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Practical Approach toREBOA
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23
LauriHandolin , VilleVänni , andViktorReva
23.1 Introduction
REBOA (resuscitative endovascular balloon occlusion of the
aorta) is an adjunct for haemorrhage control and resuscitation in patients with signicant non-compressible torso
haemorrhage (NCTH) who are at risk of imminent cardiovascular collapse and cardiopulmonary arrest. Even though
the rst report of intra-aortic balloon occlusion dates back to
Korean War, the method did not gain popularity that time,
and far more invasive resuscitative thoracic aorta clamping
took the place as a golden standard in supporting the collapsing haemodynamics in critically injured patients. During the
last decade, there has been an increased interest in REBOA,
and low-prole trauma-specic balloons have become commercially available.
Conventionally, the REBOA balloon is introduced into
the abdominal or thoracic aorta through a femoral introducer
sheath placed into the common femoral artery. The aimed
balloon deployment zone is located either blindly or under
uoroscopic guidance. The occluding effect of balloon is
related to the balloon ination compared to aortic diameter
and variating from different levels of partial occlusion to the
total occlusion. Occlusion can be released intermittently or
kept in place non-intermittently.
REBOA is not stopping the bleeding and not a curative
procedure in itself. However, REBOA is a powerful tool in
the toolbox of methods supporting the bleeding patient and
buying time for gaining the denitive bleeding control. The
decision to use REBOA practically means that the team must
simultaneously decide which key emergency bleeding control procedure will follow the balloon deployment. Practical
L. Handolin (*) · V. Vänni
Trauma Unit, Helsinki University Hospital, Helsinki, Finland
e-mail: lauri.handolin@hus.
V. Reva
Department of War Surgery, Kirov Military Medical Academy,
Saint-Petersburg, Russian Federation
use of REBOA means understanding the benets and disadvantages of the method. REBOA has major wanted and nonwanted physiological effects and consequences. It is
important to have the knowledge how REBOA is introduced
and deployed in aimed aortic location, but furthermore it is
absolutely vital to understand and be aware of the consequences and complications of the procedure. Some of the
critical patients will probably benet from REBOA, but the
balloon must be deployed in a right way, in a right time and
for the right patient.
Overuse of this powerful method will lead to unnecessary
morbidity and even mortality. On the other hand, if REBOA
is used too late as a last resort attempt to save the dying
patient, there will be no benet of all, when the inevitable
death is just pushed few minutes forwards. The aim of this
chapter is to focus on practical issues on REBOA in penetrating trauma patients in terms of getting the most benet from
it and minimizing the disadvantageous consequences.
23.2 The Physiological Eects ofAortic
Balloon Occlusion
Physiological effects of aortic balloon occlusion equal to
cross clamping the aorta. It is used to provide cardiovascular
support for a critically shocked trauma patient by increasing
the cardiac afterload, coronary perfusion and blood pressure
above the occlusion site. The cardiovascular support is lesser
in lower abdominal aortic occlusion compared to thoracic
occlusion. In addition to the cardiovascular support, aortic
occlusion decreases the blood pressure distal to the occlusion site and provides thus varying amount of proximal
bleeding control for arterial bleedings. The proximal bleeding control effect is related to the distance of the occlusion
site and arterial injury site—the longer the distance is, less
proximal bleeding control is gained due to the back bleeding
from communicating arterial branches.
Occluding the thoracic aorta causes distal ischaemia
below the occlusion site. Long-term occlusion is associated
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_23
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with ischaemia-reperfusion injury and potentially increased
risk of death. This means that there is a maximal duration of
REBOA-related profound distal ischemia patient can tolerate. Unfortunately, the maximal tolerated REBOA occlusion
time is not exactly known. The time varies from patient to
patient due to multiple reasons—patient’s physiological
resources, patient’s inherent ability to withstand ischaemia
and the duration and severeness of pre-REBOA hypoperfusion
state all contribute to the maximal tolerated occlusion time.
