G</td>
			<td></td>
		</tr>
		<tr>
			<td>4-0 Prolene 30&#39;&#39; 75 cm</td>
			<td>Ethicon</td>
			<td>8831H</td>
			<td></td>
		</tr>
		<tr>
			<td>20 ml syringe</td>
			<td>Metronic/Covidien</td>
			<td>8881512878</td>
			<td></td>
		</tr>
		<tr>
			<td>3 mL syringe</td>
			<td>Metronic/Covidien</td>
			<td>1180300555</td>
			<td></td>
		</tr>
		<tr>
			<td>6 mL syringe</td>
			<td>Metronic/Covidien</td>
			<td>1180600777</td>
			<td></td>
		</tr>
		<tr>
			<td>1000ml 0.9% Saline</td>
			<td>Baxter</td>
			<td>2B1324X</td>
			<td></td>
		</tr>
		<tr>
			<td>Foley Catheter (18F 30 cc)</td>
			<td>Bard</td>
			<td>0166V18S</td>
			<td></td>
		</tr>
		<tr>
			<td>Urinary Drainage Bag</td>
			<td>Bard</td>
			<td>154002</td>
			<td></td>
		</tr>
		<tr>
			<td>9F 10 cm Insertion Sheath</td>
			<td>Arrow</td>
			<td>AK-09903-S</td>
			<td></td>
		</tr>
		<tr>
			<td>Swan-Ganz pulmonary artery catheter (8F)</td>
			<td>Edwards Lifesciences co. CA</td>
			<td>746F8</td>
			<td></td>
		</tr>
		<tr>
			<td>Carotid Flow Probe System</td>
			<td>Transonic, Ithaca, NY</td>
			<td></td>
			<td>3, 4, or 6 mm probes</td>
		</tr>
		<tr>
			<td>SABOT catheter</td>
			<td>Hayes Inc.</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>CODA balloon catheter</td>
			<td>Cook Medical</td>
			<td>8379144</td>
			<td></td>
		</tr>
		<tr>
			<td>Ultrasound, M-Turbo</td>
			<td>SonoSite</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Amplatz Stiff Guidewire (0.035 inch, 260 cm)</td>
			<td>Cook Medical</td>
			<td>G03460</td>
			<td></td>
		</tr>
		<tr>
			<td>Arterial Blood Gas Syringes</td>
			<td>Smiths Medical</td>
			<td>4041-2</td>
			<td></td>
		</tr>
		<tr>
			<td>Arterial Blood Gas Analyzer</td>
			<td>Nova Biochemical</td>
			<td>ABL800</td>
			<td></td>
		</tr>
		<tr>
			<td>Masterflex Pump</td>
			<td>Cole Palmer</td>
			<td>HV-77921-75</td>
			<td></td>
		</tr>
		<tr>
			<td>Blood Collection Bags</td>
			<td>Terumo</td>
			<td>1BBD606A</td>
			<td></td>
		</tr>
		<tr>
			<td>Macro IV drip set</td>
			<td>Hospira</td>
			<td>12672-28</td>
			<td></td>
		</tr>
		<tr>
			<td>Pentobarbital</td>
			<td>Pfizer</td>
			<td></td>
			<td>Dose: 100 mg/kg; IV</td>
		</tr>
		<tr>
			<td>Eppendorf Tubes</td>
			<td>Sorenson</td>
			<td>11590</td>
			<td></td>
		</tr>
		<tr>
			<td>50 cc conical tubes</td>
			<td>Falcon</td>
			<td>352097</td>
			<td></td>
		</tr>
		<tr>
			<td>Formalin</td>
			<td>Fisherbrand</td>
			<td>431121</td>
			<td></td>
		</tr>
		<tr>
			<td>Bair Hugger Normothermia System</td>
			<td>Arizant Healthcare, Inc.</td>
			<td></td>
			<td></td>
		</tr>
	</tbody>
</table>

complete and partial aortic occlusion for the treatment of hemorrhagic shock in swine

Hemorrhage remains the leading cause of preventable deaths in trauma. Endovascular management of non-compressible torso hemorrhage has been at the forefront of trauma care in recent years. Since complete aortic occlusion presents serious concerns, the concept of partial aortic occlusion has gained a growing attention. Here, we present a large animal model of hemorrhagic shock to investigate the effects of a novel partial aortic balloon occlusion catheter and compare it with a catheter that works on the principles of complete aortic occlusion. Swine are anesthetized and instrumented in order to conduct controlled fixed-volume hemorrhage, and hemodynamic and physiological parameters are monitored. Following hemorrhage, aortic balloon occlusion catheters are inserted and inflated in the supraceliac aorta for 60 min, during which the animals receive whole-blood resuscitation as 20% of the total blood volume (TBV). Following balloon deflation, the animals are monitored in a critical care setting for 4 h, during which they receive fluid resuscitation and vasopressors as needed. The partial aortic balloon occlusion demonstrated improved distal mean arterial pressures (MAPs) during the balloon inflation, decreased markers of ischemia, and decreased fluid resuscitation and vasopressor use. As swine physiology and homeostatic responses following hemorrhage have been well-documented and are like those in humans, a swine hemorrhagic shock model can be used to test various treatment strategies. In addition to treating hemorrhage, aortic balloon occlusion catheters have become popular for their role in cardiac arrest, cardiac and vascular surgery, and other high-risk elective surgical procedures.

