A clinical study of the hemodynamic and metabolic effects of Zone 3 REBOA for sacral and pelvic tumor resections

A clinical study of the hemodynamic and metabolic effects of Zone 3 REBOA for sacral and pelvic tumor resections | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A clinical study of the hemodynamic and metabolic effects of Zone 3 REBOA for sacral and pelvic tumor resections Zhiqing Zhao, Jichuan Wang, Taiqiang Yan, Wei Guo, Rongli Yang, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1587848/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a key procedure in sacral and pelvic tumor resection that provides hemorrhage control. However, few studies have been performed to capture the effects of REBOA in a non-shock condition and give a detailed description of the changes occurring with the occlusion time prolongs. This study aim to examine the hemodynamic and metabolic effects of Zone 3 REBOA for sacral and pelvic tumor resections following different periods of REBOA. Methods: 121 patients underwent surgical tuomr resections of the pelvis and/or the sacrum with the use of aortic balloon occlusion were prospectively enrolled in this study from October 2020 to December 2021. All cases were divided into group A (occlusion time ≤60 min, n = 57) and group B (occlusion time ≥90 min, n = 64). Physiologic parameters were continuously recorded, and laboratory specimens were obtained at regular intervals. Results: Balloon inflation resulted in a significant increase of SBP from 106.81 to 121.84 mmHg ( p = 0.00), and decreased to 95.79 mmHg the just following balloon deflation. With the application of REBOA, the average blood loss was only 1485.21ml (range, 400-7900). When deflating the REBOA, the arterial pH was lower than baseline (7.36 vs. 7.41, p = 0.00). The arterial lactate concentration increased from 0.91 to 1.48 mmol/L, ( p = 0.00). Serum potassium measurements increased from 3.95 to 4.10 mmol/L. Serum calcium measurements decreased from 2.30 to 2.03 mmol/L. Blood creatinine decreased from 65.09 to 62.50 umol/L. All the laboratory measurements were at normal level after deflation of the REBOA. The operating time of Group B was longer than patients in Group A, and the patients in Group B need more number of blood units transfused. Except that the lactate was higher in Group B after deflation ( p = 0.00), other laboratory measurements including pH, potassium, calcium, and blood creatinine were at the same level. Conclusions: The results of this study shown that acceptable hemodynamic and metabolic stability can be attained when the occlusion time of REBOA more than 90 minutes, although the long duration of occlusion caused relatively higher lactate. Aortic occlusion Hemodynamic Sacropelvic tumor Hemostasis Figures Figure 1 Figure 2 Figure 3 Introduction The resection of bone and soft tissue tumors at pelvis and sacrum has a high risk of major and potentially fatal complications which casued by large volume of tumor and the complexity of anatomical region. This particular anatomy and the rich blood supply of the pelvis and sacrum can lead to significant intraoperative blood loss, up to 10,000 mL [ 1 ]. How to reduce blood loss during the pelvic and sacral tumor resection is critical. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a technique that reduces distal blood flow and significantly reduces blood loss. In the past decades, infrarenal aorta occlusion (Zone 3 REBOA) has been successfully used in controlling bleeding in sacropelvic resections (Fig. 1 ) [ 1 – 7 ]. However, the prolonged occlusion time can result in artery injury, ischemic necrosis of distal limb, or multiple organ dysfunction. Some studies [ 5 , 6 ] suggested that 60 minutes is a safe single continuous occlusion duration. Another study [ 3 ] showed that one single continuous occlusion duration longer than 90 minutes caused significant complications, while the overall damage was minor when the occlusion time is less than 90 minutes. In some work of animal model with hemorrhagic shock, occlusion time of 60 or 90 minutes were associated with a substantial ischemia and reperfusion injury (IRI) that increases late mortality [ 8 – 12 ]. To date, there is a paucity of evidence to prove an optimal time duration for aortic occlusion in the setting of Zone 3 REBOA in a non-shock model. In the present study, we aimed to examine the hemodynamic and metabolic effects of Zone 3 REBOA for sacral and pelvic tumor resections following different periods of REBOA. Materials And Methods This prospective clinical study performed at a single center was approved by the Ethics Review Committee (ERC) of Peking University People’s Hospital (2020PHB107-01). Patients 121 patients underwent surgical tuomr resections of the pelvis and/or the sacrum with the use of aortic balloon occlusion were prospectively enrolled in this study from October 2020 to December 2021 (Fig. 2 ). All cases were divided into group A (occlusion time ≤ 60 min) and group B (occlusion time ≥ 90 min). The diagnoses consisted of nine benign tumors, and ninety-one malignant tumors (Table I). Group A consisted of 57 patients with a mean age of 45 ± 16years. Group B consisted of 64 patients with a mean age of 43 ± 15 years. Inclusion criteria Patients who had the following characteristics were included in this study: (1) Bone and soft tissue tumors of the pelvis and sacrum, (2) age at 18 to 70, (3) underwent surgical resections with the use of aortic balloon occlusion, and (4) infrarenal aorta occlusion was only used once during sugery. Positioning technique of the aortic balloon Before surgery, a contrast-enhanced Computer Tomography (CT) scan was performed to detect the tumor vascularization, to evaluate the diameter of the aorta and femoral artery, and to exclude theoretical contraindications to the procedure. After anesthesia induction, the groin regions were sterilized with iodine solution. The femoral artery contralateral to the tumor in patients with pelivic tumor or the right femoral artery in patients with sacral tumor were punctured. Then, a percutaneous introducer sheath was placed in the femoral artery. Generally, the Coda balloon catheter (Cook Medical, USA) was applied and the balloon catheter was introduced through a 11-Fr sheath as previously described [ 1 ]. The position of balloon catheter was was confirmed by fluoroscopy utilizing a C-arm (Fig. 3 ). The distal arterial pressure and urine volume were monitored constantly which is obligatory and critical to guarantee the balloon is working properly. Moreover, jugular veins were cannulated to record central venous pressure (CVP), laboratory measurements of blood and medication administration. In the operating room, the nurse trained managed the device inflating the balloon with the predetermined volume. Venous blood gas readings including glucose and electrolytes were taken at 30-minute intervals. Anesthesiologists monitored intraoperative blood pressure, pulse rate, and hemoglobin values. After every time of 30 minutes, 0.01% heparin saline 100 ml was injected through the catheter to prevent thrombosis. Data Collection Collection includes data pertaining to demographics, location of the tumor, the diamiter of abdominal aorte and femoral artery, operating time, occlusion time, total intraoperative blood loss volume, number of blood units per patient (BUPP) transfused, and intraoperative urine volume. Systolic blood pressure (SBP) was recorded just before balloon inflation (baseline), after aortic occlusion, just following balloon deflation. Before and after occluding, we evaluated the blood gas. Laboratory measurements including hemoglobin (Hb), arterial pondus hydrogenii (pH), lactate, potassium (K + ), calcium (Ca 2+ ), serum creatinin (Scr), prothrombin