Animal data and limited human data suggests that periods
of thoracic aorta occlusion exceeding 40min can result in
irreversible organ injury and death. Experienced cliniciansbased consensus is that aim should be to minimize occlusion
time as short as possible. The maximal tolerated occlusion
time is considered to be around 30min in supra-diaphragmatic occlusion (zone 1) and 60–90min in infrarenal aorta
(zone 3) (Figs.23.1 and 23.2). It has been seen in clinical
retrospective analysis that the time from balloon ination to
deation, the so-called balloon time, was shorter in survivors
compared to non-survivors. That may be related to the more
severe reperfusion injuries due to a longer balloon time, but
also to the severity of the injuries, since longer balloon times
are probably needed in more severe cases. Also, longer
occlusion time has been related to increased release of interleukin- 6 in animal studies. Elevated cytokine levels are
increasing the incidence of multiorgan failure risk, which is
related to overall survival.
The systemic ischaemia after balloon ination is not the
only unwanted physiological consequence. In case of a possible bleeding source above the occlusion site, the increased
mean arterial pressure will result in increased bleeding.
Fig. 23.1 Left picture shows contrast lled REBOA balloon in zone 1.
Zone 3 balloon in pelvic fracture with external C-clamp on the right.
Note the manual xation of the catheter shaft preventing from balloon
migration before the shaft has been secured properly
L. Handolin et al.
Fig. 23.2 Left picture shows contrast lled REBOA balloon in zone 1.
Zone 3 balloon in pelvic fracture with external C-clamp on the right.
Note the manual xation of the catheter shaft preventing from balloon
migration before the shaft has been secured properly
Sudden and very high (even supraphysiologic) increase in
blood pressure is related especially to supra-diaphragmatic
zone 1 total occlusion. Increased afterload results in increased
oxygen consumption of the heart, and the sudden increase
into detrimentally high blood pressure may put the heart
under non-tolerable exertion and contribute to cardiac failure. The patients with pre-existing cardiac condition are
more prone to these adverse effects. The systemic effects of
REBOA are less dramatic and dissipated in abdominal aorta
zone 3 occlusion.
The effects of balloon deation are causing sudden cardiovascular derangements. Systemic blood pressure
decreases as the cold, acidotic blood is ushed back to circulation from visceral circulation and lower extremities
below the previous occlusion. The reperfused blood contains elevated levels of carbon dioxide, lactate and potassium, nitric oxide, other ischaemic metabolites and
pro-inammatory mediators. These cause vasodilation,
decreased cardiac contractility and hypotension. In the
worst case, this may result in non-tolerable haemodynamic
collapse.
Aortic occlusion and the following release of the occlusion (reperfusion) have a major effect on the amount of perfused tissue. The sudden changes in amount of perfused
tissue affect the amount of ventilation required to oxygenate
the circulating volume. Decreased amount of perfused tissue
will produce less carbon dioxide. Especially in mechanically
ventilated patients, this leads to hyperventilation if the ventilation is not adjusted accordingly. Conversely, after the balloon deation, the increased amount of perfused tissue will
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yield an opposite effect and lead to hypoventilation. All
major deviations from the level of normoventilation are
potentially harmful for the critically ill patient and should be
avoided.
23.3 Team Approach Is Crucial intheUse
ofREBOA
Proper and well-timed teamwork is essential in treatment of
every severely injured patient. Team preparedness must start
long before a patient is arriving—it is an issue of institutional
protocol, agreement, dry and wet lab training. Upon patient
admission, once the decision is made, the REBOA needs to
be deployed immediately by the personnel available in-house
24/7. This highlights the need of multidisciplinary team
approach, where at least one or two attending team members
must have the capability of performing the vascular access
and REBOA balloon deployment. Developing a structured
learning system for in-hospital trauma team members and
regular multidisciplinary training increases team preparedness and the overall REBOA capability amongst the attending personnel.
During the admissions of critically injured patient, the
resuscitation team becomes busy with the urgent resuscitative and supportive measures. If REBOA is decided to be
used and applied by the original team members, that add-on
procedure will naturally prolong the time the team needs to
work on the patient for some extra minutes. To save that
time, the alternative strategy is to have a special add-on
REBOA team (Fig.23.3) supporting the original team and
focusing only on the vascular access, balloon deployment
and balloon ination-deation adjustment. Special REBOA
team is a valuable supportive resource for resuscitation teams
but may not be applicable in all systems due to a limited
number of human personnel.
Aortic occlusion causes sudden and dramatic changes in
patient’s physiology. The basic elements of teamwork, such
as communication and updated knowledge on the past, current and planned proceedings, must be crystal clear for the
entire resuscitation team all the time. It is vital to have continuous communication and maintain the situational awareness between REBOA and anaesthetic teams to be able to
understand and interpret the changes in patient’s circulatory
state. Increase in blood pressure may be due to balloon
occlusion or vasopressors, or both. On the other hand,
decreasing blood pressure does not unambiguously mean
that the effect of balloon is decreasing, but may be due to
decreased vasopressors.
