The Critical Edge Podcast

REBOA

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This episode discusses Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as a vital intervention for managing life-threatening, non-compressible bleeding below the diaphragm. Because hemorrhage is a leading cause of preventable trauma deaths, this endovascular technique serves as a less invasive alternative to open chest surgery for stabilizing hemodynamic shock. The sources outline the evolution of the technology, moving from large catheters requiring surgical repair to modern 7-French systems that allow for quicker, percutaneous access. Furthermore, the text emphasizes the necessity of specialized training and institutional protocols to ensure the balloon is placed correctly within specific aortic zones. While many studies suggest REBOA improves survival rates compared to traditional methods, the authors acknowledge that further research is needed to refine its clinical application. Ultimately, the procedure is presented as a powerful adjunct tool for trauma teams to bridge critically ill patients to definitive surgical repair.

 

 

DISCLAIMER

The Critical Edge is for educational and informational purposes only and is not intended to diagnose, treat, cure, or prevent any disease, nor does it substitute for professional medical advice, diagnosis, or treatment from a qualified healthcare provider—always seek in-person evaluation and care from your physician or trauma team for any health concerns.

 

Comprehensive Study Guide: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

This study guide synthesizes research and clinical observations regarding the use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as a critical intervention for traumatic hemorrhage. It covers the clinical indications, anatomical considerations, procedural techniques, and the current state of medical evidence surrounding the procedure.

The Clinical Challenge of Traumatic Hemorrhage

Traumatic injury is a global health crisis, accounting for approximately 9% of annual deaths worldwide (over 5 million). In the United States, injury is a leading cause of potential life lost, surpassing heart disease. Hemorrhage is the primary driver of these statistics, responsible for:

  • 40% of all trauma-related deaths.
  • 80% of trauma deaths occurring in the operating room.
  • The most common cause of potentially preventable trauma death.

    • Severe subdiaphragmatic trauma often results in uncontrolled, noncompressible hemorrhage. For patients in class III or IV hemorrhagic shock, traditional options like resuscitative thoracotomy with aortic cross-clamping often yield poor outcomes and may be considered futile. While angiographic embolization is effective, the time required to assemble an interventional team (roughly one hour) is often too long for patients in extremis.

    Overview of REBOA

    REBOA is an endovascular technique designed to provide temporary hemorrhage control and stabilize hemodynamics. By occluding the aorta, the procedure aims to:

    1. Preserve cerebral and cardiac perfusion.
    2. Decrease distal hemorrhage.
    3. Provide a "bridge" to definitive surgical or interventional repair.

      4. Though first described during the Korean Conflict by Hughes, the technique has seen a resurgence over the last two decades due to advancements in endovascular technology and instrumentation.

      Clinical Indications and Contraindications

      REBOA is generally indicated for persistently hypotensive trauma patients suspected of having subdiaphragmatic injury without concomitant thoracic injury.

      Key Criteria for Consideration
      • Systolic Blood Pressure: Patients presenting with systolic hypotension (<70 mm Hg).
      • Resuscitation Response: Patients who fail to respond or respond only transiently to initial volume and blood resuscitation.
      • Diagnostic Support: Positive findings of fluid in the abdomen via Focused Assessment with Sonography in Trauma (FAST) or radiographic evidence of significant pelvic fracture.
        • Critical Contraindications

        Significant thoracic trauma is a major contraindication. If possible, a chest X-ray must be obtained prior to deployment to exclude thoracic injury. Inflating a REBOA balloon at or distal to an aortic injury can exacerbate the injury and increase intrathoracic hemorrhage.

        Anatomical Aortic Zones and Landmarks

        For the purposes of REBOA, the aorta is divided into three distinct zones. Understanding these zones is vital for safe balloon placement.

        • Zone 1 (The Target for Global Hemorrhage): Extends from the origin of the left subclavian artery to the celiac artery. External landmarks include the sternal notch (proximal) and the xiphoid (distal).
        • Zone 2 (The "No-Go" Zone): Extends from the celiac artery to the lowest renal artery. The balloon should not be inflated in Zone 2 due to the high risk of malpositioning and causing visceral artery injury.
        • Zone 3 (The Pelvic Target): Extends from the lowest renal artery to the aortic bifurcation. The external landmark is the umbilicus. This zone is used if hemorrhage is isolated to a pelvic fracture and the patient's hemodynamics permit.
          • Procedural Evolution and Technique

          The equipment and approach for REBOA have evolved from large-bore vascular surgery tools to streamlined, trauma-specific devices.

          12-French vs. 7-French Systems

          Originally, trauma centers utilized a 12-French introducer and a 10-French Coda Balloon Catheter. This required a large arteriotomy, often necessitating an open arterial repair with vascular sutures (5-0 or 6-0 polypropylene) upon removal.