time (PT), activated partial and thromboplastin time (APTT) were taken at baseline and just following balloon deflation. The intraoperative blood loss was estimated by the sum of the volume of mechanical suction and absorption of dressings and sponges. The need for blood transfusion was determined by assessing the hemodynamic status of the patient. Balloon-related complication data were collected, such as balloon migration/rupture, aortic rupture, puncture site hemorrhage, aortic aneurysms, acute femoral arterial thrombosis (distal embolus), extremity compartment syndrome, and acute kidney injury. Data analysis Statistical analysis was performed by using SPSS version 22.0 (Armonk, NY, USA). Continuous data are recorded using mean ± standard deviation. Continuous data were analysed using Student-t test or Mann-Whitney U test while the categorical data were compared by Chi squared test. The differences of pre- and post-REBOA inflation were performed by Paired t test and Wilcoxon’s test. Significance was set at p < 0.05. Results There are 67 male and 54 female prospectively included in this study, with an average age of 44 years at the time of surgery. 55% of lesions were loacted at sacrum. The operating time, occlusion time, total intraoperative blood loss volume, number of blood units per patient transfused, and intraoperative urine volume were shown in Table 1 . Table 1 The demographics data Variable No. Patients 121 Male 67 [55%] Female 54 [45%] Mean Age (years) 44 (SD, 15; range, 18–70) Location of the tumor Sacrum 67 [55%] Pelvis 54 [45%] Diagnosis Benign tumor Neurofibroma/schwannoma 11 Fibrous dysplasia 3 Hemangioma 3 Malignant Tumor Metastatic carcinoma 19 Chordoma 19 Chondrosarcoma 16 Giant cell tumor 14 Osteosarcoma 14 Ewing Sarcoma 4 Malignant fibrous histiocytoma 2 Fibrosarcoma 2 Other malignant tumor 14 Operating Time (min) 243.10 (SD, 92.53; range, 100–600) Occulusion Time (min) 76.80 (SD, 31.00; range, 10–140) Blood Loss (ml) 1485.21 (SD, 1054.39; range, 400–7900) Intraoperative blood transfusions (U) 8.50 (SD, 5.04; range, 0-36.4) Intraoperative urine volume (ml) 936.41 (SD, 658.96; range, 100–3600) The mean diamiter of abdominal aorte and femoral artery at the side of puncture were 14.63 mm (SD, 1.96; range, 8.5–19), and 7.45 mm (SD, 1.07; range, 4.5–10.6), respectively. The femoral access was achieved in the angiography room in 47 cases, followed by the operating room (74 patients). The puncture method was blind puncture in all cases. The most frequently used sheaths were 11-Fr (89/121, 73.6%) mostly used, followed by 7-Fr (32/121, 26.4%). Balloon inflation resulted in a significant increase of SBP from 106.81 mmHg (SD 12.17; range, 80–155) to 121.84 mmHg (SD, 15.32; range, 93–185) mmHg (t = -14.54, p = 0.00), and decreased to 95.79 mmHg (SD, 9.24; range, 80–120) mmHg the just following balloon deflation (t = 17.83, p = 0.00). The blood pressure remained stable during the operation. With the application of REBOA, the average blood loss was only 1485.21ml (SD, 1054.39; range, 400–7900), mean total operative time was 243.10 min (SD, 92.53; range, 100–600), mean occlusion time was 76.80 min (SD, 31.00; range, 10–140). This procedure assisted the surgeon in identifying clearly the surgical margin and neurovascular structure surrounded by the tumors. In addition, intraoperative contamination was also minimized. When deflating the REBOA, the Hb decreased from 127.05 to 110.23 g/L ( p = 0.00). The arterial pH was lower than baseline (7.36 vs. 7.41, p = 0.00). The arterial lactate concentration increased from 0.91 to 1.48, ( p = 0.00). Serum potassium measurements increased from 3.95 to 4.10 mmol/L, (p = 0.00). Serum calcium measurements decreased from 2.30 to 2.03 mmol/L, ( p = 0.00). Blood creatinine decreased from 65.09 to 62.50 umol/L, ( p = 0.00) (Table 2 ). Table 2 Variables recorded just before balloon inflation (baseline), after aortic occlusion, just following balloon deflation (30 minutes ). Variables Baseline After aortic occlusion Following balloon deflation P value Hb (g/L) 127.05 ± 19.11 / 110.23 ± 17.15 0.00 * SBP (mmHg) 106.81 ± 12.17 121.84 ± 15.32 95.79 ± 9.24 0.00 * CVP (mmHg) 5.98 ± 2.88 7.13 ± 3.29 6.19 ± 3.32 0.00 * pH 7.41 ± 0.04 / 7.36 ± 0.04 0.00 * Lactate (mmol/L) 0.91 ± 0.32 / 1.48 ± 0.66 0.00 * K + (mmol/L) 3.95 ± 0.32 / 4.10 ± 0.37 0.00 * Ca 2+ (mmol/L) 2.30 ± 0.13 / 2.03 ± 0.14 0.00 * Scr (umol/L) 65.09 ± 15.48 / 62.50 ± 15.60 0.00 * PT (sec) 11.76 ± 0.99 / 12.95 ± 1.05 0.00 * APTT (sec) 31.84 ± 3.17 / 29.79 ± 3.99 0.00 * *: Paired samples t- test Balloon-related complication Balloon-related vascular complications included local hematoma at the puncture site in four patients, lower limb ischemia (acute arterial thrombosis) in two patient. The patient with limb ischemia was treated with embolectomy, resulting in preservation of the limb. There was no patient died in perioperative period. Occlusion time ≤60 min vs. Occlusion time ≥90 min Comparison between group A and group B were performed. There were no significant differences regarding demography, intraoperative urine volume. Also, there were no differences regarding SBP, pH, lactate, blood creatinine, potassium, and calcium at baseline. The operating time of Group B was longer than patients in Group A, and the patients in group 2 need more number of blood units transfused. Except that the lactate was slightly higher in Group B after deflation ( p = 0.00) (Table 3 ), other laboratory measurements including pH, potassium, calcium, and blood creatinine were at the same level. Table 3 The cmparison between Group A and Group B. Variables Group A (n = 57) Group B (n = 64) P value Age 45 ± 16 43 ± 15 0.529 Operating time (min) 199.12 ± 84.30 282.27 ± 81.76 0.000 Occlusion time (min) 47.25 ± 12.84 103.13 ± 13.76 0.000 Intraoperative blood loss volume (ml) 1305.26 ± 916.60 1645.47 ± 1146.92 0.076 Intraoperative urine volume (ml) 822.81 ± 738.55 1037.58 ± 565.86 0.073 Blood units transfused (U) 6.88 ± 4.50 9.76 ± 5.14 0.001 Hb at baseline (g/L) 131.47 ± 19.00 123.11 ± 18.48 0.016 Hb after deflation (g/L) 114.44 ± 17.01 106.48 ± 16.47 0.010 SBP at baseline (mmHg) 107.02 ± 12.65 106.63 ± 11.83 0.860 SBP after deflation (mmHg) 95.47 ± 9.87 96.08 ± 8.72 0.721 pH at baseline 7.41 ± 0.04 7.41 ± 0.04 0.903 pH after deflation 7.36 ± 0.04 7.37 ± 0.03 0.209 Lactate at baseline (mmol/L) 0.92 ± 0.32 0.90 ± 0.33 0.808 Lactate after deflation (mmol/L) 1.31 ± 0.54 1.64 ± 0.72 0.004 K + at baseline (mmol/L) 3.92 ± 0.34 3.97 ± 0.30 0.443 K + after deflation (mmol/L) 4.07 ± 0.40 4.13 ± 0.35 0.423 Ca 2+ at baseline (mmol/L) 2.31 ± 0.13 2.29 ± 0.13 0.360 Ca 2+ after deflation (mmol/L) 2.04 ± 0.14 2.01 ± 0.13 0.229 Scr at baseline (umol/L) 66.67 ± 16.43 63.69 ± 14.57 0.293 Scr after deflation (umol/L) 63.05 ± 16.14 62.00 ± 15.18 0.712 Discussion Lower abdominal aortic balloon occluding temporarily inflates the abdominal aorta, thereby reducing distal blood flow. In the past decades, abdominal aortic balloon occlusion has been successfully implemented in controlling bleeding in sacropelvic resections. To date, multiple clinical studies and animal studies and translational hemorrhagic models have been conducted describing the effects of REBOA in a state of hemorrhagic shock, but few studies have been performed that capture the effects of REBOA in a non-shock condition and give a detailed description of the changes occurring with the occlusion time prolongs. Previous studies have reported that the patients with aortic balloon occlusion showed significantly shorter mean operating time, lower blood loss, lower blood transfusion, and lower postoperative drainage volume than those of the patients without occlusion[ 1 , 2 ]. Although effective at creating temporary hemorrhage control, the