The balloon deation is a delicate phase in the REBOA
procedure. The anaesthesia team needs to have time to
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Fig. 23.3 REBOA team doctor (blue vest) is preparing the puncture
set to establish an arterial access during primary survey resuscitation,
whilst assistant (white-orange vest) is doing emergency scrub for the
right groin
prepare for the cardiovascular effects of reperfusion. For
that reason, the deation begins only after detailed communication and planning together with the surgical team.
Upon deation, the surgical team must maintain the ability for immediate reination of the balloon in case of cardiovascular collapse. The optimally smooth deation
phase and minimized haemodynamical consequences
mandate for constant situational awareness and orchestrated teamwork.
Balloon ination leads to dramatically decreased amount
of perfused tissue and amount of carbon dioxide in circulating blood. This may lead to disadvantageous hyperventilation unless anaesthetic team is not aware and prepared for the
aortic occlusion. The opposite will happen in balloon deation due to sudden increase in the amount of perfused tissue,
and ventilation will not maintain in sufcient level unless the
anaesthetic team is not prepared to adjust it. Especially, if the
patient has concomitant intracranial injury, hypoventilation
will result in vasodilatation in veins and increased intracranial pressure.
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L. Handolin et al.
23.4 The REBOA Procedure
The REBOA procedure can be divided into six practical
operative stages:
1. Preparation of the sheath and balloon catheter
2. Gaining arterial access and sheath introduction
3. Deployment of the REBOA device into a targeted aortic
zone
4. Balloon ination
5. Balloon deation
6. REBOA device and sheath removal
23.4.1 Preparation oftheSheath andBalloon
Catheter
Ideally, the preparation of REBOA is assigned to a specialized REBOA team member not being primarily involved in a
resuscitation of the critically ill patient. To set specic readyto- go vascular access kits and a REBOA kit rather than separate elements in an emergency room is highly recommended.
It should contain at least a 18G puncture needle, an introducer sheath (including a sheath, a dilator and a miniguidewire), compatible long wires (if applicable—some
modern catheter does not require wire insertion), the REBOA
catheter, a few 10–20mL syringes and contrast medium.
Compatible guidewires and introducer sheath, as well as balloon ination medium (preferably a contrast medium diluted
with normal saline in 1:2 ratio), are prepared alongside with
the invasive blood pressure measurement line (if
applicable).
bleeding site can be addressed with multiple closure techniques, whereas the bleeding from EIA is non-compressible
and more difcult to repair.
The puncture can be done ultrasound (US)-guided, via
open cut-down, or by blind puncture. US-guided technique is
preferrable if appropriate US device with linear probe and
enough experience is available. The depth of US eld must
be set deep enough to see the femoral head. In optimal scenario, both the bifurcation of supercial and deep femoral
arteries and the femoral head can be visualized. The CFA
should be ideally punctured just above the level of the centre
of the femoral head at 12 o’clock at a 30–45° angle. Spurting
blood return demonstrates a correct position of the needle tip
inside the artery and enables the guidewire placement using
the Seldinger technique (Fig.23.4). A sheath, either small
one (4–5 Fr) or REBOA-compatible larger one (7–8 Fr), is
then inserted over the wire. The smaller sheath can be used
for invasive blood pressure monitoring and, if clinically
required, upsized to larger REBOA-compatible sheath using
over-the-wire technique. After the correct placement of the
sheath is cleared, the sheath must be secured properly
(Fig.23.5).
Ultrasound-guided puncture may not be easy in grossly
hypovolemic vasoconstricted patients. Therefore, the team
should be ready for open cut-down to proceed with the
23.4.2 Gaining Arterial Access andSheath
Introduction
Establishing the arterial access is the pivotal moment in
REBOA procedure. Tactical and technical mistakes during
arterial access may lead to disastrous complications, pitfalls
and wasted time, so the access method needs to be familiar,
and there should be an immediate fallback option available.
A 2-min attempt for successful puncture followed by a 2-min
attempt at the contralateral side (in case of primary failure) is
justied to avoid time-wasting.
