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52. Seth R, Obuchowski AM, Zoarski GH. Endovascular repair of traumatic cervical internal carotid artery injuries: a safe and effective
treatment option. AJNR Am J Neuroradiol. 34(6):1219-1226.
53. Maras D, Lioupis C, Magous G, Tsamopoulos N, Moulakakis K,
Andrikopoulos V. Covered stent-graft treatment of traumatic internal
carotid artery pseudoaneurysms: a review. Cardiovasc Intervent Radiol.
29(6):958-968.
54. Cox MW, Whittaker DR, Martinez C, Fox CJ, Feuerstein IM, Gillespie
DL. Traumatic pseudoaneurysms of the head and neck: early endovascular intervention. J Vasc Surg. 2007;46(6):1227–1233.
55. DuBose J, Recinos G, Teixeira PGR, Inaba K, Demetriades D. Endovas-
cular stenting for the treatment of traumatic internal carotid injuries:
expanding experience. J Trauma. 2008;65(6):1561–1566.
56. Goaley TJ, Dente CJ, Feliciano DV. Torso vascular trauma at an
urban level I trauma center. Perspect Vasc Surg Endovasc Ther.
2006;18(2):102–112.
57. Mwipatayi BP, Jeffery P, Beningeld SJ, Motale P, Tunnicliffe J, Navsaria
PH. Management of extra-cranial vertebral artery injuries. Eur J Vasc
Endovasc Surg. 2004;27(2):157–162.
58. Eastridge BJ, Mabry RL, Seguin P, etal. Death on the battleeld (2001-
2011): implications for the future of combat casualty care. J Trauma
Acute Care Surg. 2012;73(6 suppl. 5):431–437.
59. Waller CJ, Cogbill TH, Kallies KJ, et al. Contemporary management of
subclavian and axillary artery injuries—a Western Trauma Association
multicenter review. J Trauma Acute Care Surg. 2017;83(6):1023–1031.
60. Rall JM, Redman TT, Ross EM, Morrison JJ, Maddry JK. Comparison of
zone 3 resuscitative endovascular balloon occlusion of the aorta and
the abdominal aortic and junctional tourniquet in a model of junctional hemorrhage in swine. J Surg Res. 2018;226:31–39.
61. Demetriades D, Asensio JA. Subclavian and axillary vascular injuries.
Surg Clin North Am. 2001;81(6):1357–1373.
62. White R, Krajcer Z, Johnson M, Williams D, Bacharach M, O’Malley E.
Results of a multicenter trial for the treatment of traumatic vascular
injury with a covered stent. J Trauma. 2006;60(6):1189–1195; dis-
cussion 1195–1196.
63. Dubose JJ, Rajani R, Gilani R, etal. Endovascular management of
axillo-subclavian arterial injury: a review of published experience.
Injury. 2012;43(11):1785–1792.
64. Assenza M, Centonze L, Valesini L, Campana G, Corona M, Modini C.
Traumatic subclavian arterial rupture: a case report and review of
literature. World J Emerg Surg. 2012;7(1):18.
65. Radowsky JS, Rodriguez CJ, Wind GG, Elster EA. A surgeon’s guide to
obtaining hemorrhage control in combat-related dismounted lower
extremity blast injuries. Mil Med. 2016;181(10):1300–1304.
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JENIANN A. YL, CHARLES JAMES FOX, and ERNEST E. MOORE
Introduction
Uncontrolled hemorrhage is the leading cause of preventable death in both the civilian and military settings.1
Thus, to achieve zero preventable deaths following trauma,
prompt and effective control of noncompressible torso
hemorrhage is essential.2 This may require aor tic occlusion
to prevent exsanguination and allow for resuscitative
efforts. Historically, this has involved emergent thoracotomy with aortic cross clamping. However, advances in
medical technology have resulted in a new method for
aortic occlusion via resuscitative endovascular balloon
occlusion of the aorta (REBOA). This minimally invasive,
endovas cular technique provides aortic occlusion without
req uiring thoracotomy in patients with life-threatening
hemorrhage.
History of Thoracic Aortic
Occlusion for Resuscitation
Thoracic aortic clamping was rst shown to be benecial
in a canine acute massive hemoperitoneum model by preventing precipitous circulatory decompensation at the
time of laparotomy.3 Since then, the use of aortic cross
clamping during massive hemorrhage has long been
reported in the literature as a technique to allow for resuscitation of the in-extremis patient following severe injury.
