MSS008: TRANSAXILLARY SELECTIVE AORTIC ARCH PERFUSION (TAX-SAAP) IN A PORCINE MODEL
Benjamin Scott, MD1; Meredith Lackie, MD1; Kyle Patterson, MD1; Andrew Pate, BS, D, ATP2; Daniel Frisby, BS, D, ATP2; John Mares, MPH1; Justin Hutzler, BS1; JT Green, MD1; David Schechtman, MD1; Elizabeth Powell, MD3; Jonathan Morrison, MBChB, PhD4; Matthew Bradley, MD1; David Burmeister, PhD1; Woo Do, MD1; Patrick Walker, MD1; 1USU Walter Reed National Military Medical Center; 2US Army Special Operations Command; 3University of Maryland School of Medicine; 4Mayo Clinic
Objectives: Exsanguination cardiac arrest (ECA) remains one of the most formidable challenges in modern trauma care, with survival rates persistently dismal. Selective aortic arch perfusion (SAAP) offers dual benefits: proximal aortic occlusion for infradiaphragmatic hemorrhage control with aortic arch perfusion for cardiocerebral resuscitation. Prior investigations of SAAP have relied on open-chest aortic cannulation or experimental percutaneous femoral access, approaches that currently limit practical clinical translation. We describe a novel porcine model of transaxillary SAAP (TAX-SAAP), employing percutaneous axillary arterial cannulation in combination with femoral venous access for extracorporeal cardiopulmonary resuscitation (ECPR) using venoarterial extracorporeal membrane oxygenation (VA ECMO) in combination with femoral arterial access for aortic balloon occlusion.
Methods: In a Yorkshire swine model (n=1), A 7 French sheath was percutaneously placed in the left common femoral artery and a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) device advanced to Zone I and left uninflated. The right femoral vein was cannulated with a 21 French percutaneous venous cannula, and the right axillary artery was accessed with a 19 French percutaneous arterial cannula. Placement of all devices was confirmed under fluoroscopy. Animals were exsanguinated into a venous reservoir until mean arterial pressure (MAP) fell below 20 mmHg and end-tidal CO2 dropped below 10 mmHg for one minute, defining ECA. After 15 minutes of unsupported ECA, TAX-SAAP was initiated after inflating the REBOA by using the shed blood on the VA ECMO circuit. Return of Spontaneous Circulation (ROSC) was defined as return of sinus cardiac rhythm with a mean arterial pressure (MAP) of 50 mmHg. End point of this model was survival time to euthanasia.
Results: After 15 minutes of unsupported arrest, ROSC was achieved after 79 seconds of TAX-SAAP. The terminal rhythm of ECA was pulseless electrical activity (PEA). Following ROSC and REBOA deflation, peak lactate was 19mmol/dL and nadir pH was 6.96, improving to 7.3 by the completion of the experiment. The model maintained survival for 131 minutes after ROSC until euthanasia. For comparison, in a prior series (n = 6) of 10 minutes of unsupported ECA, our group observed 100% mortality at 75 minutes after conventional resuscitative thoracotomy.
Conclusions: Axillary arterial cannulation for SAAP represents a novel resuscitative strategy for ECA. It can be performed percutaneously using standard techniques without reliance on new devices, highlighting its potential for rapid clinical translation to improve survival in hemorrhage victims.