The aimed puncture site is in the common femoral artery
(CFA). Puncture to supercial femoral artery (SFA) should
be avoided because of smaller calibre of the artery and thus
increased risk of puncture site complications. Also, so-called
high puncture above the inguinal ligament into the external
iliac artery (EIA) must be avoided due to the higher risk of
retroperitoneal bleeding. Post-puncture bleeding from CFA
is usually easily controlled by manual pressure, and the
Fig. 23.4 Femoral artery access. Spurting blood return and sheath’s
mini-guidewire insertion. Puncture is done under US (ultrasound) guidance in team approach manner, where the resuscitation team’s radiologist is providing the US view of the CFA after nishing the eFAST
examination
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Fig. 23.5 Sheath must be properly secured. One fast way is to use skin
clips for securing it. Note the femoral vein access that was established
after accidental venous puncture during CFA puncture attempt
“semi-Seldinger” technique, where the anterior wall of the
CFA is exposed and punctured under direct visualization.
Currently, almost 50% of vascular accesses for trauma
REBOA are performed via a cut-down. In critical scenario
with less US puncture experience, the open cut-down is
likely the most feasible technique in gaining fast arterial
access.
There are clinical scenarios where the need for REBOA
may arise intraoperatively. It does not necessarily mean
femoral arterial access. During challenging laparotomy, the
access can be achieved via intra-abdominal aortic or iliac
artery puncture. However, these approaches render the
external landmarks useless for determining desired depth,
so the conrmation of the balloon position should be done
either with manual palpation upon ination or with uoroscopy. Also, it might be linked to certain undesirable complications: puncture site leaking (difcult to control
compared to the CFA), aortic dissection or injury, so the
decision which access is optimal for using should be
weighed.
23.4.3 Deployment oftheREBOA Device into
aTargeted Aortic Zone
Balloon occlusion can be achieved with a multitude of different devices ranging from an improvised Fogarty catheter balloon to highly sophisticated, purpose-built REBOA kits.
Therefore, it is essential to familiarize oneself with the
device at hand and the specic device-related steps there are.
Different REBOA catheter systems are used differently. The
classical over-the-wire catheters are designed to be used
under uoroscopy guidance. The modern devices, specially
developed for trauma purposes, are designed for blind insertion without uoroscopy. In blind balloon catheter insertion,
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the use of the guidewire is dependent on the commercial
device at hand; if the device is designed for over-the-wire
use, it must not be advanced without the wire preventing
from intimal tear and dissection caused by a tip of the catheter. Most of the REBOA procedures are done outside hybrid
facilities; thus, the balloon catheters having soft J-tip end
designed for the blind wireless technique are preferred.
In blind technique, the catheter depth and correct positioning of the balloon can be achieved in two methods, using
either predetermined depth or external landmarks.
Commercial devices usually have depth insertion markers on
the catheter representing the distance from the (middle of
the) balloon. In adult patients with normal torso height, an
approximate distance of 46cm from the groin insertion site
represents balloon landing at descending thoracic aorta
above the celiac axis (zone 1). For zone 3, an approximate of
28cm will generally allow the balloon to land above the aortic bifurcation but below the renal arteries. External landmarks for pre-determining catheter depth means measuring
the length from the insertion site to the targeted landmark.
Mid-sternum (above xiphoid process and below suprasternal
notch) serves as external landmark for zone 1, whereas
umbilicus serves as landmark for zone 3 (Illustration 23.1).
The measuring can be done using catheter insertion cmmarkers (Fig.23.6) and may be a preferrable method due to
the ability to address the actual height of the patient’s torso.
The measured length will represent the insertion depth from
the middle of the balloon, not from the catheter tip.
23.4.4 Balloon Ination
Once the desired depth is reached, the balloon is slowly
inated with saline or 50:50 saline-contrast media solution.
Contrast media is not mandatory but will help to locate the
balloon in X-ray if the catheter does not have radiopaque
markers. Ination volume differs between balloon catheters,
aortic diameters in different zones and age groups, as well as
the aimed level of occlusion (total vs partial). The maximum
volume of the balloon differs from balloon to balloon and
must not be exceeded. The overination may lead to iatrogenic aortic and device-related fatal complications. Any
abnormal or increasing resistance during lling of the balloon prompts for immediate stop of lling.
In total occlusion, the loss of palpable pulse in contralateral groin will indicate the needed ination volume. In partial occlusion, the rough estimate of the needed volume is
gained by deating the total occlusion slowly until the point
where the groin pulse starts to be palpable again. Also, the
increase in blood pressure, especially in zone 1 deployment,
can guide to stop the lling at desired point. When lling the
balloon, the catheter must be held in place to prevent migration due to “hitting” aortic pulse wave against the balloon.
