jim manning - selective aortic arch perfusion

Is Selective Aortic Arch Perfusion the Answer?

James E. Manning, MDDepartments of Emergency Medicine and Surgery University of North Carolina at Chapel Hill School of Medicine

SMACC 2015Chicago, ILJune 25, 2015

Disclosure: Inventor on patents for the Selective Aortic Arch Perfusion assigned to the University of North Carolina at Chapel Hill. Co-Founder of Resusitech, Inc., a medical device company developing resuscitation technologies.

What is Selective Aortic Arch Perfusion?(SAAP)

Selective Aortic Arch Perfusion

Selective Aortic Arch Perfusion is a resuscitation technique that involves the blind insertion of a large-lumen balloon occlusion catheter into the descending thoracic aortic arch via a femoral artery. With the balloon inflated, the heart and brain are relatively isolated for resuscitative perfusion with an oxygen-carrying fluid in an effort to promote restoration of spontaneous circulation by the heart while protecting the brain from further ischemic insult.

Ann Emerg Med 1992; 21:1068-1065

Why SAAP?

Resuscitation MedicineKey Concept: The “Chain of Survival”

Early Recognition& Activation (911)

Early CPRRapidDefibrillation

ACLS &Transport

Post-Resuscitation ICU/Neuro Care

Two Principles

In Order to Improve Cardiac Arrest Survival:

(1) We Need Better Methods of Artificial Perfusion

(2) We Need Better Monitoring Technology

Selective Aortic Arch Perfusion

Time-critical pre-hospital / in-hospital resuscitation intervention intended to compensate for “weak links” in the Chain of Survival

.…an effort to “turn back the clock” in cardiac arrest

“Endovascular-Extracorporeal Resuscitation Era”

Momentum from two different directions

(1) Endovascular hemorrhage control:Trauma / Severe Hemorrhagic Shock

REBOA ………/ SAAP ……../ EPR

(2) Extracorporeal perfusion:Medical Cardiac Arrest / Sudden Death

CPB / EMCO / ECLS / ECPR ….…./ SAAP

ECLS/ECMO/ECPR

Joe Bellezzo, Zack Shinar, Scott Weingart Josh Ihle, Paul Nixon, Paul Forrest

Selective Aortic Arch Perfusion for Medical Cardiac Arrest/Sudden Death Manning et al, Ann Emerg Med 1992; 21:1068-1065

Medical Cardiac Arrest:

Aortic balloon occlusion allows relatively isolated perfusion of the heart and brain

Heart and brain perfusion with an oxygen-carrying fluid

Hemoglobin-based (HBOC)Fluorocarbon emulsion (PFC)Blood (allogeneic / autologous)

Intra-aortic drug administration- Epinephrine / vasoactive agents- Ischemia-reperfusion agents- Hemostatic products

Rapid hypothermia induction

Selective Aortic Arch Perfusion

SAAP can generate “supra-normal” myocardial blood flow

Baseline NSR CPR SAAP

00041 – VF CA – 1 min SAAP

VF Cardiac Arrest - SAAP with Oxygenated Blood

Oxygenated packed RBCs Aortic Epinephrine 0.01 mg/kg includedCaCl2 continuous infusion in the initial SAAP bolus

A

W

A

SAAP catheter: 11.5 Fr OD, 7.3 Fr ID of infusion lumenECMO arterial cannulas: 15 Fr & 19 Fr

Sequential Invasive Resuscitation Interventions in Medical/Non-Trauma Cardiac Arrest

If initial CPR, Defibrillation, ACLS is unsuccessful (No ROSC)

Femoral artery SAAP balloon catheter insertion &initiate SAAP with O2 carrier (HBOC, PFC, WB/pRBC)

(obtain venous access during this initial SAAP phase)

If ROSC not achieved, venous blood W/D & transitionto SAAP with Autologous Blood (partial ECMO/ECLS)

If ROSC not achieved, larger femoral arterial cannula& convert to whole body ECLS/ECPR

If ROSC not achieved, Consider: Cardiac Cathfor PCI, LVAD, VIR, CT/Vasc Surgery,

profound hypothermia (?), and cessation of resuscitation efforts

Impending Cardiovascular Collapse, especially in NCTH

Hemorrhage-induced Traumatic Cardiac Arrest (HiTCA)