procedure confers risks associated with prolonged occlusion time. The intent of the present study was to evaluate Zone 3 REBOA in sacral and pelvic tumor resections in regard to hemodynamic and metabolic effects prospectively. Besides, we compare the effect of more than 90 minutes of continuous REBOA with less than 60 minutes. These detailed hemodynamic and metabolic findings have not been reported before to the best of our knowledge. With the use of REBOA in Zone 3, the average introperative blood loss volume was only 1485.21 ml, total operative time was 243.10 min. The mean occlusion time was 76.80 min. This procedure assisted the surgeon in identifying clearly the surgical margin and neurovascular structure surrounded by the tumors. In addition, intraoperative contamination was also minimized. The results of this study uphold the current recommendations for lower abdominal aortic balloon occluding is a effective technique to significant reduces blood loss, and offers more visible operation field for surgeons to perform [ 1 , 2 , 4 – 6 ]. In current study, the SBP was increased significantly from 107.22 mmHg just before balloon inflation to 122.25 mmHg after aortic occlusion ( p = 0.00), and decreased to 95.70 mmHg the just following balloon deflation ( p = 0.00). The observed hemodynamic response is due to the effect of increasing cardiac afterload and blood volume redistribution. Relatively, more blood was reserved in proximal trunk. If the arterial blood pressure increases significantly during aortic occlusion, vasodilators can be used to control it. When we deflated the balloon, inflammatory response resulted in to pooling of the blood in the distal parts of the body, and dramatic decrease of SBP was casued by reactive hyperemia in the distal body [ 13 ]. However, the transient hypotension will be increased to the basal level after rapid infusion of solution and blood transfusion. Overall, the blood pressure remained stable during the operation. When deflating the REBOA, the hemoglobin decreased from 127 g/L to 110 g/L ( p = 0.00). Potassium increased from 3.95 to 4.10 mmol/L (p = 0.00). Lactate increased from 0.91 to 1.48 mmol/L ( p = 0.00). Calcium decreased from 2.30 to 2.03 mmol/L ( p = 0.00). Blood creatinine decreased from 65.09 to 62.50 umol/L ( p = 0.00). The reduction of hemoglobin was due to two sides: one is the resection of the tumor results in blood loss, another is reperfusion after deflation causes redistribution of blood flow. Ischemia and reperfusion cause reactive hyperemia mediated by the inflammatory response leading to pooling of the blood in the distal parts of the body whereby systemic hypovolemia arises [ 1 ]. The deflation caused incresed pH and potassium concentrations after reperfusion. A plausible explanation could be the ischemic insult caused by a combination of hemorrhagic shock and hypoperfusion due to REBOA. During reperfusion, potassium and ischemic metabolites from necrotic cells were reintroduced into circulating blood. IRI also caused hyperkalemia in all groups through acidosis and reduced excretion in the kidneys. During the procedure, urine output monitoring is important. If the urine output is less than 0.5 mL·kg·h, the position of the balloon may be too high and may require an adjustment. In this study, the average intraoperative urine output is 936.41 ml. And interestingly, the Scr was lower than before occlusion due to higer SBP during occlusion and fluid supply. Therefore, acute kidney injury was not observed in this study. Regarding to the occlusion time, we can see in this study, except that the lactate was higher in Group B after deflation ( p = 0.004) (Table 3 ), other laboratory measurements including pH, potassium, and calcium, and Scr were at the same level ( p >0.05). Many animal data suggests that prolonged occlusion of the aorta is associated with ischemia-reperfusion injury, high rates of spinal cord ischemia, and potentially an increased risk of death [ 14 – 16 ]. The profound distal ischemia means that there is a maximal duration of use for REBOA that cannot be extended. In previous studies, the researchers suggested a continuous occlusion duration should be better within 60 min. However, in the current study, we performed a Zone 3 balloon occlusion which was different with other studies. The occlusion ballon of lower abdominal aorta was situated distal to the superior mesenteric artery and the renal artery. Therefore, it will not impair the blood supply of abdominal viscera and kidney. Abviously, to determine a safe aortic occlusion time is probably impossible in clinical practice, but the results of this study shown that acceptable hemodynamic and metabolic stability can be attained during >90 minutes occlusion of REBOA, although the long duration of occlusion caused relatively higher lactate. Declarations Acknowledgements Not applicable. Funding This study was supported by The Capital’s Funds for Health Improvement and Research (No. 2020-2-4085). Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Ethics approval and consent to participate All methods were performed in accordance with the Declaration of Helsinki. This study was approved by the Ethics Review Committee (ERC) of Peking University People’s Hospital (2020PHB107-01). Informed written consent to participate in the study were obtained from all subjects or guardians. Consent for publication Not applicable. Authors' contributions ZQZ: Designing the study, Collecting and analyzing the data, Preparing the manuscript. JCW: Collecting and analyzing the data, Preparing the manuscript. TQY: Designing the study, Analyzing the data, Preparing the manuscript, Supervision. WG: Collecting the data, Preparing the manuscript. RLY: Collecting the data, Preparing the manuscript. XDT: Collecting the data, Preparing the manuscript. YY: Collecting the data, Preparing the manuscript. References Tang X, Guo W, Yang R, Tang S, Dong S (2010) Use of aortic balloon occlusion to decrease blood loss during sacral tumor resection. J Bone Joint Surg Am 92:1747–1753. DOI 10.2106/JBJS.I.01333 Luo Y, Duan H, Liu W, Min L, Shi R, Zhang W, Zhou Y, Tu C (2013) Clinical evaluation for lower abdominal aorta balloon occluding in the pelvic and sacral tumor resection. 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Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 03 Jun, 2022 Reviews received at journal 18 May, 2022 Reviewers agreed at journal 07 May, 2022 Reviewers invited by journal 07 May, 2022 Editor assigned by journal 03 May, 2022 Editor invited by journal 03 May, 2022 Submission checks completed at journal 03 May, 2022 First submitted to journal 23 Apr, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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People's Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Guo","suffix":""},{"id":103110725,"identity":"0fbd78e7-686b-4e0c-804d-d5f48b3a8b12","order_by":4,"name":"Rongli Yang","email":"","orcid":"","institution":"Peking University People's Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Rongli","middleName":"","lastName":"Yang","suffix":""},{"id":103110726,"identity":"4e1cc904-0033-433b-b8a9-601f63a72752","order_by":5,"name":"Xiaodong Tang","email":"","orcid":"","institution":"Peking University People's Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xiaodong","middleName":"","lastName":"Tang","suffix":""},{"id":103110727,"identity":"8c4c26bb-cb75-4e14-a9d7-26b5f58e85b2","order_by":6,"name":"Yi Yang","email":"","orcid":"","institution":"Peking University People's Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yi","middleName":"","lastName":"Yang","suffix":""}],"badges":[],"createdAt":"2022-04-23 15:14:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1587848/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1587848/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":21669076,"identity":"91cd3134-61ce-400f-a284-a819cee87590","added_by":"auto","created_at":"2022-05-19 15:34:11","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":147323,"visible":true,"origin":"","legend":"\u003cp\u003eThe diagram of infrarenal aorta occlusion (Zone 3 REBOA).