          Modern practice favors the 7-French ER-REBOA catheter. This device is:

          • Wireless: Does not require a guidewire for advancement.
          • Percutaneous: Designed for rapid insertion in trauma bays rather than just the operating room.
          • Low Profile: The smaller arteriotomy typically only requires direct pressure for five minutes at the time of removal rather than surgical closure.
            • Standardized Steps for Placement
            1. Access: Identify femoral vessels (ultrasound, palpation, or landmarks). Access the common femoral artery 2-cm distal to the inguinal ligament.
            2. Exchange: Replace the arterial line with the appropriate REBOA introducer.
            3. Measurement: Use external landmarks (sternal notch, xiphoid, umbilicus) to estimate the required catheter depth.
            4. Positioning: Advance the catheter to the target zone (usually Zone 1 at the level of the xiphoid).
            5. Confirmation: Obtain radiographic confirmation (fluoroscopy or X-ray) of the position.
            6. Inflation: Slowly inflate the balloon with saline (or a saline/contrast mix) until moderate resistance is felt. Monitor proximal hemodynamic changes.
            7. Migration Monitoring: Especially with 7-French devices, the balloon is susceptible to distal migration. Periodic imaging is required to facilitate repositioning.
              8. Temporal Limits

              The REBOA balloon cannot remain inflated indefinitely due to profound distal ischemia and worsening acidosis. Survival rates drop significantly if inflation exceeds 60 minutes. Deflation should occur as soon as definitive hemorrhage control is achieved.

              Training and Institutional Implementation

              Successful REBOA implementation requires a balance between specialized skill and emergency accessibility. Training models often involve a "REBOA champion"—a surgeon who attends external training and then establishes an internal program.

              At the University of Florida, this model included:

              • A 1.5-hour slide presentation.
              • Hands-on simulation training for surgeons and senior residents (PGY-4 and PGY-5).
              • Brief (30-minute) orientation sessions for nurses and ancillary staff.
              • Periodic recurrent training until clinical experience is established.
                • Comparison with Resuscitative Thoracotomy

                REBOA is not a total replacement for resuscitative thoracotomy; the two procedures are not mutually exclusive. Resuscitative thoracotomy remains the indicated choice for:

                • Supradiaphragmatic injuries.
                • Cases where femoral arterial access is not feasible.
                • Patients with extensive atherosclerosis.
                • Situations requiring open cardiac massage.
                  • Clinical Outcomes and Research Findings

                  The efficacy of REBOA is a subject of ongoing debate, with various studies presenting differing results:

                  • Moore et al. (2015): Found significantly higher survival in REBOA patients (37.5%) compared to those receiving resuscitative thoracotomy (9.5%).
                  • Dubose (Registry Study): Reported higher hemodynamic stability (48% vs. 28%) and improved survival (28% vs. 16%) with REBOA compared to open aortic occlusion.
                  • Abe et al. (Japan): Associated REBOA with lower mortality and fewer thoracic complications than aortic cross-clamping.
                  • Nunez (Meta-analysis): Suggested a positive effect on survival across 13 studies.
                  • Northern: Documented the utility of REBOA in combat/austere environments.
                  • Joseph et al. (TQIP Study): Provided a dissenting view, suggesting that REBOA patients had increased mortality and higher rates of acute kidney injury and amputation.
                    • Glossary of Key Terms
                    • Arteriotomy: An incision into an artery, such as the one made in the femoral artery to insert the REBOA introducer.
                    • Class III/IV Hemorrhagic Shock: Severe stages of shock characterized by significant blood loss and life-threatening hemodynamic instability.
                    • Distal Migration: The tendency of the inflated balloon to move further down the aorta (away from the heart), often caused by increased proximal blood pressure.
                    • ER-REBOA: A specific 7-French wireless catheter designed for rapid emergency use without the need for a guidewire.
                    • Extremis: A state of extreme medical necessity or being near death.
                    • FAST (Focused Assessment with Sonography in Trauma): A rapid bedside ultrasound examination used to identify free fluid (usually blood) in the abdominal or pericardial cavities.
                    • Hybrid Operating Room: A surgical theater equipped with advanced medical imaging devices, facilitating both open surgery and endovascular procedures.
                    • Innominate/Subclavian Artery: Blood vessels near the aortic arch; the left subclavian marks the beginning of Zone 1.
                    • Pseudoaneurysm: A complication at the arterial access site where blood leaks and is contained by surrounding tissue; prevented by applying direct pressure after REBOA removal.
                    • Subdiaphragmatic: Located below the diaphragm; refers to injuries in the abdomen or pelvis.
                    • Visceral Artery: Arteries supplying major abdominal organs (e.g., celiac and renal arteries), located primarily in Zone 2.
                      • ...more
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