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Zone 3
Umbilicus Xiphoid
Zone 2 Zone 1
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Illustration 23.1 Showing
the general concept of the
REBOA, targeted landing
zones in aorta and external
landmarks for both zones 1
and 3
Fig. 23.6 Using xiphoid process as an external landmark to measure
desired depth for zone 1 balloon deployment. Note open cut-down for
arterial access in the right groin in arresting patient with mechanical
chest compression device
L. Handolin et al.
reperfusion burden and not exceed 30 min for zone 1 and
60min for zone 3. Release of the occlusion is a critical moment
and must not be done suddenly. The following reperfusion and
sudden drop in blood pressure with the risk of circulatory collapse may be reduced with slow and staged deation protocol.
Staged slow deation with 2mL withdraws every 20–30 s
with concomitant blood pressure monitoring will provide the
patient’s physiology some time to adopt to changing situation,
as well as time for the anaesthesia team to escalate the cardiovascular and ventilatory supportive measures. The need for
clear communication and constant situational awareness
within the whole team is mandatory as well as the capability to
re-inate the balloon if needed.
23.4.6 REBOA Device andSheath Removal
This “hammer effect” mandates the constant xing of the
catheter shaft at desired depth during the whole balloon
ination time. The securing of the shaft can be done with
strong adhesive tapes, sutures and central catheter clips or
held by hand.
For situational awareness, the time of ination must be
noted. Especially in zone 1, the balloon should not be inated
continuously for more than 30min. Intermittent deation of
the balloon in zone I may help decreasing the ischaemic consequences to the kidney and abdominal organs.
23.4.5 Balloon Deation
Balloon deation should be done as soon as adequate haemorrhage control has been achieved to prevent severe ischaemia-
Any catheter or sheath inserted into vessels provoke thrombogenesis and increase the risks of arterial thrombosis with
disastrous complications. Exsanguinated patients are typically coagulopathic which diminishes risks of early thrombosis, but as soon as the patient is stabilized, the risk of
thrombogenic complications increases. Therefore, the
REBOA catheter should be withdrawn as early as clinically
possible. Large-bore introducer sheath (>8 Fr) should also be
removed before patient transport to the ICU. The smaller
sheaths cause less complications and, if prompted by the
patient’s condition, can be left for a few hours more until the
need for redeployment has been decimated.
The sheath must not be ushed upon removal due to the
risk of ushing sheath’s intraluminal thrombus into the arterial system. Instead, aspiration prior to sheath removal may
reduce the risk of possible sheath tip’s thrombus escape.
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Larger sheaths (>8 Fr) require specic measures to be applied
for vascular access closure such as open exploration with
direct repair, fascia closure technique or vascular closure
devices. Smaller sheaths (<8 Fr) may usually be safely
removed by manual compression for 10min even in severe
trauma patients with coagulation decits. However, smaller
6- or 8-Fr closure devices are widely available and easy to
use. If any difculty is encountered when removing the catheter, the catheter and the introducer sheath should be removed
as a unit. In open cut-down, the puncture site cannot be controlled by pressure and needs surgical closure.
Close 24-h monitoring of the lower extremity perfusion
and the puncture site is mandatory. Despite severe complications, as amputations, being uncommon and decreased risk
of thromboembolic complications with modern smaller size
sheaths (7 Fr), the risk of complications still exists. Usually,
the treatment for this means a combination of thrombectomy,
endarterectomy and/or patch angioplasty for the CFA.
23.5 Indications andContraindications
During the Korean War, Lieutenant Colonel Carl Hughes
used the technique of introducing a balloon catheter into the
aorta through open access in femoral artery. This technique
was used in treatment of two moribund casualties, both suffering from an abdominal gunshot wound. Both patients
were admitted with 40 mmHg SBP, underwent massive
blood transfusion and were taken to surgery with critical
hypotension and undetectable BP.Despite the initial positive
haemodynamic response from catheter occlusion, both
patients ultimately died. In his documentation, Hughes contemplated potential indications for the procedure: severe
shock and moribund patient status (considered to be with
SBP < 60–70mm Hg), evidence of intra-abdominal bleeding, inability to control BP after administration of 10units of
blood or other causes of severe shock when centralization of
perfusion into vital organs is urgently required.
