Procedure

Resuscitative Endovascular Balloon Occlusion of the Aorta

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Resuscitative Endovascular Balloon Occlusion of the Aorta, REBOA

  • See Also
  1. Emergency Thoracotomy
  2. Hemorrhagic Shock
  • Indications
  1. Noncompressible, subdiaphragmatic Hemorrhage in the Abdomen or Pelvis
    1. Consider in severe Hemorrhagic Shock before Cardiac Arrest
  2. Does not replace Resuscitative Thoracotomy
    1. REBOA is an adjunct that reduces subdiaphragmatic Hemorrhage
    2. Chest Hemorrhage is a relative contraindication to REBOA as it would likely increase chest bleeding
  3. Severe Pelvic Fractures who have not had Cardiac Arrest who need immediate temporizing measures
    1. May be considered in Peri-Arrest patient without obvious source of Hemorrhage
    2. Best used for short-term bridging to definitive procedure (risk of distal ischemia)
  • Contraindications (Cases in Which Emergency Thoracotomy are instead indicated)
  1. Penetrating Chest Trauma
  2. Uncontrolled chest Hemorrhage
  3. Cardiac Tamponade
  4. Previous vascular surgery
  5. Suspected aortic injury
  • Technique
  1. Performed in 5-10 minutes in skilled hands
  2. Catheter insertion length determined prior to insertion (mark stop point)
  3. Common femoral artery cannulated
    1. Traditionally performed via very large bore catheters (12-14F)
    2. Newer commercial kits use arterial catheters smaller than 14F
    3. Typically placed under Bedside Ultrasound guidance
  4. Percutaneous balloon delivered via femoral artery catheter and inflated in aorta above level of suspected Hemorrhage
    1. Avoid catheter placement in Zone 2 (between Celiac Artery and renal arteries)
    2. Zone 1: Subdiaphragmatic (typical target for balloon placement), but above Celiac Artery
      1. Indicated for intra-abdominal bleeding (e.g. positive FAST Scan) to reduce splanchnic flow
    3. Zone 3: Between renal arteries and iliac Bifurcation
      1. Indicated for pelvic source of bleeding
  5. Percutaneous balloon inflation
    1. Arterial waveform monitored during balloon passage and inflation
    2. Inflate the percutaneous balloon until target
      1. Systolic Blood Pressure increases by 10 mmHg AND
      2. Pulse is not present in contralateral lower extremity
  • Efficacy
  1. Efficacy is difficult to measure for a last-ditch effort to stave off death for minutes to allow for emergent surgery
  2. Studies in 2016, suggest lower efficacy than initially thought, and may be associated with higher mortality
    1. Inoue (2016) J Trauma Acute Care Surg 80(4): 559-67 +PMID: 26808039 [PubMed]
  3. Retrospective study showed reduced mortality in Hemorrhagic Shock with REBOA compared with Resuscitative Thoracotomy
    1. However, this was not a direct comparative trial and further studies are needed
    2. Cralley (2023) JAMA Surg 158(2):140-50 +PMID: 36542395 [PubMed]
  • Complications
  1. Aortic Dissection, pseudoaneurysm (or other aortic injury)
  2. Suprarenal Occlusion (balloon too high, unless intended for zone 1)
  3. Internal organ and lower extremity ischemic injury
  4. Distal Thromboembolism
  • Resources
  1. HQMedEd (Glenn Paetow)
    1. http://hqmeded.com/resuscitative-endovascular-balloon-occlusion-aorta-reboa/
  • References
  1. Inaba in Herbert (2013) EM:Rap 13(11): 3-4
  2. Shoenberger, Swadron and Inaba in Herbert (2018) 18(12): 10-11
  3. Ringhauser (2019) Crit Dec Emerg Med 33(6): 19-25
  4. Hughes (1954) Surgery 36(1):65-8 [PubMed]