Overall outcomes have been favorable when considering
the otherwise fatal nature of the pathology, and it has
allowed for survival of patients when employed in the
appropriate scenario. Cross clamping of the aorta is usually
enacted as part of an Emergency Department thoracotomy
(EDT), undertaken for a range of scenarios (chest, abdominal,
or extremity injury) where preservation of threatened
coronary and cerebral circulation is paramount. Military
data report overall survival rates of up to 11% for EDT
(and 17% when EDT and aortic cross clamping has been
performed as a prelude to laparotomy for hemorrhage
control).6 Civilian data report EDT survival rates approach ing
8%.7 In both populations, EDT for penetrating thoracic injury
seems to confer greatest benet whether by assisting with
the control of bleeding, decompression of the pericardium,
preventing bronchovenous air embolism, or administration
of internal cardiac massage.
invasive pro cedure; it places a signicant morbidity on the
patient in addition to the potential complications of aortic
occlusion.
8
6–8
EDT is necessarily a very
4,5
History of REBOA
REBOA provides an alternative to EDT and aortic clamping
by using endovascular technology to accomplish the same
physiologic effects. The use of REBOA for the exsanguinating trauma patient dates back to the Korean War when, in
1954, Dr. Carl Hughes described aortic occlusion using a
20-mL balloon catheter to control traumatic hemorrhage
in two moribund casualties.9 Though ultimately unsuccessful in these patients, Dr. Hughes proposed the potential
utility of this intervention in the setting of massive hemorrhage. Although intraaortic balloon occlusion continued to
be intermittently revisited in the literature, it had generally
poor outcomes and failed to gain support as a means for
hemorrhage control.
The evolution of vascular surgery to include endovascular
techniques led to a renewed interest for balloon occlusion
of the aorta. This resulted in renement of the technique
as well as increased operator familiarity with improved
patient outcomes. One of its most popularized applications
was as a life-saving measure for ruptured aortic aneurysm
patients.
suggested a similar utility for patients suffering from hemorrhagic shock of other etiologies; thus, it was revisited as a
potential resuscitative measure in trauma.
13,14
Its successful implementation in this setting
10–12
15,16
Physiologic Limitations
Several studies using hemorrhagic shock porcine models
have been performed to elucidate the physiologic impact
of REBOA. One early study compared thoracotomy with
cross clamping to REBOA and suggested that REBOA was
superior. This was based on diminished acidosis (serum lactate levels, partial pressure of carbon dioxide) and lowered
requirement for volume replacement and inotrope in the
REBOA group.17 The impact of prolonged occlusion time
has also been studied in large animal models but impact
with relation to occlusion time is variable. One study demonstrated diminished return of ow in the aortic branch
vessels even following proximal balloon deation (suggesting an additional mechanism of ischemia/reperfusion
injury that exerts its effect beyond the initial occlusion).18
A further investigation found that 90 minutes of occlusion
produced a higher lactate burden but no major differences
in renal, cerebral, spinal, or myocardial organ dysfunction
as compared with 30 minutes of balloon time, with other
evidence suggesting that liver necrosis is the consistent
sequela of longer aortic occlusion times.19 Lack of dened
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11 • Resuscitative Endovascular Balloon Occlusion of the Aorta 127
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experimental agreement around the dose-response curve
between visceral complications and balloon time may be
due to signicant collateralization20 and the tolerance of different systems to aortic occlusion: for instance, 60 minutes
of aortic occlusion resulted in a 12.5% rate of spinal cord
injury-related mortality in one animal study.21 Prolonged
REBOA times have also been associated with decreased
FiO2:PaO2 ratios, potentially mediated through the release
of inammatory cytokines such as interleukin-6.22 Collectively, these studies demonstrate that REBOA does carry
systemic consequences but these may be less marked than
those associated with EDT-mediated aortic cross clamping.
Large animal studies are of great use in assessing potential
benet but translating the end-organ consequences must
always be caveated: for instance, prior clinical experience
with high thoracic aortic occlusion for postinjury aortic
repair indicate a progressive risk of spinal cord injury after
30 minutes
23,24
—a signicantly shortened time compared
to representative large animal models.