\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1587848/v1/268ecc52348f54b6a943d0f9.jpg"},{"id":21668204,"identity":"c1fb1504-1417-41c0-93b2-855dc77cf5e8","added_by":"auto","created_at":"2022-05-19 15:29:11","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":82317,"visible":true,"origin":"","legend":"\u003cp\u003eClinical study design flow diagram.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1587848/v1/306033091549018163300ea6.jpg"},{"id":21668205,"identity":"f17094e5-4a6a-4063-92c2-f96b5d5dc606","added_by":"auto","created_at":"2022-05-19 15:29:11","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2535067,"visible":true,"origin":"","legend":"\u003cp\u003eAngiogram should show no blood flowin the distal aorta when the balloon is filled with the injected contrast.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1587848/v1/b39e82f4e028fc84226cb904.jpg"},{"id":21669077,"identity":"67b68f89-f412-460a-a25f-7c8e4c5820e5","added_by":"auto","created_at":"2022-05-19 15:34:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":464970,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1587848/v1/3f5d4a8d-800c-4e8e-850d-674663bcb4eb.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A clinical study of the hemodynamic and metabolic effects of Zone 3 REBOA for sacral and pelvic tumor resections","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe resection of bone and soft tissue tumors at pelvis and sacrum has a high risk of major and potentially fatal complications which casued by large volume of tumor and the complexity of anatomical region. This particular anatomy and the rich blood supply of the pelvis and sacrum can lead to significant intraoperative blood loss, up to 10,000 mL [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. How to reduce blood loss during the pelvic and sacral tumor resection is critical. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a technique that reduces distal blood flow and significantly reduces blood loss.\u003c/p\u003e \u003cp\u003eIn the past decades, infrarenal aorta occlusion (Zone 3 REBOA) has been successfully used in controlling bleeding in sacropelvic resections (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) [\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, the prolonged occlusion time can result in artery injury, ischemic necrosis of distal limb, or multiple organ dysfunction. Some studies [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] suggested that 60 minutes is a safe single continuous occlusion duration. Another study [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] showed that one single continuous occlusion duration longer than 90 minutes caused significant complications, while the overall damage was minor when the occlusion time is less than 90 minutes. In some work of animal model with hemorrhagic shock, occlusion time of 60 or 90 minutes were associated with a substantial ischemia and reperfusion injury (IRI) that increases late mortality [\u003cspan additionalcitationids=\"CR9 CR10 CR11\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. To date, there is a paucity of evidence to prove an optimal time duration for aortic occlusion in the setting of Zone 3 REBOA in a non-shock model. In the present study, we aimed to examine the hemodynamic and metabolic effects of Zone 3 REBOA for sacral and pelvic tumor resections following different periods of REBOA.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cp\u003eThis prospective clinical study performed at a single center was approved by the Ethics Review Committee (ERC) of Peking University People\u0026rsquo;s Hospital (2020PHB107-01).\u003c/p\u003e\n\u003cdiv class=\"Section2\" id=\"Sec3\"\u003e\n \u003ch2\u003ePatients\u003c/h2\u003e\n \u003cp\u003e121 patients underwent surgical tuomr resections of the pelvis and/or the sacrum with the use of aortic balloon occlusion were prospectively enrolled in this study from October 2020 to December 2021 (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). All cases were divided into group A (occlusion time\u0026thinsp;\u0026le;\u0026thinsp;60 min) and group B (occlusion time\u0026thinsp;\u0026ge;\u0026thinsp;90 min). The diagnoses consisted of nine benign tumors, and ninety-one malignant tumors (Table I). Group A consisted of 57 patients with a mean age of 45\u0026thinsp;\u0026plusmn;\u0026thinsp;16years. Group B consisted of 64 patients with a mean age of 43\u0026thinsp;\u0026plusmn;\u0026thinsp;15 years.\u003c/p\u003e\n \u003cdiv class=\"Section3\" id=\"Sec4\"\u003e\n \u003ch2\u003eInclusion criteria\u003c/h2\u003e\n \u003cp\u003ePatients who had the following characteristics were included in this study: (1) Bone and soft tissue tumors of the pelvis and sacrum, (2) age at 18 to 70, (3) underwent surgical resections with the use of aortic balloon occlusion, and (4) infrarenal aorta occlusion was only used once during sugery.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec5\"\u003e\n \u003ch2\u003ePositioning technique of the aortic balloon\u003c/h2\u003e\n \u003cp\u003eBefore surgery, a contrast-enhanced Computer Tomography (CT) scan was performed to detect the tumor vascularization, to evaluate the diameter of the aorta and femoral artery, and to exclude theoretical contraindications to the procedure.\u003c/p\u003e\n \u003cp\u003eAfter anesthesia induction, the groin regions were sterilized with iodine solution. The femoral artery contralateral to the tumor in patients with pelivic tumor or the right femoral artery in patients with sacral tumor were punctured. Then, a percutaneous introducer sheath was placed in the femoral artery. Generally, the Coda balloon catheter (Cook Medical, USA) was applied and the balloon catheter was introduced through a 11-Fr sheath as previously described [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e]. The position of balloon catheter was was confirmed by fluoroscopy utilizing a C-arm (Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). The distal arterial pressure and urine volume were monitored constantly which is obligatory and critical to guarantee the balloon is working properly. Moreover, jugular veins were cannulated to record central venous pressure (CVP), laboratory measurements of blood and medication administration.\u003c/p\u003e\n \u003cp\u003eIn the operating room, the nurse trained managed the device inflating the balloon with the predetermined volume. Venous blood gas readings including glucose and electrolytes were taken at 30-minute intervals. Anesthesiologists monitored intraoperative blood pressure, pulse rate, and hemoglobin values. After every time of 30 minutes, 0.01% heparin saline 100 ml was injected through the catheter to prevent thrombosis.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec6\"\u003e\n \u003ch2\u003eData Collection\u003c/h2\u003e\n \u003cp\u003eCollection includes data pertaining to demographics, location of the tumor, the diamiter of abdominal aorte and femoral artery, operating time, occlusion time, total intraoperative blood loss volume, number of blood units per patient (BUPP) transfused, and intraoperative urine volume. Systolic blood pressure (SBP) was recorded just before balloon inflation (baseline), after aortic occlusion, just following balloon deflation. Before and after occluding, we evaluated the blood gas. Laboratory measurements including hemoglobin (Hb), arterial pondus hydrogenii (pH), lactate, potassium (K\u003csup\u003e+\u003c/sup\u003e), calcium (Ca\u003csup\u003e2+\u003c/sup\u003e), serum creatinin (Scr), prothrombin time (PT), activated partial and thromboplastin time (APTT) were taken at baseline and just following balloon deflation.