Selective Aortic Arch Perfusion - Summary by: Jim Manning Selective Aortic Arch Perfusion (SAAP) is an endovascular-extracorporeal perfusion resuscitation technique designed specifically to treat cardiac arrest. SAAP involves the blind insertion of a large-lumen balloon occlusion catheter into the descending thoracic aortic arch via a femoral artery. With the SAAP catheter balloon inflated in the thoracic aorta, the heart and brain are relatively isolated for resuscitative perfusion through the SAAP catheter lumen with an oxygen-carrying fluid (such as blood, hemoglobin-based oxygen carrier or fluorocarbon emulsion). SAAP promotes restoration of spontaneous circulation (ROSC) by the heart while protecting the brain from further ischemic insult. SAAP can be used to treat both hemorrhage-induced traumatic cardiac arrest and medical, non-traumatic cardiac arrest. In traumatic cardiac arrest, SAAP provides the combination of (1) thoracic aortic balloon occlusion for control of hemorrhage below the diaphragm, (2) rapid volume replacement in hemorrhage-induced hypovolemia to restore normovolemia and (3) perfusion of the heart and brain in an effort to achieve ROSC. SAAP also allows titration of small doses of intra-aortic adrenaline or other medications to achieve ROSC. In medical cardiac arrest, SAAP catheter balloon occlusion of the thoracic aorta limits the distribution of oxygenated perfusate toward the heart and brain. Since medical cardiac arrest patients are not typically hypovolemic, SAAP with an exogenous oxygen-carrier is a volume loading intervention that can only be used for a short time period (5-10 min). If ROSC is not achieved with the limited volume of exogenous oxygen-carrier, femoral venous access during initial SAAP infusion allows venous blood withdrawal for continued SAAP support to promote ROSC without further volume loading (autologous blood SAAP or, essentially, aortic arch ECMO). Intra-aortic adrenaline and anti-reperfusion agents can also be used. Even if ROSC is not rapidly achieved, SAAP serves as a bridge that limits hypoperfusion until cannulation for full body ECMO can be achieved.

1. Is Selective Aortic Arch Perfusion
the Answer?
James E. Manning, MD
Departments of Emergency Medicine and Surgery
University of North Carolina at Chapel Hill School of Medicine
SMACC 2015
Chicago, IL
June 25, 2015
Disclosure: Inventor on patents for the Selective Aortic Arch Perfusion assigned to the
University of North Carolina at Chapel Hill. Co-Founder of Resusitech, Inc., a medical
device company developing resuscitation technologies.

2. What is Selective Aortic Arch Perfusion?
(SAAP)

3. Selective Aortic Arch Perfusion
Selective Aortic Arch Perfusion
is a resuscitationtechnique that
involves the blind insertionof a
large-lumenballoon occlusion
catheter into the descending
thoracic aortic arch via a
femoral artery. With the
balloon inflated, the heart and
brain are relativelyisolated for
resuscitative perfusionwith an
oxygen-carrying fluid in an
effort to promote restoration of
spontaneous circulationby the
heart while protecting the brain
from further ischemic insult.

4. Ann Emerg Med 1992; 21:1068-1065

5. Why SAAP?

6. Resuscitation Medicine
Key Concept: The “Chain of Survival”
Early Recognition
& Activation(911)
Early CPR
Rapid
Defibrillation
ACLS &
Transport
Post-Resuscitation
ICU/Neuro Care

7. Two Principles
In Order to Improve Cardiac Arrest Survival:
(1)We Need Better Methods of Artificial Perfusion
(2)We Need Better Monitoring Technology

8. Selective Aortic Arch Perfusion
Time-critical pre-hospital / in-hospital resuscitation
intervention intended to compensate for “weak links”
in the Chain of Survival
.…an effort to “turn back the clock” in cardiac arrest

9. “Endovascular-Extracorporeal Resuscitation Era”
Momentum from two different directions
(1) Endovascular hemorrhage control:
Trauma / Severe Hemorrhagic Shock
REBOA ………/ SAAP ……../ EPR
(2) Extracorporeal perfusion:
Medical Cardiac Arrest / Sudden Death
CPB / EMCO / ECLS / ECPR ….…./ SAAP

11. ECLS/ECMO/ECPR
Joe Bellezzo, Zack Shinar, Scott Weingart Josh Ihle, Paul Nixon, Paul Forrest

12. Selective Aortic Arch Perfusion for Medical Cardiac Arrest/Sudden Death
Manning et al, Ann Emerg Med 1992; 21:1068-1065
Medical Cardiac Arrest:
Aortic balloon occlusionallows
relativelyisolatedperfusion of
the heart and brain
Heart and brain perfusion with
an oxygen-carrying fluid
Hemoglobin-based(HBOC)
Fluorocarbon emulsion(PFC)
Blood (allogeneic / autologous)
Intra-aortic drug administration
- Epinephrine / vasoactive agents
- Ischemia-reperfusion agents
- Hemostatic products
Rapid hypothermia induction

15. Selective Aortic Arch Perfusion
SAAP can generate “supra-normal” myocardial blood flow
Baseline NSR CPR SAAP

16. 00041 – VF CA – 1 min SAAP

17. VF Cardiac Arrest - SAAP with Oxygenated Blood
Oxygenated packed RBCs Aortic Epinephrine 0.01 mg/kg included
CaCl2 continuous infusion in the initial SAAP bolus