Clinical Outcomes
Aortic occlusion and supradiaphragmatic clamping of the
aorta can improve patient outcomes, particularly after massive bleeding from penetrating trauma, with survival rates
from 17% to more than 20% in certain populations.
The clinical evidence concerning efcacy of REBOA is
mixed. A retrospective analysis of a Japanese trauma data
bank series found 625 patients who had been treated with
REBOA; matched patients who did not undergo REBOA
group had a survival advantage despite longer times to
surgery.27 However, a further observational study from
Japan revealed lower mortality with REBOA compared with
matched patients who underwent aortic cross clamping.28
Similarly, the Aortic Occlusion in Resuscitation for Trauma
and Acute Care Surgery (AORTA) registry reported improved
survival to discharge (9.6% of REBOA patients vs. 2.5%
of thoracotomy patients), although REBOA patients were
more likely to present with intact vital signs.
certainly elevates central blood pressure, but conrmatory
evidence of impact on mortality is absent.31 One complicating
29,30
REBOA
6,25,26
factor is the difference in time to aortic occlusion between
the two modalities; aortic cross clamping via thoracotomy can be accomplished at a median of 317 seconds as
opposed to REBOA at a median of 474 seconds. It seems
that gaining vascular access accounts for a good part of this
time; once this step is achieved, time to aortic occlusion is
(median) 245 seconds.32 Part of the difculty in assessing
the benet of REBOA is that most published studies document institutional use for different indications, in different
populations, within different care systems, with different
equipment. Drawing conclusions as to benet and risk in
individual patients and settings are difcult; the results of
the UK REBOA study,33 a randomized controlled study set in
multiple major trauma centers within the United Kingdom,
may help discern benet when completed.
Technical Aspects of REBOA
TOOLS AND MATERIALS
Prior to the introduction of wireless, uoroscopy-free systems, establishing balloon occlusion of the aorta required
an arterial access kit, a sheath, a wire, and a balloon
(Fig.11.1). In some places, cost considerations may per-
suade surgeons to continue to use these tools. Regardless
of the supplier, access of the femoral artery can be obtained
using a micropuncture set, which will include a microneedle, microwire, and a 4- or 5-Fr transitional dilator. The
benet of a micropuncture set is minimization of damage from inaccurate punctures while attempting access.
Through this transitional dilator, a 0.035-inch introducer
wire can be advanced retrograde into the femoral vessel in
order to exchange over wire for an initial sheath. Alternatively, a 21-gauge hollow needle can be used for access and
will allow passage of a 0.021-inch introducer wire directly.
Over this wire, a sheath can then be advanced into the
artery to establish secure access. Sheaths should be chosen
based on length and French size. Longer sheaths are typically not required, and therefore standard sheath lengths
of 10 to 15 cm is adequate. The French size of the sheath
reects the inner diameter and indicates the maximum
Fig. 11.1 Basic endovascular tools required to accomplish aortic balloon occlusion prior to availability of commercial REBOA kits: (left to right) a micro-
puncture set for initial arterial entry, a sheath for stable arterial access, a stiff wire, and an appropriately sized compliant occlusion balloon.
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size of an item that can be passed through it. As such, the
French size is determined by the balloon chosen for aortic
occlusion.
Commercial kits are now available for REBOA to streamline the insertion process, and their lower prole design
has replaced the larger 12- and 14-Fr sheath systems that
required arterial repair in favor of 7-Fr sheath systems. The
Rescue Balloon (Tokai Medical Products, Japan) and the
REBOA Balloon Kit (REBOA Medical, Norway) are preassembled kits with 7-Fr–compatible compliant balloons of
sufcient diameter for aortic occlusion. These devices are
still intended to be passed over-the-wire. In contrast, the
ER-REBOA catheter (Prytime Medical, Arvada, CO) utilizes
a peel-away sheath for rapid insertion on a wireless catheter with a curved P-tip to position and avoid branch cannulation without wire exchanges (Fig. 11.2). Positioning is
conrmed radiographically, but insertion does not require
uoroscopic guidance as length markers allow the physician to advance the catheter with or without imaging to
the desired distance. Furthermore, the smaller sheath size
eliminates the need for adjunct procedures to close the arteriotomy, as manual pressure alone is typically adequate to
achieve hemostasis.