\u003c/p\u003e\n \u003cp\u003eThe intraoperative blood loss was estimated by the sum of the volume of mechanical suction and absorption of dressings and sponges. The need for blood transfusion was determined by assessing the hemodynamic status of the patient.\u003c/p\u003e\n \u003cp\u003eBalloon-related complication data were collected, such as balloon migration/rupture, aortic rupture, puncture site hemorrhage, aortic aneurysms, acute femoral arterial thrombosis (distal embolus), extremity compartment syndrome, and acute kidney injury.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec7\"\u003e\n \u003ch2\u003eData analysis\u003c/h2\u003e\n \u003cp\u003eStatistical analysis was performed by using SPSS version 22.0 (Armonk, NY, USA). Continuous data are recorded using mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. Continuous data were analysed using Student-t test or Mann-Whitney U test while the categorical data were compared by Chi squared test. The differences of pre- and post-REBOA inflation were performed by Paired t test and Wilcoxon\u0026rsquo;s test. Significance was set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThere are 67 male and 54 female prospectively included in this study, with an average age of 44 years at the time of surgery. 55% of lesions were loacted at sacrum. The operating time, occlusion time, total intraoperative blood loss volume, number of blood units per patient transfused, and intraoperative urine volume were shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Tab1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eThe demographics data\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e121\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e67 [55%]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e54 [45%]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean Age (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e44 (SD, 15; range, 18\u0026ndash;70)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocation of the tumor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSacrum\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e67 [55%]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePelvis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e54 [45%]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiagnosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBenign tumor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeurofibroma/schwannoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFibrous dysplasia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHemangioma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMalignant Tumor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMetastatic carcinoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChordoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChondrosarcoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGiant cell tumor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOsteosarcoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEwing Sarcoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalignant fibrous histiocytoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFibrosarcoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther malignant tumor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOperating Time (min)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e243.10 (SD, 92.53; range, 100\u0026ndash;600)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOcculusion Time (min)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e76.80 (SD, 31.00; range, 10\u0026ndash;140)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBlood Loss (ml)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e1485.21 (SD, 1054.39; range, 400\u0026ndash;7900)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntraoperative blood transfusions (U)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e8.50 (SD, 5.04; range, 0-36.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntraoperative urine volume (ml)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e936.41 (SD, 658.96; range, 100\u0026ndash;3600)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eThe mean diamiter of abdominal aorte and femoral artery at the side of puncture were 14.63 mm (SD, 1.96; range, 8.5\u0026ndash;19), and 7.45 mm (SD, 1.07; range, 4.5\u0026ndash;10.6), respectively. The femoral access was achieved in the angiography room in 47 cases, followed by the operating room (74 patients). The puncture method was blind puncture in all cases. The most frequently used sheaths were 11-Fr (89/121, 73.6%) mostly used, followed by 7-Fr (32/121, 26.4%).\u003c/p\u003e\n\u003cp\u003eBalloon inflation resulted in a significant increase of SBP from 106.81 mmHg (SD 12.17; range, 80\u0026ndash;155) to 121.84 mmHg (SD, 15.32; range, 93\u0026ndash;185) mmHg (t = -14.54, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.00), and decreased to 95.79 mmHg (SD, 9.24; range, 80\u0026ndash;120) mmHg the just following balloon deflation (t\u0026thinsp;=\u0026thinsp;17.83, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.00). The blood pressure remained stable during the operation.\u003c/p\u003e\n\u003cp\u003eWith the application of REBOA, the average blood loss was only 1485.21ml (SD, 1054.39; range, 400\u0026ndash;7900), mean total operative time was 243.10 min (SD, 92.53; range, 100\u0026ndash;600), mean occlusion time was 76.80 min (SD, 31.00; range, 10\u0026ndash;140). This procedure assisted the surgeon in identifying clearly the surgical margin and neurovascular structure surrounded by the tumors. In addition, intraoperative contamination was also minimized.\u003c/p\u003e\n\u003cp\u003eWhen deflating the REBOA, the Hb decreased from 127.05 to 110.23 g/L (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.00). The arterial pH was lower than baseline (7.36 vs. 7.41, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.00). The arterial lactate concentration increased from 0.91 to 1.48, (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.00). Serum potassium measurements increased from 3.95 to 4.10 mmol/L, (p\u0026thinsp;=\u0026thinsp;0.00). Serum calcium measurements decreased from 2.30 to 2.03 mmol/L, (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.00). Blood creatinine decreased from 65.09 to 62.50 umol/L, (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.00) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Tab2\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eVariables recorded just before balloon inflation (baseline), after aortic occlusion, just following balloon deflation (30 minutes ).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAfter aortic occlusion\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFollowing balloon deflation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHb\u003c/strong\u003e \u003cem\u003e(g/L)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e127.05\u0026thinsp;\u0026plusmn;\u0026thinsp;19.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e110.23\u0026thinsp;\u0026plusmn;\u0026thinsp;17.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSBP\u003c/strong\u003e \u003cem\u003e(mmHg)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e106.81\u0026thinsp;\u0026plusmn;\u0026thinsp;12.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e121.84\u0026thinsp;\u0026plusmn;\u0026thinsp;15.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95.79\u0026thinsp;\u0026plusmn;\u0026thinsp;9.