Central aortic wire confirmation for emergent endovascular procedures: As fast as surgeon-performed ultrasound Sundeep Guliani, MD, Michael Amendola, MD, Brian Strife, MD, Gordon Morano, MD, Jeffrey Elbich, MD, Francisco Albuquerque, MD, Daniel Komorowski, MD, Malcolm Sydnor, MD, Ajai Malhotra, MD, and Mark Levy, MD, Richmond, Virginia BACKGROUND: Uncontrolled hemorrhage is the leading cause of preventable death after trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an evolving technique for controlling noncompressible torso hemorrhage. A challenge limiting REBOA use is the dependence on fluoroscopy for confirmation of intra-aortic positioning of a guide wire, a necessary component for safe and accurate balloon deployment. The current study evaluates using surgeon-performed sonography alone, without fluoroscopy, in identifying the aorta and the presence of an intra-aortic guidewire. We postulate that with the use of the subxiphoid Focused Abdominal Sonography for Trauma (FAST) view, both the aorta and an intra-aortic guide wire can be reliably identified. METHODS: One hundred angiography patients underwent femoral arterial cannulation and guide wire advancement to the supraceliac aorta. From the subxiphoid FAST view, the aorta was identified in both sagittal and transverse planes. Intra-aortic wire identification was subsequently recorded. The rate of preferential central aortic wire positioning from unaided guide wire advancement was also observed. RESULTS: The mean patient age and body mass index were 61.8 years and 27.0 kg/m 2 , respectively. Eighty-eight percent of the studies were performed using portable point-of-care ultrasound machines. Identification of the aorta via the subxiphoid FASTwas successful in 97 (97%) of 100 patients in the sagittal and 98 (98%) of 100 patients in the transverse orientation. Among visualized aortas, an intra-aortic wire was identifiable in 94 (97%) of 97 patients in the sagittal and 91 (93%) of 98 patients in the transverse orientation. Unaided wire advancement achieved preferential central aortic positioning in 97 (97%) of 100 patients. Fluoroscopy-free ultrasound identification of an advancing intra-aortic guide wire was successful in 56 (98%) of 57 patients. CONCLUSION: The subxiphoid FAST view can reliably identify a central aortic guidewire in both transverse and sagittal orientations. Unaided guide wire advancement has a high likelihood of both preferential central aortic positioning and subsequent ultrasound identification. These findings eliminate the need for routine fluoroscopy for this important initial maneuver during emergency endovascular procedures. (J Trauma Acute Care Surg. 2015;79: 549Y554. Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.) LEVEL OF EVIDENCE: Diagnosticstudy, level V. KEY WORDS: Resuscitative endovascular balloon occlusion of the aorta; endovascular surgery; hemorrhagic shock; resuscitation; ultrasound. U ncontrolled hemorrhage is the leading cause of prevent- able death in both civilian and military trauma. 1Y3 There has been recent reappraisal of endovascular aortic balloon oc- clusion as a maneuver to prevent exsanguination after massive injury. 4 By acutely temporizing bleeding and providing hemo- dynamic support, it may potentially prolong the window of pa- tient salvage. Originally described in 1954 during the Korean War, the technique however has laid largely dormant because of difficulties with predictable deployment maneuvers in an emer- gency setting. 5 With the expansion of endovascular technology, aortic balloon occlusion was more recently described to prevent exsanguination in the setting of ruptured aortic aneurysms. 6 It was shown to be effective in stabilizing patients before surgical hemorrhage control could be performed. 7,8 The benefit of such endovascular procedures in trauma patients presenting with uncontrolled bleeding has more recently been suggested. 9Y12 Several challenges currently limit the application of resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma. Among these is the dependence on fluoroscopic guidance for balloon deployment. Although fluoroscopy has been primarily used for balloon placement in the past, rapid mobilization of it is not feasible in many settings commonly encountered in trau- matic hemorrhage. The initial steps in REBOA involve common femoral artery cannulation with guide wire advancement and sheath placement. Deployment requires confirmation of an intra-aortic guide wire, atop which an occlusion balloon is advanced. Central aortic wire confirmation is an essential component of safe deployment. In- correct guide wire positioning would lead to malpositioned bal- loon advancement and inflation with catastrophic consequences to a patient already in extremis. Overaggressive advancement of a guide wire likewise risks complications including ventricular EAST 2015 PLENARY P APER J Trauma Acute Care Surg Volume 79, Number 4 549 Submitted: September 5, 2014, Revised: June 7, 2015, Accepted: June 15, 2015. From the Divisions of Vascular Surgery (S.G., M.A., F.A., M.L.), Interventional Radiology (B.S., G.M., J.E., D.K., M.S.), and Acute Care Surgery (A.M.), Virginia Commonwealth University, Richmond, Virginia. This study was presented at the 28th Annual Scientific Assembly of the Eastern Asso- ciation for the Surgery of Trauma, January 13Y17, 2015, in Lake Buena Vista, Florida. Address for reprints: Sundeep Guliani, 1200 E. Broad St, PO 980108, Richmond, VA 23298; email: Sundeep.guliani@gmail.com. DOI: 10.1097/TA.0000000000000818 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.