Finally, a use for balloons: Extended automated endovascular support enhances closed-loop resuscitation in a porcine model of shock.

Abstract

Endovascular Perfusion Augmentation for Critical Care (EPACC) is a method of dynamic aortic balloon catheter titration for precision hemodynamic support. EPACC has the potential to augment hemodynamics in conjunction with conventional resuscitation strategies. We previously described how even short periods of EPACC, along with an automated fluid and drug delivery system termed Precision Automated Critical Care Management (PACC-MAN) can reduce resuscitation requirements over the first few hours after severe ischemia-reperfusion injury (IRI). We sought to understand if an initial 180 minutes of EPACC+PACC-MAN can offset vasopressor requirements over 24 hours of critical care compared with PACC-MAN alone in an established IRI model. Twelve swine underwent 30% hemorrhage, then 45 minutes of complete zone 1 aortic occlusion, inducing IRI and vasoplegia. Animals were then transfused to euvolemia and randomized to EPACC+PACC-MAN (180 min of dynamic partial aortic balloon pressure augmentation that autonomously adjusted based on the animal's physiology) or PACC-MAN automated critical care alone. Critical care lasted for 24 hours in both groups. Primary outcomes included duration of hypotension (mean arterial pressure <60 mm Hg), hypertension (mean arterial pressure >70 mm Hg), total crystalloid, and norepinephrine volumes. Secondary outcomes included lactate load, creatinine, urine output, biomarkers, and histopathology. Percent time spent in hypotension for EPACC+PACC-MAN versus PACC-MAN (3.10% vs. 3.75%, p=0.47) and hypertension (8.90% vs 5.58%, p=0.13) was not significantly different. Total crystalloid volume for EPACC+PACC-MAN versus PACC-MAN was not significant (198.3 mL/kg vs. 308.2 mL/kg, P=0.38). EPACC+PACC-MAN required significantly less norepinephrine during the study period (210.77 mcg/kg vs. 1102.0 mcg/kg, p=0.045). Supporting hemodynamics with EPACC to mitigate severe vasoplegia of initial resuscitation has a sustained effect on limiting vasopressor requirements in this 24-hour study, without compromising physiologic endpoints. Automation of endovascular devices may play an adjunctive role in managing severe shock states and augmenting autonomous resuscitation, particularly in resource-constrained care environments. (J Trauma Acute Care Surg 2026;00:000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). Level IV.