There are two groups of effects that are sought after with
practical use of REBOA:
1. Cardiovascular resuscitative effects:
(a) Support in haemodynamics in severe hypotension
• Prevention of post-induction hypotension
• Prevention of laparotomy-associated hypotension
(associated with abdominal compartment release)
• Decreasing the extensive use of vasopressors
2. Operative surgery-related effects:
• Control of haemorrhage
• Proximal aortic control (replacing thoracic aortic
clamping)
• Reduction of blood transfusion requirements
23.5.1 Indications
Since then, the most common indication for REBOA has been
critical haemodynamic instability and impending cardiac
arrest. However, the use of REBOA at peri-arrest state will
result in selection bias—patients with extremely severe injuries will have the highest probability of death, and thus the
overall use of REBOA may easily be considered as futile. The
abovementioned casualties and many trauma patients afterwards have been too sick to survive despite endovascular aortic balloon occlusion. However, the development of
endovascular surgery and the REBOA technique itself alongside with novel low-prole catheters on the market has led to
broadening of the haemodynamic envelope for REBOA.This
has elevated the threshold of systolic BP for REBOA up to
90mmHg. Certainly, trauma patients admitted with the systolic BP of 70–90 mmHg require specic focus on haemostatic measures and are most likely to benet from early
haemorrhage control.
Compared to the Hughes data (where balloon occlusion
was performed after resuscitation efforts in combat environment), today’s practice has been shifting towards early vascular access and balloon deployment as soon as feasible.
There is some evidence that early vascular access, performed
within the rst 20min from patient’s admission, with subsequent REBOA and other endovascular life-saving interventions, may improve survival.
Patient’s haemodynamic state can be divided into different levels of preparedness for REBOA, and the procedure
can be swiftly advanced according to progression in haemodynamic state (Table23.1).
Patients with exsanguinating subdiaphragmatic injuries
(abdominal, pelvic or lower extremity junctional injuries)
are potential candidates for REBOA. Critically unstable
patients are at high risk of cardiac arrest during anaesthesia
induction, and thus mechanical elevation of BP with
improved coronary perfusion may help to avoid it. Another
possible application of balloon occlusion is an intraoperative
REBOA when the control of a major haemorrhage is technically challenging or exploration of major retroperitoneal
haematoma is warranted.
Table 23.1 REBOA preparedness levels according to systolic blood
pressure
Systolic blood
pressure, mmHg Decision
>90 Consider/prepare femoral arterial access
90–80 Insertion of a femoral arterial sheath
80–70 Insertion of a balloon catheter
70–60 Immediate balloon ination in a target
zone (zone 1 or zone 3)
<60 Immediate balloon ination in zone 1
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Illustration 23.2 A simple
decision-making algorithm
for REBOA in penetrating
injuries according to patient’s
hemodynamic status and
penetrating wound location
L. Handolin et al.
In a crashing patient with penetrating wounds below the
xyphoid process, REBOA can be used to replace the need for
anterolateral thoracotomy and aortic cross-clamping. The
horizontal plane at the level of the xyphoid process can be
used as external landmark that divides the supra- and subdiaphragmatic areas. The xyphoid process has proven to be both
safe and practical landmark for early decision to initiate the
REBOA procedure in penetrating trauma (Illustration 23.2).
In abdominal penetrating injuries, there is a theoretical
risk of iatrogenic aortic injury if the balloon catheter is
passed into the pre-existing aortic wall injury. This risk can
be minimized if the procedure is performed by an experienced operator and under uoroscopic guidance, and if the
procedure is discontinued if any resistance during the wire or
catheter insertion is met. In penetrating injury with suspected
iliac artery injury, contralateral vascular access should be
performed to avoid iatrogenic injuries.
In high-volume endovascular units routinely familiar with
upper extremity arterial access, the use of left upper extremity for balloon entry will mitigate the risk for iatrogenic aortic injuries in case of penetrating abdominal injuries.
However, for safe implementation, a certain level of expertise and uoroscopy are required, and thus the transbrachial
access is not recommended as rst-line option in routine
practice.