Although blind insertion techniques will be discussed,
imaging guidance is preferred. An ultrasound machine
with a linear probe should be used while obtaining arterial
access to visualize the femoral vessels. Additionally, a portable radiograph machine can be used to aid in placement
by verifying wire and balloon locations within the patient.
The presence of these technologies within the trauma bay
should be established prior to patient arrival for maximal
efciency of REBOA.
STEP-BY-STEP PLACEMENT
Herein we describe the steps to successfully insert an endovascular balloon for aortic occlusion. REBOA is placed conceptually in ve steps: arterial access, balloon positioning,
balloon ination, balloon deation, and sheath removal
(Box 11.1).
34
Arterial Access
The rst step for REBOA is to establish arterial access, which
is accomplished percutaneously. The vessel may be palpable
in a patient who is able to sustain a systolic blood pressure
(SBP) above 70 mm Hg. However, a patient in extremis
may not have a palpable pulse to guide access. In an emergent situation, this can be accomplished by using anatomic landmarks to identify the common femoral artery.
Theinguinal ligament can be approximated by connecting
the anterior superior iliac spine and the pubic tubercle. The
artery should be accessed approximately 2 to 3 cm below
the inguinal ligament, where it overlies the middle third of
the femoral head (Fig. 11.3A). Following these landmarks
should result in vessel cannulation above the bifurcation in
an easily compressible area, thereby minimizing potential
access complications of ischemia and uncontrolled hemorrhage. Accessing below the inguinal crease typically results
in cannulation at a lower level, namely the supercial
femoral artery, and should be avoided due to higher risks
of thrombosis and pseudoaneurysm. On the other hand,
cannulating too cephalad in the external iliac artery may be
Fig. 11.2 The ER-REBOA catheter (Prytime Medical, Arvada, CO) with
mounted compliant balloon on a 7-Fr sheath–compatible catheter
(A), utilized in a patient with presumed pelvic injury with sheeting for
temporary stabilization (B).
Box 11.1 Technical Steps for REBOA
1. Arterial access and placement of sheath
2. Balloon selection and positioning within the aorta
3. Balloon inflation
4. Balloon deflation
5. Removal of balloon and sheath
REBOA, Resuscitative endovascular balloon occlusion of the aorta.
associated with uncontrolled bleeding because direct pressure cannot be applied in this area.
In any circumstance, routine ultrasound guidance for
vessel cannulation is recommended. Ultrasonography is
used to directly visualize the common femoral artery and
ensure that it is accessed above the femoral bifurcation and
below the inguinal ligament (Fig. 11.3B). Using routine
11 • Resuscitative Endovascular Balloon Occlusion of the Aorta 129
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Fig. 11.3 Anatomic landmarks used to identify the common femoral artery for percutaneous access at approximately 2 to 3 cm below the inguinal
ligament where it overlies the middle third of the femoral head (A) and the ultrasound landmarks used to identify the common femoral artery for percutaneous access by viewing the femoral bifurcation and accessing above this level but below the inguinal ligament (B). CFA, Common femoral artery;
CFV, common femoral vein; FV, femoral vein; L, lateral; M, medial; PFA, profunda femoris artery; SFA, superficial femoral artery.
ultrasound has been shown to improve operator success in
cannulation as well as to minimize arterial complications.35
Therefore, when possible it is recommended to obtain arte rial access with ultrasound guidance in REBOA. It is important to note that if arterial access cannot be accomplished
using these minimally invasive methods, femoral cutdown
for direct vascular exposure is an option and may be preferred
in a patient undergoing cardiopulmonary resuscitation.
Once initial access to the common femoral artery with
a needle is accomplished, a starter wire with a oppy tip is
introduced into the vessel. In our practice, this is a 0.021inch wire over which a sheath can be directly inserted. Of
note, this is best accomplished using two operators so that
one can stabilize the needle while the other handles the
wire until secure access is established. If no resistance is
encountered with passage of this wire, an arterial sheath
can then be advanced into the artery over the wire without
need for imaging guidance. This sheath serves as a stable
point of arterial access through which one can advance the
REBOA catheter and perform further endovascular interventions. Based on current specications of aortic occlusion
balloons, a 7-Fr sheath is adequate for REBOA placement;
however, a larger 8-Fr sheath is preferred if simultaneous
contrast administration is planned.