SAAP in Trauma

Aortic Hemostasis and Resuscitation

AHRNCTH/decompensated Hemorrhage-inducedhemorrhagic shock Traumatic Cardiac Arrest (HiTCA)but NOT impending CV collapse/CA if CA occurs

REBOA SAAP ROSC not achieved

ROSC but EPRmyocardial dysfx

ECLS ECLS inadequate(ECMO)

REBOA – Resuscitative Endovascular Balloon Occlusion of the AortaSAAP – Selective Aortic Arch PerfusionEPR – Emergency Preservation & ResuscitationECLS – Extracorporeal Life Support (Extracorporeal Membrane Oxygenation)

Selective Aortic Arch Perfusion for Hemorrhage-Induced Cardiac Arrest Manning et al, Crit Care Med 2001; 29:2067-2074

Trauma / Hemorrhagic Shock:

Aortic balloon occlusion to limit abdominal/pelvic blood loss caudal to the balloon (functional aortic cross-clamp)

Perfusion of the heart & brain with an oxygenated solution (HBOC, fluorocarbon, whole blood) to ROSC & to restore intravascular volume rapidly

Intra-aortic administration- Epinephrine / vasoactive agents- Ischemia-reperfusion agents- Hemostatic products

Temperature regulation (??)

Oxygen-Carrier Perfusate for SAAP:

PFCs & HBOCs – still “future capability” in the USA

Present capabilityWhole BloodPacked RBCs

(citrate anticoagulant issue)

SAAP in Hemorrhage-induced Cardiac Arrest

Selective Aortic Arch Perfusion with Hemoglobin-Based Oxygen Carrier-201 for resuscitation from exsanguination cardiac arrest in swine

Manning et al. Crit Care Med 2001; 29:2067-2074

SAAP with oxygenated HBOC-201 vs. SAAP with oxygenated LR Swine liver laceration model, rapid exsanguination, cardiac arrest at 10-13 mins

Sustained ROSC in 6/6 SAAP – HBOC-201 1-hour survival in 5/6Transient ROSC in 2/6 SAAP – LR (with Ao-Epi) 1-hour survival in 0/6

ROSC time for SAAP – HBOC-201 was 1.9±1.0 min

Oxygen-Carrier Perfusate for SAAP:

PFCs & HBOCs – still “future capability” in the USA

Present capabilityWhole BloodPacked RBCs

(citrate anticoagulant issue)

SAAP in Hemorrhage-induced Cardiac Arrest

00031 – HiTCA – 1 min SAAP

SAAP with HBOC-201 in Hemorrhage-induced Cardiac Arrest

AHR: SAAP with Oxygenated Stored Blood

SAAP-whole blood (10 mL/kg/min) + intra-aortic Ca++ infusionROSC at about 1.5 min

Ann Emerg Med 1993; 22:703-708

AHR: SAAP with Oxygenated Stored Blood

SAAP-packed RBCs (10 mL/kg/min) + intra-aortic Ca++ infusionAortic epinephrine (0.01 mg/kg) at 3 min of SAAP, ROSC

AHR: SAAP with Oxygenated Stored Blood

SAAP-whole blood (10 mL/kg/min) + intra-aortic Ca++ infusionROSC but MAP < 60 mmHg, Aortic epinephrine (0.003 mg/kg)

Aortic Hemostasis and Resuscitation

AHRNCTH/decompensated Hemorrhage-inducedhemorrhagic shock Traumatic Cardiac Arrest (HiTCA)but NOT impending CV collapse/CA if CA occurs

REBOA SAAP ROSC not achieved

ROSC but EPRmyocardial dysfx

ECLS ECLS inadequate(ECMO)

REBOA – Resuscitative Endovascular Balloon Occlusion of the AortaSAAP – Selective Aortic Arch PerfusionEPR – Emergency Preservation & ResuscitationECLS – Extracorporeal Life Support (Extracorporeal Membrane Oxygenation)

Is Selective Aortic Arch Perfusion the answer?

Is Selective Aortic Arch Perfusion the answer?

Maybe, in part……

SAAP is one of the interventions we could have in our “resuscitation toolkit” to help us save the lives of our cardiac arrest patients….before it’s too late.

Thank You!

&

A Toast to SMACC!