Summary of indications for REBOA in penetrating
trauma:
• Wound location below the plane of xyphoid process in
suspected major arterial injury in the abdomen or pelvis
• Severe shock (SBP <90–70 mm Hg) due to noncompressible torso haemorrhage with no response to
uid/blood resuscitation
• Cardiac arrest or impending cardiac arrest (with no or low
probability of cardiac or chest injury)
• Major junctional lower extremity or perineal injury
• Uncontrolled intraoperative abdominal or pelvic
bleeding
• Major retroperitoneal midline (zone 1) hematoma
23.5.2 Contraindications
It is practical to divide the bleeders into supra- and subdiaphragmatic categories as ongoing haemorrhages from neck
and chest injuries are contraindications for REBOA.REBOA,
or any aortic occlusion, will elevate the BP above the zone of
occlusion and thus lead to increased bleeding from injuries
located above the occlusion. In penetrating injury to the
chest with haemodynamic instability, there is always a risk
of cardiac injury. Aortic balloon ination and aortic occlusion may increase the risk of cardiac tamponade in case of
penetrating cardiac injury, thus decreasing the probability of
survival. Thoraco-abdominal injuries should also warrant
high level of suspicion and caution in decision-making. In
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199
such cases, extended FAST ultrasound may help to rule out
possible signs of chest pathology such as major haemothorax
or pericardial uid. Positive e-FAST ndings in the chest
contraindicate REBOA. The FAST ultrasound surpasses
chest X-ray as emergency imaging modality in penetrating
trauma, as it is more sensitive to both cardiac tamponade and
haemothorax. Conversely, the pre-REBOA chest X-ray may
reveal a suspected blunt aortic injury (in the form of mediastinal widening) in blunt trauma, which quite naturally is a
strong contraindication for aortic occlusion and REBOA.
There must be a planned emergency bleeding control
intervention and fast access to it if REBOA is to be used. No
REBOA should be done if there is no immediate access to a
surgical intervention, neither should REBOA delay the initiation of the surgical procedure. Thus, the absence of
standby readiness for REBOA procedure (alongside with
appropriate devices and expertise) or the lack of capability to
immediate life-saving surgery is considered a contraindication for REBOA.
Summary of contraindications for REBOA in penetrating
trauma:
• Penetrating thoracic injury with suspicion of major intra-
thoracic bleeding or cardiac injury
• Penetrating neck injury
• Suspected aortic injury
• No capability for immediate surgical intervention (espe-
cially contraindicating aortic zone 1 balloon
deployment)
• No standby readiness and expertise for REBOA use
23.6 How toReduce Complications
ofREBOA
REBOA is an invasive procedure that carries a signicant
risk of complications and residual morbidity. Considering
the extreme nature of the REBOA procedure, the risk of
complications cannot be completely mitigated. Knowing the
and early recognition of complications minimize potential
hazards. REBOA-related complications can be divided into
three practical categories—technical, physiological and strategical (Table23.2).
23.6.1 Technical Complications
The most common technical pitfalls are access site injury,
proximal arterial injury, device-related pitfalls and balloon
migration. These complications can be mitigated by proper
training and familiarizing oneself with the device, yet the
successful operation of the REBOA mandates some experi-
Table 23.2 Table of REBOA-related complications
Technical Physiological Strategical
Arterial injury Increased
cardiac post-load
Aortic injury Abdominal
ischaemia
Faulty positioning Renal failure Balloon left alone
Migration Spinal cord
injury
Balloon rupture Arterial
thrombosis
Balloon jammed in
sheath upon catheter
removal
Leg ischaemia Wasting time or
Reperfusion
injury
Unprepared team
Under- or overuse of
REBOA
Too long occlusion
Too fast and
non-coordinated
deation
ailing
ence in endovascular techniques alongside with general
understanding of vascular anatomy.
Already diseased vessels (calcication, aneurysm formation or elongation) carry more risk of technical failure of
either the vessel or the device. Especially the blind deployment of the balloon becomes increasingly hazardous in
patients with pre-existing peripheral arterial disease. In case
of existing vasculopathy, ultrasound-guided puncture and
uoroscopy-guided procedure should be preferred. In such
cases, the arterial access establishment is safer to start with
micropuncture technique followed by larger sheath upsizing.
Long supporting sheaths (>20cm) should be avoided in such
patients due to the risk of dissection in kinked iliac arteries.
Selected patients with underlying iliac artery atherosclerosis
might also benet from antegrade catheter deployment via
the brachial artery, but it mandates uoroscopy guidance and
certain level of expertise. Due to the above-discussed issues,
elderly people (>65years old) are not appropriate candidates
for blind REBOA procedure.