19. A
W

20. A
SAAP catheter: 11.5 Fr OD, 7.3 Fr ID of infusion lumen
ECMO arterial cannulas: 15 Fr & 19 Fr

21. Sequential Invasive Resuscitation Interventions in
Medical/Non-Trauma Cardiac Arrest
If initial CPR, Defibrillation, ACLS is unsuccessful (No ROSC)
Femoral artery SAAP balloon catheter insertion &
initiate SAAP with O2 carrier (HBOC, PFC, WB/pRBC)
(obtain venous access during this initial SAAP phase)
If ROSC not achieved, venous blood W/D & transition
to SAAP with Autologous Blood (partial ECMO/ECLS)
If ROSC not achieved, larger femoral arterial cannula
& convert to whole body ECLS/ECPR
If ROSC not achieved, Consider: Cardiac Cath
for PCI, LVAD, VIR, CT/Vasc Surgery,
profound hypothermia (?), and
cessation of resuscitation efforts

22. Impending Cardiovascular Collapse, especially in NCTH
Hemorrhage-induced Traumatic Cardiac Arrest (HiTCA)
SAAP in Trauma

23. Aortic Hemostasis and Resuscitation
AHR
NCTH/decompensated Hemorrhage-induced
hemorrhagic shock Traumatic Cardiac Arrest (HiTCA)
but NOT impending
CV collapse/CA if CA occurs
REBOA SAAP ROSC not achieved
ROSC but EPR
myocardial dysfx
ECLS ECLS inadequate
(ECMO)
REBOA – Resuscitative Endovascular Balloon Occlusion of the Aorta
SAAP – Selective Aortic Arch Perfusion
EPR – Emergency Preservation & Resuscitation
ECLS – Extracorporeal Life Support (Extracorporeal Membrane Oxygenation)

24. Selective Aortic Arch Perfusion for Hemorrhage-Induced Cardiac Arrest
Manning et al, Crit Care Med 2001; 29:2067-2074
Trauma / Hemorrhagic Shock:
Aortic balloon occlusionto
limit abdominal/pelvic blood
loss caudal to the balloon
(functional aortic cross-clamp)
Perfusion of the heart & brain
with an oxygenated solution
(HBOC, fluorocarbon, whole
blood) to ROSC & to restore
intravascular volume rapidly
Intra-aortic administration
- Epinephrine / vasoactive agents
- Ischemia-reperfusion agents
- Hemostatic products
Temperature regulation(??)

26. Oxygen-Carrier Perfusate for SAAP:
PFCs & HBOCs – still “future capability” in the USA
Present capability
Whole Blood
Packed RBCs
(citrate anticoagulant issue)
SAAP in Hemorrhage-induced Cardiac Arrest

27. Selective Aortic Arch Perfusion with Hemoglobin-BasedOxygen Carrier-201
for resuscitationfrom exsanguination cardiac arrest in swine
Manning et al. Crit Care Med 2001; 29:2067-2074
SAAP with oxygenated HBOC-201 vs. SAAP with oxygenated LR
Swine liver lacerationmodel, rapid exsanguination, cardiac arrest at 10-13 mins
Sustained ROSC in 6/6 SAAP – HBOC-201 1-hour survival in 5/6
Transient ROSC in 2/6 SAAP – LR (with Ao-Epi) 1-hour survival in 0/6
ROSC time for SAAP – HBOC-201 was 1.9±1.0 min

28. Oxygen-Carrier Perfusate for SAAP:
PFCs & HBOCs – still “future capability” in the USA
Present capability
Whole Blood
Packed RBCs
(citrate anticoagulant issue)
SAAP in Hemorrhage-induced Cardiac Arrest

29. 00031 – HiTCA – 1 min SAAP

30. SAAP with HBOC-201 in Hemorrhage-induced Cardiac Arrest

31. AHR: SAAP with Oxygenated Stored Blood
SAAP-whole blood (10 mL/kg/min) + intra-aortic Ca++ infusion
ROSC at about 1.5 min

32. Ann Emerg Med 1993; 22:703-708

33. AHR: SAAP with Oxygenated Stored Blood
SAAP-packed RBCs (10 mL/kg/min) + intra-aortic Ca++ infusion
Aortic epinephrine (0.01 mg/kg) at 3 min of SAAP, ROSC

34. AHR: SAAP with Oxygenated Stored Blood
SAAP-whole blood (10 mL/kg/min)+ intra-aortic Ca++ infusion
ROSC but MAP < 60 mmHg, Aortic epinephrine (0.003 mg/kg)

35. Aortic Hemostasis and Resuscitation
AHR
NCTH/decompensated Hemorrhage-induced
hemorrhagic shock Traumatic Cardiac Arrest (HiTCA)
but NOT impending
CV collapse/CA if CA occurs
REBOA SAAP ROSC not achieved
ROSC but EPR
myocardial dysfx
ECLS ECLS inadequate
(ECMO)
REBOA – Resuscitative Endovascular Balloon Occlusion of the Aorta
SAAP – Selective Aortic Arch Perfusion
EPR – Emergency Preservation & Resuscitation
ECLS – Extracorporeal Life Support (Extracorporeal Membrane Oxygenation)

37. Is Selective Aortic Arch Perfusion the answer?

38. Is Selective Aortic Arch Perfusion the answer?
Maybe, in part……
SAAP is one of the interventions we could have in
our “resuscitation toolkit” to help us save the lives
of our cardiac arrest patients….before it’s too late.

39. Thank You!
&
A Toast to SMACC!