Positioning of the Balloon
The next step is introduction of the balloon and its positioning within the aorta. A compliant balloon of adequate
diameter to occlude the aorta should be selected along with
an appropriate sheath to accommodate the balloon. Several
compliant balloons that are compatible with a 6- or 7-Fr
sheath are now commercially available for aortic occlusion
as described previously. In our practice, the ER-REBOA
catheter is used (Prytime Medical, Arvada, CO); this wireless
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catheter has an atraumatic P-tip with mounted compliant
balloon between radiopaque marker bands and a distal
arterial line port for monitoring blood pressure.
In relation to REBOA, the aorta is divided in three zones:
zone 1 is from the left subclavian artery to above the celiac
trunk; zone 2 represents the visceral aorta from the celiac
artery to the lowest renal artery; and zone 3 is the infrarenal aorta (Fig. 11.4). Based on the pattern of injury, the
balloon is positioned in the appropriate zone of the aorta
and its location conrmed radiographically. Optimally, a
zone 3 REBOA should be positioned just above the aortic
bifurcation. Zone 2 REBOA is generally avoided due to the
risk of visceral malperfusion. Zone 1 REBOA should be just
above the celiac axis, so as to minimize risk of spinal cord
ischemia.
Balloon positioning can be performed based on estimations of aortic lengths without uoroscopic guidance.
A cadaver model was used to demonstrate feasibility of
accurate balloon placement and ination based on visualized anatomic landmarks on ultrasound.36 However,
this method is limited by user prociency with ultrasonography in addition to patient habitus. Scott et al. demonstrated in a swine model that an “all-in-one” catheter
deployed based on an external estimate of length from
the inguinal ligament to the midsternum had a successful
placement rate of 87% in the distal thoracic aorta.37 Fixed
distance models rely on population-based computed tomographic measurements to then determine standard insertion lengths to zone 1 and zone 3
38–40
(Table 11.1). Such
guidelines are of particular utility in prehospital, combat,
or austere settings, where imaging technology is not easily
accessible.
Balloon Inflation
After conrming position of the occlusive balloon, it is then
inated while also monitoring SBP. An appropriately sized
syringe with a mix of 1/3 contrast and 2/3 saline is used to
Table 11.1 Approximate Length of Catheter Insertion
Per Zone for Average Height Patients with Corresponding
Aortic Diameter and Balloon Inflation Volume for the
ER-REBOA Catheter (Prytime Medical, Arvada, CO) as
Guidelines for Fluoroscopy-Free Insertion and Inflation
Catheter Insertion
Length (cm)
Zone 1 50 21 13
Zone 3 30 15 8
Aortic Diameter
(mm)
Balloon Inflation
Volume (cc)
ll the balloon until its outer walls are opposed and parallel
to the aorta. This contrast dilution is important because of
its viscosity, which can impede facile balloon ination and
deation. Tactile feedback as a marker of aortic wall tension
during balloon ination is critical, and resistance should
prompt cessation of ination. A stopcock can be used to
then lock off the syringe at a certain volume of ination.
Again, notice of the external length of the balloon can be
used as a reference to intermittently check its position and
minimize migration. Known volumes corresponding with
external diameters can be used to guide balloon ination
based on typical aortic diameters per zone (see Table 11.1).
A plain x-ray is important to verify the balloon position.
Constant awareness of overall occlusion time is important,
as prolonged occlusion beyond 30 minutes in zone 1 may
have adverse consequences.
Balloon Deflation
Following resuscitation of the patient with subsequent
improvement of hemodynamics, the occlusive balloon
should be deated as soon as possible. Similar to release of
an aortic cross clamp, restoration of ow with reperfusion
can result in a number of events including acidosis, hypotension, hyperkalemia, and cardiac arrest. The decision
Fig. 11.4 Aortic zones related to resuscitative endovascular balloon occlusion of the aorta (REBOA). Zone 1 extends from the origin of the left subclavian
artery to the celiac artery and is a potential zone of occlusion. Zone 2 extends from the celiac artery to the lowest renal artery and is not an occlusion
zone. Zone 3 is defined from the lowest renal artery to the aortic bifurcation. REBOA in this zone may be effective for pelvic and junctional femoral (contralateral) hemorrhage.32 (Reproduced with permission from Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta
(REBOA) as an adjunct for hemorrhagic shock. J Trauma. 2011;71:1869–1872.)