Balloon migration is bound to happen in all zone 1 occlusions due to the hammering effect of aortic ow, if the catheter is not properly secured in place. Ideally, the person
allocated for the balloon prevents this from happening whilst
keeping time and upholding the situational awareness for the
whole operating team.
Total aortic occlusion in zone 1 usually results in an elevation of systemic BP by 50–60mmHg. If no increase is
noted, then one of the following should be suspected:
• Venous catheterization; accidental venous puncture
instead of arterial resulting in balloon ination some-
where in the central venous system.
• Iatrogenic arterial injury; the arterial wall is perforated or
ruptured at a zone of inating balloon causing major
bleeding.
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• Major arterial injury above the balloon or cardiac injury;
the increase in blood pressure results in increased bleeding above the occlusion site.
• Balloon rupture; no occlusion gained.
• Balloon is accidentally deployed in non-targeted location;
non-targeted blind accidental catheterization of the contralateral iliac or femoral artery
Most of the complications can be prevented by using an
appropriate technique with care and common sense. Aortic
perforation or rupture and balloon rupture during ination
are also possible complications that may be recognized by a
sudden drop of blood pressure. Whilst the latter is easily seen
by appearance of blood in the inating channel of the
REBOA catheter, the former is usually fatal. Ination of the
balloon with care until resistance is felt is the main recommendation to prevent it. X-ray control of potential balloon
position is typically required at least once to conrm that
desired aortic location has been reached.
23.6.2 Physiological Complications
Physiological complications are related to the compromising
physiological effects described in the earlier paragraphs.
Signicant central pressure increase, heart strain and reperfusion problems can be minimized with clear communication and solid teamwork with the anaesthesia team. Still,
most of the patients who might benet from REBOA are
already bled out and pre-ischaemic, which increases adverse
events related to reperfusion and abdominal ischaemia.
Tactics as partial and intermittent REBOA should be
deployed with full attention to ventilation and perfusion status of the patients whilst deating the balloon.
Abdominal ischaemia, renal failure and abdominal com-
partment syndrome should be routinely monitored in the
ICU for all REBOA patients. Balloon time should be kept to
minimum to dissipate these events, and successful operation
should be followed by vigilant intensive care. A keen eye
should be kept on both thromboembolic events and reperfusion. Trans-bladder monitoring of intra-abdominal pressure
is routinely used to screen for intra-abdominal hypertension
or compartment syndrome. Lower extremities can be monitored with pulse oximetry, and when in doubt, the threshold
for angiography, access site exploration or fasciotomy should
be kept low (Fig.23.7).
23.6.3 Strategical Complications
Both overuse and underuse of REBOA reect negatively to
the overall results. The decision for an arterial entry is a
L. Handolin et al.
Fig. 23.7 Pulse oximeter provides a one technically simple way of
monitoring the lower leg perfusion after groin puncture
judgement call and the possible need should be recognized
early on. Early arterial access can be easily achieved and easily removed (if not required), but also simplies REBOA
placement when the patient is deteriorating during rst minutes after arrival—the very scenario where the “crush” vascular access has higher chances of failure. Furthermore, clear
protocol for establishing the arterial access is warranted,
alongside with strict time cap for each attempt and immediately available back-up plan.
It is recommended that zone 1 REBOA should only be performed if the anticipated time to surgery is less than 15min.
Prolonged total zone 1 REBOA for interhospital transportation or any other reason carries signicant risks of complications and death. The decision to perform REBOA must contain
the preparations for the emergency surgery in terms of minimizing the balloon ination time. The total balloon occlusion
time must be minimized and decision to shift from total occlusion to partial or intermittent occlusion must be made as soon
as patient’s physiology allows. Deploying the balloon and then
forgetting it will result in major strategical failure.
The possibility of REBOA deployment does not necessarily mean that the patient will benet from it. Overuse of
REBOA will result in unnecessary complications and morbidity. Trauma surgeon must understand the technical, physiological and strategic aspects of the procedure to be able to
minimize the complications and address one when needed.
Following a clear REBOA protocol including indications
and contraindications will help in nding the correct patients.
The complexity and urgent nature of the procedure call for
training for the whole team involved. Seemingly straightforward technical procedure is bound to fail if the device is
unfamiliar and the teamwork aspect gets overlooked. As in
all critical actions, the team does not rise on the occasion but
sinks to the level of training.
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