\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[ngerman,english]{babel}



\usepackage{float}








\begin{document}

\title{Ruptured abdominal aortic aneurysm treated with early REBOA and open
abdominal management with applied shoelace technic}



\author[1]{Ginga Suzuki}%
\author[1]{Ryo Ichibayashi}%
\author[1]{Saki Yamamoto}%
\author[1]{Hibiki Serizawa}%
\author[2]{Takahide Yao}%
\author[2]{Toru Kameda}%
\author[1]{Yoshimi Nakamichi}%
\author[1]{Masayuki Watanabe}%
\author[2]{Hiroshi Masuhara}%
\author[1]{Mitsuru Honda}%
\affil[1]{Toho University Omori Medical Center}%
\affil[2]{Toho University}%


\vspace{-1em}



  
  \date{June 16, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
We report a successful case of ruptured abdominal aortic aneurysm (rAAA)
treated with endovascular aortic repair (EVAR) following resuscitative
endovascular balloon occlusion of the aorta (REBOA) and treated with
devised open abdominal management (OAM) for abdominal compartment
syndrome (ACS). We used an applied shoelace technique with vacuum pack
closure.%
\end{abstract}%



\sloppy


Article type: Case report

Title: Ruptured abdominal aortic aneurysm treated with early REBOA and
open abdominal management with applied shoelace technic

Running title: RAAA treated with REBOA and devised OAM

Authors: Ginga Suzuki \textsuperscript{1}, Ryo
Ichibayashi\textsuperscript{1}, Saki Yamamoto \textsuperscript{1},
Hibiki Serizawa\textsuperscript{1}, Takahide Yao \textsuperscript{2},
Toru Kameda\textsuperscript{2}, Yoshimi Nakamichi \textsuperscript{1},
Masayuki Watanabe \textsuperscript{1}, Hiroshi Masuhara
\textsuperscript{2}, Mitsuru Honda \textsuperscript{1}

Institution: 1. Critical Care Center, Toho University Omori Medical
Center, 6-11-1 Omori-nishi, Ota-ku, Tokyo 143-8541, Japan

2. Division of Cardiovascular Surgery, Department of Surgery, School of
Medicine, Faculty of Medicine, Toho University, 6-11-1 Omori-nishi,
Ota-ku, Tokyo 143-8541, Japan

Corresponding author: Ginga Suzuki (ginga.suzuki@med.toho-u.ac.jp)

Critical Care Center, Toho University Omori Medical Center

6-11-1 Omori-nishi, Ota-ku, Tokyo 143-8541, Japan

Tel 03-3762-4151, FAX 03-3762-4129

Key words: ruptured abdominal aortic aneurysm, open abdominal
management, REBOA, abdominal compartment syndrome

Key Clinical Message

The resuscitative endovascular balloon occlusion of the aorta and and
devised open abdominal management may effective for treatment of
abdominal compartment syndrome due to ruptured abdominal aortic
aneurysm.

This study is reported with the consent of the patient.

Abstract

We report a successful case of ruptured abdominal aortic aneurysm (rAAA)
treated with endovascular aortic repair (EVAR) following resuscitative
endovascular balloon occlusion of the aorta (REBOA) and treated with
devised open abdominal management (OAM) for abdominal compartment
syndrome (ACS). We used an applied shoelace technique with vacuum pack
closure.

Introduction

Ruptured abdominal aortic aneurysm (rAAA) is a serious condition with a
high fatality rate\textsuperscript{1,2}, and urgent attention is needed.
It is desirable to stop the bleeding as soon as possible, but it takes a
certain time to transfer to the operating room, and shock and cardiac
arrest may occur during that time. Therefore, insertion of resuscitative
endovascular balloon occlusion of the aorta (REBOA) may be attempted at
the initial treatment\textsuperscript{1,2}. It is less invasive than
surgical aortic occlusion, and previous researches report its
effectiveness\textsuperscript{1,2}.

In addition, endovascular aortic repair (EVAR) following REBOA may be
effective and less invasive than artificial vessel replacement. However,
inability to remove the hematoma can lead to abdominal compartment
syndrome.\textsuperscript{2,3}

In the present case, we diagnosed ruptured abdominal aortic aneurysm and
performed EVAR with REBOA support. And we treated postoperative
abdominal compartment syndrome with applied shoelace technic as open
abdominal management (OAM).

This study has been approved by Toho University Omori Medical Center
ethical committee.

Case report

The patient was 76-year-old man. No significant medical history or
family history. His family found him lying down in the bathroom at home
and called an ambulance.

