title: Central aortic wire confirmation for emergent endovascular procedures: As fast as surgeon-performed ultrasound.
abstract: 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 guide wire. 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, respectively. Eighty-eight percent of the studies were performed using portable point-of-care ultrasound machines. Identification of the aorta via the subxiphoid FAST was 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.
  
  
  CONCLUSIONS
  The subxiphoid FAST view can reliably identify a central aortic guide wire 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.
  
  
  METHODS
  Diagnostic study, level V.
authors.affiliation: 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.
authors.forename: Sundeep
authors.initials: S
authors.lastname: Guliani
authors.forename: Michael
authors.initials: M
authors.lastname: Amendola
authors.forename: Brian
authors.initials: B
authors.lastname: Strife
authors.forename: Gordon
authors.initials: G
authors.lastname: Morano
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Elbich
authors.forename: Francisco
authors.initials: F
authors.lastname: Albuquerque
authors.forename: Daniel
authors.initials: D
authors.lastname: Komorowski
authors.forename: Malcolm
authors.initials: M
authors.lastname: Sydnor
authors.forename: Ajai
authors.initials: A
authors.lastname: Malhotra
authors.forename: Mark
authors.initials: M
authors.lastname: Levy
mesh_terms: D059925:Anatomic Landmarks; D000792:Angiography; D001012:Aorta, Abdominal / Q000000981:diagnostic imaging* / Q000293:injuries*; D057510:Endovascular Procedures / Q000295:instrumentation*; D005260:Female; D005263:Femoral Artery; D005471:Fluoroscopy; D006470:Hemorrhage / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D019095:Point-of-Care Systems; D014463:Ultrasonography