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCVP\u003c/strong\u003e \u003cem\u003e(mmHg)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.98\u0026thinsp;\u0026plusmn;\u0026thinsp;2.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.13\u0026thinsp;\u0026plusmn;\u0026thinsp;3.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.19\u0026thinsp;\u0026plusmn;\u0026thinsp;3.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003epH\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.41\u0026thinsp;\u0026plusmn;\u0026thinsp;0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.36\u0026thinsp;\u0026plusmn;\u0026thinsp;0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLactate\u003c/strong\u003e \u003cem\u003e(mmol/L)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.91\u0026thinsp;\u0026plusmn;\u0026thinsp;0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.48\u0026thinsp;\u0026plusmn;\u0026thinsp;0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eK\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e+\u003c/strong\u003e\u003c/sup\u003e \u003cem\u003e(mmol/L)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.95\u0026thinsp;\u0026plusmn;\u0026thinsp;0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.10\u0026thinsp;\u0026plusmn;\u0026thinsp;0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCa\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e2+\u003c/strong\u003e\u003c/sup\u003e\u003cem\u003e(mmol/L)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.03\u0026thinsp;\u0026plusmn;\u0026thinsp;0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eScr\u003c/strong\u003e \u003cem\u003e(umol/L)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65.09\u0026thinsp;\u0026plusmn;\u0026thinsp;15.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62.50\u0026thinsp;\u0026plusmn;\u0026thinsp;15.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePT\u003c/strong\u003e \u003cem\u003e(sec)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.76\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.95\u0026thinsp;\u0026plusmn;\u0026thinsp;1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAPTT\u003c/strong\u003e \u003cem\u003e(sec)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31.84\u0026thinsp;\u0026plusmn;\u0026thinsp;3.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29.79\u0026thinsp;\u0026plusmn;\u0026thinsp;3.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e*: Paired samples t- test\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eBalloon-related complication\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eBalloon-related vascular complications included local hematoma at the puncture site in four patients, lower limb ischemia (acute arterial thrombosis) in two patient. The patient with limb ischemia was treated with embolectomy, resulting in preservation of the limb. There was no patient died in perioperative period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOcclusion time \u0026le;60 min vs. Occlusion time \u0026ge;90 min\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eComparison between group A and group B were performed. There were no significant differences regarding demography, intraoperative urine volume. Also, there were no differences regarding SBP, pH, lactate, blood creatinine, potassium, and calcium at baseline. The operating time of Group B was longer than patients in Group A, and the patients in group 2 need more number of blood units transfused. Except that the lactate was slightly higher in Group B after deflation (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.00) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e), other laboratory measurements including pH, potassium, calcium, and blood creatinine were at the same level.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Tab3\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eThe cmparison between Group A and Group B.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGroup A (n\u0026thinsp;=\u0026thinsp;57)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGroup B (n\u0026thinsp;=\u0026thinsp;64)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45\u0026thinsp;\u0026plusmn;\u0026thinsp;16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43\u0026thinsp;\u0026plusmn;\u0026thinsp;15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.529\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOperating time \u003cem\u003e(min)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e199.12\u0026thinsp;\u0026plusmn;\u0026thinsp;84.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e282.27\u0026thinsp;\u0026plusmn;\u0026thinsp;81.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOcclusion time \u003cem\u003e(min)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.25\u0026thinsp;\u0026plusmn;\u0026thinsp;12.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e103.13\u0026thinsp;\u0026plusmn;\u0026thinsp;13.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntraoperative blood loss volume \u003cem\u003e(ml)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1305.26\u0026thinsp;\u0026plusmn;\u0026thinsp;916.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1645.47\u0026thinsp;\u0026plusmn;\u0026thinsp;1146.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.076\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntraoperative urine volume \u003cem\u003e(ml)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e822.81\u0026thinsp;\u0026plusmn;\u0026thinsp;738.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1037.58\u0026thinsp;\u0026plusmn;\u0026thinsp;565.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.073\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBlood units transfused \u003cem\u003e(U)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.88\u0026thinsp;\u0026plusmn;\u0026thinsp;4.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.76\u0026thinsp;\u0026plusmn;\u0026thinsp;5.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHb at baseline \u003cem\u003e(g/L)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e131.47\u0026thinsp;\u0026plusmn;\u0026thinsp;19.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e123.11\u0026thinsp;\u0026plusmn;\u0026thinsp;18.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHb after deflation \u003cem\u003e(g/L)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e114.44\u0026thinsp;\u0026plusmn;\u0026thinsp;17.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e106.48\u0026thinsp;\u0026plusmn;\u0026thinsp;16.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSBP at baseline \u003cem\u003e(mmHg)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e107.02\u0026thinsp;\u0026plusmn;\u0026thinsp;12.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e106.63\u0026thinsp;\u0026plusmn;\u0026thinsp;11.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.860\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSBP after deflation \u003cem\u003e(mmHg)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95.47\u0026thinsp;\u0026plusmn;\u0026thinsp;9.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e96.08\u0026thinsp;\u0026plusmn;\u0026thinsp;8.