His vital signs on arrival were as follows: Glasgow Coma Scale was
E3V4M6, body temperature was 35.9, blood pressure was unmeasurable,
heart rate was 93, respiratory rate was 22, in addition,
SpO\textsubscript{2} was unmeasurable. An abdominal echo was performed
and we recognized an abdominal aortic aneurysm and a relatively
high-intensity soft tissue shadow around it. On arrival, he complained
of abdominal pain, and was diagnosed as ruptured abdominal aortic
aneurysm. Rapid infusion was performed from the peripheral routes, and a
vascular sheath was quickly inserted into the right femoral artery and
the left brachial artery and transformed to the fluoroscopy room. REBOA
(Rescue Ballon?, Tokai Medical Products, Aichi, Japan) was inserted
through the sheath of the right femoral artery. While seeing through the
fluoroscopy, the guide wire was carefully inserted and inflated at the
level of Th12. An increase in blood pressure in the upper limbs was
confirmed (93/66 mmHg). After that, enhanced CT was performed (Figure 1)
and he was transformed to the operating room. A 55\selectlanguage{ngerman}×68 mm aortic aneurysm
was found from just below the bifurcation of the renal artery to just
above the bifurcation of the common iliac artery, and retroperitoneal
blood and leakage of contrast medium were observed. The blood test
findings on arrival are shown in Table 1.

After the introduction of anesthesia, the REBOA was replaced with
Reliant\selectlanguage{english}? balloon catheter (Medtronic Japan Co., Ltd., Tokyo, Japan) to
occlude the aorta at the level just above the celiac artery. Next to the
occlusion, an aortography was performed by inserting a pig tail catheter
from the left femoral artery. The rupture area was unknown, but it was
confirmed that EVAR was possible. GORE\selectlanguage{english}?EXCLUDER\selectlanguage{english}?C3\selectlanguage{english}? (W.L. Gore \&
Associates, inc. , Delaware, United States) was selected as the device.
After the placement of the Trunk-Ipsilateral Leg Endoprosthesis\selectlanguage{english}? (W.L.
Gore \& Associates, inc. , Delaware, United States), it was confirmed
that there was no endoleak after adjusting the position. Subsequently,
the intravesical pressure was found to be 25 mmHg, and an increase in
intraabdominal pressure was suspected. A midline abdominal incision from
just below the xiphoid process to just above the pubic symphysis was
performed to prevent abdominal compartment syndrome (ACS). After washing
the abdominal cavity, temporary closure was performed with a vacuum
pack.\textsuperscript{4}

After returning to the ICU, blood products were transfused to stabilize
breathing and circulation. Water removal by hemodialysis was started on
the third day of hospitalization. On the 3rd day of hospitalization, a
temporary closure was opened to confirm hemostasis, and the abdominal
cavity was observed. Although hemostasis was confirmed, it was judged
that intestinal edema was so strong that he could not close the abdomen.
Subsequent closure of the abdomen was expected to be difficult, so
another vacuum pack closure was performed to prevent shortening of the
peritoneum, subcutaneous tissue, and skin. By applying the shoelace
technique,\textsuperscript{5} the peritoneum, subcutaneous tissue, and
skin were lumped together through a vessel cotton tape and pulled toward
the opposite side. A vacuum pack closure was added above the shoelace
and temporarily closure was performed again (Figure 2). After that, the
water was removed, and a laparotomy closure was performed on the 6th day
of hospitalization, although some intestinal edema remained. ACS did not
come after the operation.

Postoperatively, septic shock was accompanied by ventilator-related
pneumonia, but he was successfully recovered. A tracheotomy was
performed on the 17th day of hospitalization, but rehabilitation was
started and he was transferred to the general ward when he was able to
sitting at the bed edge with assistance.

Discussion

It is considered that there were two important points that saved the
present case. First, rapid diagnosis, rapid infusion and balloon
occlusion were performed. Second, it was possible to close the abdomen
relatively early by performing OAM applying the shoelace
technique\textsuperscript{5} when the hemostasis was confirmed.

Regarding the first point, we diagnosed by abdominal echo, performed
rapid fluid infusion from 3 peripheral routes of 18G, and placed REBOA
prior to CT. As a result, the occlusion was achieved in 35 minutes from
arrival. Lifesaving is difficult if cardiac arrest occurs immediately
after arrival, and left thoracotomy and direct aortic occlusion may be
selected. In the present case, although the shock persisted, rapid
infusion primarily prevented cardiac arrest, and the shock could be
removed with a minimally invasive method with REBOA. This treatment was
a good bridge for EVAR performed later, and it is considered that the
treatment was less invasive than the performed by thoracotomy and
laparotomy with artificial vessel. Regarding the REBOA access, it has
been reported that it is able to be inserted from the left brachial
artery, \textsuperscript{6,7} but we use the left or right femoral
artery as the first choice and the left upper brachial artery as the
second choice. This is because access from the left brachial artery, the
risk of peripheral emboli from the aortic arch or the descending aorta
is higher than with the femoral approach.\textsuperscript{7} It may be
difficult to insert the REBOA from the femoral artery depending on the
meandering of the artery or aorta. In that case, the access is switched
to the left brachial artery. Also in the present case, the REBOA
procedure was performed after simultaneously inserted sheaths in both
the femoral and the brachial artery.

