Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

By Arvin Akhavan 

“Cross-clamping” the aorta from the inside. That’s Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). Vascular surgeons have been using the technique now for nearly 20 years in order to stop bleeding below the diaphragm in Abdominal Aortic Aneurysm repairs. It was reported as far back as the Korean War for shock management. Its utility as a quick (down to 60-90 seconds once arterial access has been obtained) and minimally invasive temporizing measure for hemorrhage control in trauma/shock situations makes it promising for use by intensivists and EM physicians.

Much like cross-clamping, the rationale behind REBOA is that occlusion of the aorta at a level proximal to a bleed provides maintained cerebral and coronary perfusion while the site of hemorrhage is operatively managed. The procedure involves obtaining common femoral artery access (essentially similar to an arterial line placement), introduction of a wire and then sheath up to the desired level of occlusion, insertion of a balloon to that location, and, finally, inflation of the balloon to provide occlusion of the aorta at a location proximal to a bleed that has induced shock.

Hear more about the technicalities here:

EMCrit Podcast

REBOA Review Article

A recent clinical case series describing REBOA at civilian trauma centers is summarized below:

A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation. Trauma Acute Care Surg. 2013 Sep; 75(3):506.

• Study Design: Case series
• Study Population and Intervention: Retrospective observations of six cases where REBOA was used as a matter of routine clinical care. REBOA was performed when the surgeon felt that aortic occlusion was required to prevent further deterioration of the patient. 
  
• Results: Total n=6, blunt (n=4) and penetrating (n=2) trauma. Three in the descending aorta (known as zone 1, at the level of the diaphragm) and three in the infrarenal aorta (zone 3). Mean systolic BP at time of REBOA: 59 (SD of 27). Mean increase in blood pressure after REBOA, 55 (20). No REBOA-related complications and no hemorrhage-related mortality.
  
• Interpretations: REBOA seems to be a reasonable and effective means of hemorrhage control for certain patients in end-stage shock.
  
• Take-away points and comments: REBOA is feasible method of controlling exsanguinating hemorrhage, and is projected to grow in utility with the existing technology and training of acute care surgeons and possibly intensivists and EM physicians. However, this is only a series of six cases and results, although promising, need further review and research. 
  
• Further Studies/Questions: Development of devices to facilitate arterial access; development of devices that minimize complications of the procedure; studies to define who benefits from REBOA over conventional treatments/protocols; studies to determine which providers can perform the procedure safely and effectively.

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References:

1. Brenner M et al. A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation. J Trauma Acute Care Surg. 2013 Sep; 75(3):506.
2. Stannard A et al. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma Acute Care Surg. 2011 Dec; 71(6):1869-72.