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.721\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003epH at baseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.41\u0026thinsp;\u0026plusmn;\u0026thinsp;0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.41\u0026thinsp;\u0026plusmn;\u0026thinsp;0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.903\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003epH after deflation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.36\u0026thinsp;\u0026plusmn;\u0026thinsp;0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.37\u0026thinsp;\u0026plusmn;\u0026thinsp;0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.209\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLactate at baseline \u003cem\u003e(mmol/L)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.90\u0026thinsp;\u0026plusmn;\u0026thinsp;0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.808\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLactate after deflation \u003cem\u003e(mmol/L)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.31\u0026thinsp;\u0026plusmn;\u0026thinsp;0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.64\u0026thinsp;\u0026plusmn;\u0026thinsp;0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eK\u003csup\u003e+\u003c/sup\u003e at baseline \u003cem\u003e(mmol/L)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.97\u0026thinsp;\u0026plusmn;\u0026thinsp;0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.443\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eK\u003csup\u003e+\u003c/sup\u003e after deflation \u003cem\u003e(mmol/L)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.07\u0026thinsp;\u0026plusmn;\u0026thinsp;0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.423\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCa\u003csup\u003e2+\u003c/sup\u003e at baseline \u003cem\u003e(mmol/L)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.31\u0026thinsp;\u0026plusmn;\u0026thinsp;0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.29\u0026thinsp;\u0026plusmn;\u0026thinsp;0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.360\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCa\u003csup\u003e2+\u003c/sup\u003e after deflation \u003cem\u003e(mmol/L)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.04\u0026thinsp;\u0026plusmn;\u0026thinsp;0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.01\u0026thinsp;\u0026plusmn;\u0026thinsp;0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.229\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eScr at baseline \u003cem\u003e(umol/L)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66.67\u0026thinsp;\u0026plusmn;\u0026thinsp;16.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63.69\u0026thinsp;\u0026plusmn;\u0026thinsp;14.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.293\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eScr after deflation \u003cem\u003e(umol/L)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63.05\u0026thinsp;\u0026plusmn;\u0026thinsp;16.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62.00\u0026thinsp;\u0026plusmn;\u0026thinsp;15.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.712\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eLower abdominal aortic balloon occluding temporarily inflates the abdominal aorta, thereby reducing distal blood flow. In the past decades, abdominal aortic balloon occlusion has been successfully implemented in controlling bleeding in sacropelvic resections. To date, multiple clinical studies and animal studies and translational hemorrhagic models have been conducted describing the effects of REBOA in a state of hemorrhagic shock, but few studies have been performed that capture the effects of REBOA in a non-shock condition and give a detailed description of the changes occurring with the occlusion time prolongs.\u003c/p\u003e\n\u003cp\u003ePrevious studies have reported that the patients with aortic balloon occlusion showed significantly shorter mean operating time, lower blood loss, lower blood transfusion, and lower postoperative drainage volume than those of the patients without occlusion[\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e]. Although effective at creating temporary hemorrhage control, the procedure confers risks associated with prolonged occlusion time. The intent of the present study was to evaluate Zone 3 REBOA in sacral and pelvic tumor resections in regard to hemodynamic and metabolic effects prospectively. Besides, we compare the effect of more than 90 minutes of continuous REBOA with less than 60 minutes. These detailed hemodynamic and metabolic findings have not been reported before to the best of our knowledge.\u003c/p\u003e\n\u003cp\u003eWith the use of REBOA in Zone 3, the average introperative blood loss volume was only 1485.21 ml, total operative time was 243.10 min. The mean occlusion time was 76.80 min. This procedure assisted the surgeon in identifying clearly the surgical margin and neurovascular structure surrounded by the tumors. In addition, intraoperative contamination was also minimized. The results of this study uphold the current recommendations for lower abdominal aortic balloon occluding is a effective technique to significant reduces blood loss, and offers more visible operation field for surgeons to perform [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eIn current study, the SBP was increased significantly from 107.22 mmHg just before balloon inflation to 122.25 mmHg after aortic occlusion (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.00), and decreased to 95.70 mmHg the just following balloon deflation (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.00). The observed hemodynamic response is due to the effect of increasing cardiac afterload and blood volume redistribution. Relatively, more blood was reserved in proximal trunk. If the arterial blood pressure increases significantly during aortic occlusion, vasodilators can be used to control it. When we deflated the balloon, inflammatory response resulted in to pooling of the blood in the distal parts of the body, and dramatic decrease of SBP was casued by reactive hyperemia in the distal body [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, the transient hypotension will be increased to the basal level after rapid infusion of solution and blood transfusion. Overall, the blood pressure remained stable during the operation.\u003c/p\u003e\n\u003cp\u003eWhen deflating the REBOA, the hemoglobin decreased from 127 g/L to 110 g/L (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.00). Potassium increased from 3.95 to 4.10 mmol/L (p\u0026thinsp;=\u0026thinsp;0.00). Lactate increased from 0.91 to 1.48 mmol/L (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.00). Calcium decreased from 2.30 to 2.03 mmol/L (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.00). Blood creatinine decreased from 65.09 to 62.50 umol/L (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.00). The reduction of hemoglobin was due to two sides: one is the resection of the tumor results in blood loss, another is reperfusion after deflation causes redistribution of blood flow. Ischemia and reperfusion cause reactive hyperemia mediated by the inflammatory response leading to pooling of the blood in the distal parts of the body whereby systemic hypovolemia arises [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e]. The deflation caused incresed pH and potassium concentrations after reperfusion. A plausible explanation could be the ischemic insult caused by a combination of hemorrhagic shock and hypoperfusion due to REBOA. During reperfusion, potassium and ischemic metabolites from necrotic cells were reintroduced into circulating blood. IRI also caused hyperkalemia in all groups through acidosis and reduced excretion in the kidneys. During the procedure, urine output monitoring is important. If the urine output is less than 0.5 mL\u0026middot;kg\u0026middot;h, the position of the balloon may be too high and may require an adjustment. In this study, the average intraoperative urine output is 936.41 ml. And interestingly, the Scr was lower than before occlusion due to higer SBP during occlusion and fluid supply. Therefore, acute kidney injury was not observed in this study.