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to begin balloon deation must be actively communicated
and coordinated across the multidisciplinary trauma care
team. The balloon is deated by releasing the stopcock and
applying negative pressure, while manually holding and
maintaining its position within the aorta as a number of
attempts at deation with intermittent re-ination may
be necessary. Slow deation of the balloon by removing 1
to 2 mL every 2 to 3 minutes is preferred to prevent rapid
changes in hemodynamics.
41
Balloon and Sheath Removal
After deation, the balloon can be removed from the aorta
once no longer required. Sheath removal should also be
done as soon as possible, but after reversal of any coexistent coagulopathy. Large-bore sheath access can promote
arterial clot formation, and this can be increased among
trauma patients with associated coagulopathy that is typically dynamic.42 Therefore, intermittent ushing of the
sheath with heparinized saline is recommended until its
removal. A 7-Fr sheath can be removed without arterial
repair. Generally, any access of 9 Fr and above requires
closure of the arteriotomy, as manual pressure will not
reliably accomplish hemostasis. Groin cutdown with
direct exposure of the vessels can be performed by making an incision along the sheath and using this as a guide
to dissect down to the femoral vessels. The artery can then
be primarily repaired after ushing the vessel thoroughly
and allowing for back-bleeding to remove any clots. Alternatively, percutaneous closure devices can also be used to
provide arterial closure. Wire access is maintained following balloon and sheath removal, and the closure device is
advanced over-the-wire into the vessel and then deployed.
However, this should be limited to operators familiar with
this technique and a cutdown should be performed if it
fails.
Treatment Algorithm
Our institutional algorithm incorporates clinical assessment, extended focused abdominal sonographic examination for trauma, and basic radiographic imaging obtained in
the trauma bay to determine areas of primary hemorrhage
and level of hemodynamic compromise in order to guide
management (Fig. 11.5). Patients arriving to the trauma
bay while receiving cardiopulmonary resuscitation undergo
emergent thoracotomy if within the time constraints for
known benet.43 Exceptions are patients with isolated pelvic
or extremity trauma undergoing short-term cardiopulmonary resuscitation where REBOA may be preferred. However, there is a risk of missed thoracic or abdominal injury
with ongoing bleeding that must be acknowledged.
Patients presenting in hemorrhagic shock due to thoracic
trauma should undergo thoracotomy, either emergently in
the trauma bay or in the operating room (OR). REBOA in these
patients may, in fact, worsen their injury due to increased
aortic pressure with accelerated blood loss and increased
ventricular afterload. Therefore, if REBOA is employed with
a thoracic injury, the SBP should be maintained at less than
100 mm Hg to minimize this risk. This is critically important
in those with a potential thoracic aortic injury. The desired
pressure in the setting of a concomitant traumatic brain
injury is poorly understood but must also be considered.
With presumed abdominal hemorrhage, patients with a
SBP of 80 mm Hg or greater should be transferred to the
OR without delay to avoid further complications. A sheath
should be inserted in responders with a SBP of 80 to 90 mm
Hg so that a REBOA may be inserted quickly in the event of
rapid deterioration. In patients with a SBP less than 80 mm
Hg, REBOA in the emergency department may temporize
major visceral bleeding and stabilize the patient for transport to the OR.
Fig. 11.5 Algorithm for utilization of emergent thoracotomy versus endovascular balloon occlusion to accomplish aortic cross clamping for resuscitation. Systolic blood pressure (SBP) should be maintained less than 100 mm Hg with possible thoracic aortic injury and less than 120 mm Hg with possible traumatic brain injury. CPR, Cardiopulmonary resuscitation; EDT, emergency department thoracotomy; OR, operating room; REBOA, resuscitative
endovascular balloon occlusion of the aorta.
Pattern of
injury
Thoracic EDT EDT
Abdominal
Pelvic
Extremity
CPR SBP <60
EDT
EDT vs.
REBOA
EDT vs.