Regarding the second point, in the present case we carried out a devised
vacuum pack closure in consideration that the peritoneum, subcutaneous
tissue, and skin may contract and become unable to close. Although the
usual vacuum pack closure was performed in the first surgery, it was
expected that the intestinal edema would be strong and the laparotomy
closure would be difficult in the second observation. In order to
prevent from shortening the peritoneum, subcutaneous tissue, and skin as
much as possible, vacuum pack closure was performed by passing a bunch
of skin from the peritoneum through a vessel tape and pulling the
abdominal wall in a manner similar to the shoelace technique. on the 6th
day of hospitalization, intestinal edema was still present, but we were
able to close the abdomen. The abdomen was closed relatively early
considering the infection of the stent graft. We think that the
laparotomy closure was performed at an appropriate time because he
passed without ACS. This is partly because the applied shoelace
technique prevented the shortening of the peritoneum and skin. We
considered that this method may be useful in OAM where it is expected to
be difficult to close.

Conclusion

Abdominal echo is useful for rapid diagnosis of rAAA. If shock persists
even after rapid infusion, rapid REBOA before CT may prevent cardiac
arrest. In OAM for ACS, an applied shoelace technique may be
advantageous for the secondary abdominal closure.

Disclosure Statement

Conflict of Interest: None declared

Author Contributions

Study conception: GS

Data collection: GS, RI

Writing: GS, RI, TY, HM

Critical review and revision: all authors

Final approval of the article: all authors

Accountability for all aspects of the work: all authors

Ethics approval

We got the patient's family consent for this report.

Funding information

Not applicable.

Acknowledgments

The authors are greatly indebted to all the personnel at the Critical
Care Center, Toho University Omori Medical Center.

References

\begin{enumerate}
\tightlist
\item
  Borger van der Burg BLS, van Dongen TTCF, Morrison JJ, et al. A
  systematic review and meta-analysis of the use of resuscitative
  endovascular balloon occlusion of the aorta in the management of major
  exsanguination. Eur J Trauma Emerg Surg. 2018; 44: 535-50.
\item
  Aoki C, Kondo N, Saito Y, et al. Improved Outcomes for Ruptured
  Abdominal Aortic Aneurysms Using Integrated Management Involving
  Endovascular Clamping, Endovascular Replacement, and Open Abdominal
  Decompression. Ann Vasc Dis. 2017; 10: 22-8.
\item
  Ersryd S, Gidlund KD, Wanhainen A, et al. Editor's Choice - Abdominal
  Compartment Syndrome after Surgery for Abdominal Aortic Aneurysm:
  Subgroups, Risk Factors, and Outcome. Eur J Vasc Endovasc Surg. 2019;
  58: 671-9.
\item
  Barker DE, Kaufman HJ, Smith LA, et al. Vacuum pack technique of
  temporary abdominal closure: a 7-year experience with 112 patients. J
  Trauma. 2000; 48: 201-6.
\item
  Harris I. Gradual closure of fasciotomy wounds using a vessel loop
  shoelace. Injury. 1993; 24: 565-6.
\item
  Raux M, Marzelle J, Kobeiter H, et al. Endovascular balloon occlusion
  is associated with reduced intraoperative mortality of unstable
  patients with ruptured abdominal aortic aneurysm but fails to improve
  other outcomes. J Vasc Surg. 2015; 61: 304-8.
\item
  Matsuda H, Tanaka Y, Hino Y, et al. Transbrachial arterial insertion
  of aortic occlusion balloon catheter in patients with shock from
  ruptured abdominal aortic aneurysm. J Vasc Surg. 2003; 38: 1293-6.
\end{enumerate}

Figure Legends

Figure 1. The enhanced CT scan on admission.

The white arrow and arrowhead represent the celiac artery and
resuscitative endovascular balloon, respectively. The balloon is
deflated in half. A large amount of blood is found in the
retroperitoneal cavity.

Figure 2. The vacuum pack closure whit an applied shoelace technique.

The peritoneum, subcutaneous tissue, and skin were lumped together
through a cotton tape and pulled toward the opposite side\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/figure1/figure1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/figure-2/figure-2}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