Hemodynamic and Physiological Parameters:
The MAP decreased immediately after the hemorrhage (Figures 3A - 3D). During the balloon inflation phase, animals in the complete occlusion group experienced a higher proximal MAP compared to the animals in the partial occlusion group (Figures 3A and 3B). The average distal MAP during the balloon inflation was higher in the...

Watch this Scientific Journal Video about Complete and Partial Aortic Occlusion for the Treatment of Hemorrhagic Shock in Swine at JoVE.com

Complete and Partial Aortic Occlusion for the Treatment of Hemorrhagic Shock in Swine

Here, we present a protocol demonstrating a hemorrhagic shock model in swine that uses aortic occlusion as a bridge to definitive care in trauma. This model has application in testing a wide range of surgical and pharmacological therapeutic strategies.

Hemorrhage remains the leading cause of preventable deaths in trauma. Endovascular management of non-compressible torso hemorrhage has been at the ...

This method can help answer key questions in the field of trauma care, including strategies to treat non-compressible torso hemorrhage. The main advantage of this technique is that it can help test relevant endovascular resuscitative strategies in a clinically realistic large animal model with the physiology that mimics that of humans. The implications of this technique extend towards the treatment of hemorrhagic shock, which is a leading cause of preventable death in trauma.Generally, people new to this method will struggle, because it requires surgical expertise and knowledge of critical care physiology. After confirming an appropriate level of sedation using a hind limb pinch, use a conventional laryngoscope fitted with a 12 inch lighted Miller blade to pass the tip of the blade through the oropharynx of the anesthetized pig. Taking care not to damage the oral mucosa or the teeth, slowly advance the blade tip to the epiglottis, lifting the epiglottis with the blade, and continuing past the laryngeal inlet until a clear view of the larynx is obtained.Place a 6.5 or 7 French endotracheal tube with a stylet between the vocal folds, into the trachea, and inflate the balloon cuff with 10 to 15 cubic centimeters of air to prevent leaking around the cuff or aspiration of the gastric contents. Then, connect the endotracheal tube to the mechanical ventilator through a breathing filter, and secure the tube around the maxilla with cotton tape. For a femoral artery and vein cannulation, scrub the operative sites with a copious volume of povidone iodine for five minutes, and place the sterile surgical towels around the operative sites to preserve the sterility of the surgical fields.Using a scalpel fitted with a number 10 sterile surgical blade, identify the inguinal crease and make a vertical eight centimeter incision in the right groin, four centimeters above and four centimeters below the right inguinal crease. Dissect through the subcutaneous tissue, and place two Weitlaner retractors into the incision. Using Mixter right angle forceps and an electrocautery, dissect through the connective tissues and muscle until the neurovascular bundle is clearly exposed, and cautiously dissect the artery, taking care to preserve the lateral nerve.Use a 20 gauge angled introducer needle to puncture the artery, and advance a round-tipped, 0.35 inch guide wire through the lumen of the angled needle. When the guide wire is in place, withdraw the needle over the guide wire, holding slight pressure over the arteriotomy to prevent bleeding, and insert a 14 French insertion sheath over the guide wire. Then, cannulate the left femoral artery and vein as just demonstrated.For carotid artery and external jugular vein cannulation, use a number 10 blade scalpel to make a six centimeter vertical incision about two centimeters lateral to the midline on the left side of the neck. Use electrocautery to dissect through the subcutaneous tissue until the sternocleidomastoid muscle is exposed, and dissect along the lateral border of the muscle to expose the left external jugular vein. Then, cannulate the vessel with an 8 French catheter as just demonstrated.For left common carotid artery exposure, dissect the medial edge of the sternocleidomastoid muscle, until the carotid triangle, which contains the carotid artery, the vagus nerve, and the internal jugular vein, is observed. Cannulate the carotid artery as previously demonstrated, with a 5 French catheter. For the contralateral dissection, isolate the right external jugular vein and right common carotid artery, as demonstrated for their lateral counterparts.Then, use a 9 French introducer sheath to cannulate the right external jugular vein, and place a four millimeter carotid artery flow probe around the right common carotid artery. Next, insert the pulmonary artery catheter through the 9 French insertion sheath 15 to 18 centimeters into the right external jugular vein. Once the catheter is in place, inflate the balloon with no more than 1.5 cubic centimeters of air.Advance the catheter and observe the monitor to evaluate the transition of the pressure from the right atrium to the right ventricle, to the pulmonary artery, to the pulmonary artery wedge pressure. Then, deflate the balloon and confirm that a pulmonary artery trace returns to the monitor. For cystostomy tube placement, use a number 10 blade scalpel to make a midline five centimeter lower abdominal incision, and extracorporealize the urinary bladder.Using electrocautery, make a small opening in the bladder and suction out the urine, and use a 4-0 polypropylene suture to perform a temporary purse string closure of the bladder. Place an 18 French foley catheter inside the bladder lumen, and use a 10 cubic centimeter syringe to inflate the balloon. Then, tie the suture to secure the catheter within the bladder lumen.For aortic balloon catheter insertion, insert a 0.035 inch, 260 centimeter Amplatz stiff guide wire through the 14 French insertion sheath. Confirm its location in the supraceliac aorta using ultra sonography. Then, insert the balloon occlusion catheter over the guide wire, into the supraceliac aorta.After calculating the total blood volume, use an automated pump to hemorrhage 35%of the total blood volume over 20 minutes, into standard blood collection bags for storage at four degrees Celsius. When all the blood has been stored, inflate the aortic balloon occlusion catheter with 9 to 12 cubic centimeters of air, or until no further decrease in the distal mean arterial pressure following an additional balloon inflation is noted. After 40 minutes of occlusion, use the automated pump to resuscitate the animal, with whole blood equal in volume to 20%of the total blood volume via the left femoral vein catheter over 20 minutes.Then, deflate the balloon incrementally over five minutes. During the balloon inflation phase, animals in the complete occlusion group experience a higher proximal mean arterial pressure, compared to animals in the partial occlusion group, while the average distal mean arterial pressure during the balloon inflation is higher in the partial occlusion group compared to complete occlusion group, reflecting the partial distal aortic flow. Following resuscitation, the proximal and distal mean arterial pressure increases in both groups, and returns to baseline following the balloon deflation for the remainder of the critical care phase.All animals experience reflex tachycardia immediately following the hemorrhage that undergoes an incremental increase during the balloon inflation phase in both groups. Following hemorrhage, the central venous pressure decreases in both groups, undergoing an increase following balloon deflation, and returning to baseline after resuscitation. Similarly, the cardiac output decreases following hemorrhage, increases during balloon inflation, and returns to baseline following balloon deflation in resuscitation in both groups.The carotid flow decreases in both groups immediately following hemorrhage, with the complete occlusion group demonstrating a higher carotid flow rate compared to the partial occlusion group. Following resuscitation and balloon deflation, the carotid flow rate recovers towards baseline in both groups, but at a lower level in the complete occlusion group. After watching this video, you should have a much better understanding of how to use large animal models to test aortic occlusion using endovascular strategies.Also, just like any other surgical operation, you have to be careful in handling the instruments to be able to do it safely.