REBOA
mm Hg
REBOA
REBOA
REBOA REBOA
SBP 60–80
mm Hg
EDT vs. OR
REBOA
REBOA
SBP >80
mm Hg
OR for
thoracotomy
OR for
laparotomy
OR for pelvic
packing
OR
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Patients in hemorrhagic shock secondary to pelvic trauma
represent a unique scenario where we selectively place a zone
3 REBOA with a SBP between 80 and 90 mm Hg to permit
a rapid total body CT scan prior to the OR. All patients with
a SBP less than 80 mm Hg should undergo prompt REBOA
placement. At our institution, control of pelvic bleeding is
accomplished by preperitoneal pelvic packing in the OR,44
whereas other institutions may perform pelvic angioembolization. Alternatively, the REBOA catheter may be used to
facilitate angiography via contralateral access, and endovascular treatment for pelvic hemorrhage accomplished in the
OR45 (Fig. 11.6).
Finally, patients with signicant lower extremity
trauma resulting in shock may also benet from zone 3
REBOA. Our institutional algorithm utilizes REBOA in
these patients for SBP less than 80 mm Hg; once stabilized, they can be transferred either for additional imaging or the OR for treatment. Thus far, the only literature
supporting REBOA for extremity trauma is select case
reports. The impact of the ischemia incurred from zone
3 occlusion on injured extremities is unknown, but certainly periods greater than 90 minutes are well tolerated
and some have reported ination for 120 minutes without problems.
46
Fig. 11.6 Zone 3 aortic occlusion (red arrow) in a hemodynamically unstable patient with a pelvic ring disruption (yellow arrow) on plain radiography (A)
and corresponding three-dimensional pelvic computed tomography (B) with sagittal reformatted image depicting successful aortic balloon occlusion
(C) exemplifies an ideal candidate for resuscitative endo vascular balloon occlusion of the aorta (REBOA).
11 • Resuscitative Endovascular Balloon Occlusion of the Aorta 133
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the passage of wires, catheters, or other devices can result
Extended Applications of REBOA
in intimal dissection. Small, non–hemodynami cally signi-
cant dissections may be observed without con sequence; owPartial REBOA (P-REBOA) is a described alternative to complete balloon occlusion of the aorta.47 Either a designed
limiting dissections must be addressed, but these can usually
be treated with an en dovas cular approach.
catheter with partial occlusion or intermittent release have
been described. In doing so, one can reduce the total ischemic time and extent of reperfusion injury while allowing
for longer time to denitive intervention with subsequent
balloon removal. Similarly, the development of an endovascular variable aortic control (EVAC) system to autoregulate
aortic ow in a continuous manner as an alternative to
P-REBOA with extension of occlusion times has also been
demonstrated in animal models.48 An alternative application of this method is intermittent REBOA with planned
intervals of deation in between periods of ination; this
method has been shown in swine models to extend the tolerance of zone 1 occlusion up to 120 minutes.49 Furthermore, lower extremity cooling reduced ischemic muscle
injury and compartment pressures following prolonged
zone 3 occlusion in a swine hemorrhagic model.50 These
techniques may extend physiologically tolerable occlusion
times when utilized in patients.
Additionally, REBOA in other clinical settings has been
explored. Its use in a swine model with combined hemorrhagic shock and traumatic brain injury (TBI) was associated with poor outcomes due to worsened shock, arguing
against the benet of REBOA for patients with TBI.51
Further excessive SBP may increase cerebral edema when
cerebral autoregulation is compromised. Thus, the role of
REBOA has yet to be dened for patients with known TBI.
REBOA has proven benecial in other settings of massive
hemorrhage such as among peripartum women with
abnormal placentation52 as well as mitigating major venous
injuries when deployed in the inferior vena cava.53 As such,
the application of REBOA may expand to other clinical
settings with hemorrhagic shock as a resuscitative measure
until denitive treatment can be accomplished.
Complications of REBOA
ARTERIAL ACCESS COMPLICATIONS
Access site complications occur in 1% to 9% of percutaneous interventions, with reduced rates of complications
when using routine imaging guidance.35 The most common
complication related to arterial access is failure to achieve
hemostasis at the puncture site, resulting in hematoma
and/or pseudoaneurysm. Their clinical signicance varies and ultimately open repair of the vessel may be required
for resolution (Fig. 11.7A). Arteriovenous stula is another
potential access site complication. This is the rarest of such
complications and is due to simultaneous ipsilateral vein
and artery access as well as inadvertent access of the vein
when attempting arterial access or vice versa. Up to 38% of
acquired arteriovenous stulae will spontaneously resolve
within 1 year.