\u003c/p\u003e\n\u003cp\u003eRegarding to the occlusion time, we can see in this study, except that the lactate was higher in Group B after deflation (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e), other laboratory measurements including pH, potassium, and calcium, and Scr were at the same level (\u003cem\u003ep\u003c/em\u003e\u0026nbsp;\u0026gt;0.05). Many animal data suggests that prolonged occlusion of the aorta is associated with ischemia-reperfusion injury, high rates of spinal cord ischemia, and potentially an increased risk of death [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]. The profound distal ischemia means that there is a maximal duration of use for REBOA that cannot be extended. In previous studies, the researchers suggested a continuous occlusion duration should be better within 60 min. However, in the current study, we performed a Zone 3 balloon occlusion which was different with other studies. The occlusion ballon of lower abdominal aorta was situated distal to the superior mesenteric artery and the renal artery. Therefore, it will not impair the blood supply of abdominal viscera and kidney. Abviously, to determine a safe aortic occlusion time is probably impossible in clinical practice, but the results of this study shown that acceptable hemodynamic and metabolic stability can be attained during \u0026gt;90 minutes occlusion of REBOA, although the long duration of occlusion caused relatively higher lactate.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by The Capital\u0026rsquo;s Funds for Health Improvement and Research (No. 2020-2-4085).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll methods were performed in accordance with the Declaration of Helsinki. This study was approved by the Ethics Review Committee (ERC) of Peking University People\u0026rsquo;s Hospital (2020PHB107-01). Informed written consent to participate in the study were obtained from all subjects or guardians.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZQZ: Designing the study, Collecting and analyzing the data, Preparing the manuscript.\u003c/p\u003e\n\u003cp\u003eJCW: Collecting and analyzing the data, Preparing the manuscript.\u003c/p\u003e\n\u003cp\u003eTQY: Designing the study, Analyzing the data, Preparing the manuscript, Supervision.\u003c/p\u003e\n\u003cp\u003eWG: Collecting the data, Preparing the manuscript.\u003c/p\u003e\n\u003cp\u003eRLY: Collecting the data, Preparing the manuscript.\u003c/p\u003e\n\u003cp\u003eXDT: Collecting the data, Preparing the manuscript.\u003c/p\u003e\n\u003cp\u003eYY: Collecting the data, Preparing the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTang X, Guo W, Yang R, Tang S, Dong S (2010) Use of aortic balloon occlusion to decrease blood loss during sacral tumor resection. 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DOI \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/sla.0000000000003408\u003c/span\u003e\u003cspan address=\"10.1097/sla.0000000000003408\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWikstr\u0026ouml;m MB, Sm\u0026aring;rs M, Karlsson C, Stene Hurts\u0026eacute;n A, H\u0026ouml;rer TM, Nilsson KF (2021) A randomized porcine study of the hemodynamic and metabolic effects of combined endovascular occlusion of the vena cava and the aorta in normovolemia and in hemorrhagic shock. The journal of trauma and acute care surgery 90:817\u0026ndash;826. DOI \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/ta.0000000000003098\u003c/span\u003e\u003cspan address=\"10.1097/ta.0000000000003098\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Aortic occlusion, Hemodynamic, Sacropelvic tumor, Hemostasis","lastPublishedDoi":"10.21203/rs.3.rs-1587848/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1587848/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eBackground:\u003c/em\u003e\u003c/strong\u003e Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a key procedure in sacral and pelvic tumor resection that provides hemorrhage control. However, few studies have been performed to capture the effects of REBOA in a non-shock condition and give a detailed description of the changes occurring with the occlusion time prolongs. This study aim to examine the hemodynamic and metabolic effects of Zone 3 REBOA for sacral and pelvic tumor resections following different periods of REBOA.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eMethods:\u003c/em\u003e \u003c/strong\u003e121 patients underwent surgical tuomr resections of the pelvis and/or the sacrum with the use of aortic balloon occlusion were prospectively enrolled in this study from October 2020 to December 2021. All cases were divided into group A (occlusion time ≤60 min, n = 57) and group B (occlusion time ≥90 min, n = 64). Physiologic parameters were continuously recorded, and laboratory specimens were obtained at regular intervals.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eResults:\u003c/em\u003e \u003c/strong\u003eBalloon inflation resulted in a significant increase of SBP from 106.81 to 121.84 mmHg (\u003cem\u003ep\u003c/em\u003e = 0.00), and decreased to 95.79 mmHg the just following balloon deflation. With the application of REBOA, the average blood loss was only 1485.21ml (range, 400-7900). When deflating the REBOA, the arterial pH was lower than baseline (7.36 vs. 7.41, \u003cem\u003ep\u003c/em\u003e = 0.00). The arterial lactate concentration increased from 0.91 to 1.48 mmol/L, (\u003cem\u003ep\u003c/em\u003e = 0.00). Serum potassium measurements increased from 3.95 to 4.10 mmol/L. Serum calcium measurements decreased from 2.30 to 2.03 mmol/L. Blood creatinine decreased from 65.09 to 62.50 umol/L. All the laboratory measurements were at normal level after deflation of the REBOA. The operating time of Group B was longer than patients in Group A, and the patients in Group B need more number of blood units transfused. Except that the lactate was higher in Group B after deflation (\u003cem\u003ep\u003c/em\u003e = 0.00), other laboratory measurements including pH, potassium, calcium, and blood creatinine were at the same level.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConclusions:\u003c/em\u003e\u003c/strong\u003e The results of this study shown that acceptable hemodynamic and metabolic stability can be attained when the occlusion time of REBOA more than 90 minutes, although the long duration of occlusion caused relatively higher lactate.\u003c/p\u003e","manuscriptTitle":"A clinical study of the hemodynamic and metabolic effects of Zone 3 REBOA for sacral and pelvic tumor resections","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-05-19 15:29:09","doi":"10.21203/rs.3.rs-1587848/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-06-03T05:53:45+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-05-18T21:51:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1cf50894-ab41-45e3-a128-b52b3841ea38","date":"2022-05-07T10:25:56+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-05-07T09:50:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-05-03T10:13:04+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-05-03T08:32:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-05-03T08:02:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2022-04-23T15:02:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b88c146c-d90d-4b4a-9195-56c183759313","owner":[],"postedDate":"May 19th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2022-06-20T06:44:12+00:00","versionOfRecord":[],"versionCreatedAt":"2022-05-19 15:29:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1587848","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1587848","identity":"rs-1587848","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}