Selective Pelvic Perfusion May Prolong the Duration of Survivable Infrarenal Aortic and Inferior Vena Caval Occlusion

Introduction: Surgery for pelvic trauma and oncologic resections presents difficult challenges due to intricate anatomy and limited operative exposure. These high-risk surgeries might require prolonged Zone 3 (infrarenal) aortic occlusion, leading to potentially fatal ischemia–reperfusion injury. We investigated whether the use of a distal extracorporeal membrane oxygenation (ECMO) perfusion system with endovascular hemorrhage control devices placed in both the aorta and inferior vena cava (REBOAVC) in Zone 3 can prolong the duration of safe occlusion in a porcine model.Methods: Three anesthetized, mechanically ventilated Duroc-cross pigs were instrumented to monitor hemodynamics, oxygenation, and tissue injury markers. All pigs underwent 90 minutes of infrarenal REBOAVC and femoral venoarterial low-flow ECMO (8F/10F femoral cannulation; 0.57 ± 0.03 L/min) with inline hemofiltration using an Oxiris filter. Physiological parameters and hemodynamics were monitored throughout the occlusion period.Results: Hemodynamic and metabolic stability was maintained during 90 minutes of Zone 3 occlusion with ECMO– REBOAVC–hemofiltration, with markers of distal tissue perfusion and kidney function remaining similar to baseline values (lactate 2.78 ± 0.30 mmol/L, pH 7.48 ± 0.01, potassium 4.20 ± 0.06 mmol/L, creatinine 1.20 ± 0.06 mmol/L, urine output 2.44 ± 0.83 mL/kg per hour).Conclusions: Small-bore femorally placed ECMO cannulas provided sufficient perfusion to distal tissue in a porcine model with infrarenal aortic/vena caval occlusion, suggesting that an integrated ECMO–REBOAVC–hemofiltration system has potential to improve survivability for prolonged aortic occlusion for complex pelvic operations. Selective Abdominopelvic Bypass with ECMO–REBOAVC (SABER) is proposed as a controlled reperfusion strategy involving a stepwise approach to combine endovascular hemorrhage control and artificial selective perfusion to optimize surgical field visualization and physiological outcomes.