Arterial dissection can be caused by disruption of plaque
in atherosclerotic vessels following access (Fig. 11.7B). Ultrasound guidance can be used to identify and avoid areas of
signicant calcic disease to minimize this risk. Addi tionally,
54
Fig. 11.7 Example of arterial access complications. (A) Classic “yinyang” sign demonstrating mixed flow on color wave ultrasonography from a femoral artery pseudoaneurysm due to failed access site
hemostasis. (B) Right common femoral arterial dissection following
arterial access. (Reproduced with permission from Biffl W, Fox CJ, Moore
EE. The role of REBOA in the control of exsanguinating torso hemorrhage.
J Trauma
. 2015;78:1054–1058.)
134 SECTION 3 • Emerging Technologies and New Approaches to Vascular Trauma and Shock
https://t.me/medicina_free
Thrombosis with or without distal embolization following REBOA is a potential life- and limb-threatening complication. Systemic heparinization is typically suggested in
patients with large sheaths in place; unfortunately, this may
not be possible in patients with an ongoing coagulopathy.
However, ushing with heparinized saline prior to sheath
removal is recommended. A thorough vascular examination should be performed following arterial access and
sheath removal; concerning examination ndings such as
discrepant pulses, pallor, paresthesias, or poikilothermia
should prompt further investigation.
For such complications, sheath size directly relates to the
risk of ischemic events. Large sheath sizes have reported
complication rates of up to 30%,55 whereas smaller sheaths
(<9 Fr) have been shown to have a lower incidence of arterial access-related complications.
56,57
Saito et al. reported
a 21.3% amputation rate among survivors in their series
using a 10-Fr commercial REBOA device.58 However, in
their recent review of the AORTA registry, Brenner et al.
found an overall rate of distal embolism to be 4.8% and
an amputation rate of 1.2%.30 Similarly, Matsumara et al.
found that small sheaths resulted in minor complications
that did not require intervention. In contrast, large sheaths
were associated with a 4% intervention rate, and sheaths
upsized for therapeutic needs and/or additional ipsilateral
arterial access were associated with a 67% amputation
56
rate.
temporary re-ination much like releasing an aortic cross
clamp.59 The release of ischemic metabolites may also result
in acidosis and hyperkalemia, impacting numerous physiologic processes including cardiac contractility, systemic
vascular resistance, and coagulopathy. Prolonged ischemia
can lead to progressive organ dysfunction and tissue loss.
This can clinically manifest as acute lung, liver, and kidney
PLACEMENT-RELATED COMPLICATIONS
Though not required for placement of the ER-REBOA catheter, wire management is important when being used for
placement of the occlusion balloon. Whereas most wires
have an atraumatic tip by design, the stiff wires necessary to
pass a balloon can cause signicant damage if placed incorrectly. Wire passage into branch vessels or too proximal across
the aortic valve can result in damage to these structures with
major consequences. Similarly, malposition of the balloon
can occur, particularly as currently about 30% of REBOA
are placed using blind insertion30 (Fig. 11.8). Although such
models used to determine these insertion lengths have a high
reported accuracy, variations in torso length and arterial tortuosity may result in inaccurate deployment from “standard”
lengths, particularly of zone 3.37 Ination of a malpositioned
balloon can cause signicant damage. Firstly, inaccurate
balloon occlusion can result in unintended visceral malperfusion, inadequate hemorrhage control with ongoing bleeding, or worsening of proximal injuries. Furthermore, blind
ination based on aortic diameter at the presumed balloon
position can result in overination of the vessel, leading to
intimal injury or rupture. Finally, the pulsation of the aorta
can result in migration of the balloon or wire; therefore,
constant monitoring of their position based on external
landmarks in addition to securing these once appropriately
positioned is recommended.
REPERFUSION COMPLICATIONS
Balloon deation results in reestablishment of systemic
circulation with resultant ischemia/reperfusion injury.
Patients may experience vasodilation and hypotension,
and slow deation is recommended with possible need for
Fig. 11.8 Plain radiographs showing a malpositioned aortic occlusion
balloon found in zone 2 along the visceral plate (A) and into the right
hypogastric artery (B). (Reproduced with permission from Davidson A, et
al. The pitfalls of REBOA: risk factors and mitigation strategies. J Trauma
Acute Care Surg. 2018;84(1):192–202.)
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