Research

JoVE Journal

Medicine

Fixed Volume or Fixed Pressure: A Murine Model of Hemorrhagic Shock

It is common knowledge that severe blood loss and traumatic injury can lead to a cascade of detrimental signaling events often resulting in mortality. 1, ...

2-Methacryloyloxyethyl Phosphorylcholine Polymer Treatment of Complete Dentures to Inhibit Denture Plaque Deposition

Removable dentures made of poly (methyl methacrylate) (PMMA) are prone to bacterial adherence and dental plaque formation, which is called denture plaque. ...

Uncontrolled Hemorrhagic Shock Modeled via Liver Laceration in Mice with Real Time Hemodynamic Monitoring

Uncontrolled hemorrhage is an important cause of preventable deaths among trauma patients. We have developed a murine model of uncontrolled hemorrhage via ...

Reproducible Motor Deficit Following Aortic Occlusion in a Rat Model Of Spinal Cord Ischemia

Spinal cord ischemia is a fatal complication following thoracoabdominal aortic aneurysm surgery. Researchers can investigate the strategies for preventing ...

Standardized Hemorrhagic Shock Induction Guided by Cerebral Oximetry and Extended Hemodynamic Monitoring in Pigs

Hemorrhagic shock ranks among the main reasons for severe injury-related death. The loss of circulatory volume and oxygen carriers can lead to an ...

Complete and Partial Resuscitative Endovascular Balloon Occlusion of the Aorta for Hemorrhagic Shock

Resuscitative endovascular balloon occlusion of the aorta (REBOA) devices grew out of a military-civilian partnership to develop new capabilities for ...

Ascending Aortic Banding for Studying Pressure-Overload Induced Heart Failure

A Minimally Invasive Model of Aortic Stenosis in Swine

Author Spotlight: Development of a Minimally Invasive Large-Animal Model for Reliable and Reproducible Cardiovascular Research 

Large animal models of heart failure play an essential role in the development of new therapeutic interventions due to their size and physiological ...

Description of a Swine Infant Model of Volume-Controlled Hemorrhagic Shock

Hemorrhagic shock is a leading cause of morbidity and mortality in pediatric patients. Interpretation of the clinical indicators validated in adults to ...

Vascular Cannulation with Hemorrhagic Shock Induction in Rats

Developing a Clinically Relevant Hemorrhagic Shock Model in Rats

Author Spotlight: Developing Innovative Therapeutic Strategies for Hemorrhagic Shock Research

Over the recent decades, the development of animal models allowed us to better understand various pathologies and identify new treatments. Hemorrhagic ...