Trauma: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

General

  • A Balloon Occlusion Catheter Inserted Through the Femoral Artery Retrograde to Occlude the Aorta & Prevent Bleeding
  • Less Physiologic Disturbance & Higher Success than Aortic Cross Clamping
  • Overall Outcomes & Survival Unknown
  • Serves as an Adjunct but Should Not Delay Definitive Repair (OR/IR)

Indications

  • Poorly Defined & Evolving
  • Generally: Abdominal or Pelvic Trauma in Hemorrhagic Shock

Contraindications

  • Evidence of Neck or Thoracic Hemorrhage
    • Bleeding is Exacerbated by Occlusion
  • Penetrating Thoracic Trauma
  • Cardiac Arrest When ED Thoracotomy is Indicated Instead

REBOA Catheter 1

Aortic Zones

  • Zone I: Left Subclavian to Celiac Trunk
    • Goal Zone for Intraabdominal or Retroperitoneal Hemorrhage
    • Cause Mesenteric & Renal Ischemia
  • Zone II: Celiac Trunk to Renal Arteries
    • Never Inflate in Zone II – Cause Mesenteric & Renal Ischemia Which Can Be Avoided in Zone III
  • Zone III: Renal Arteries to the Bifurcation
    • Goal Zone for Pelvic Hemorrhage

Placement

  • Access Common Femoral Artery (Similar to an Arterial Line)
  • Measure & Mark Insertion Depth on Guidewire & Catheter
    • Guidewire: Insertion to Sternal Angle via Umbilicus
      • *Some Newer Catheters Do Not Require Guidewire
    • Catheter:
      • Zone I: Insertion to Xiphoid via Umbilicus or Simply to Sternal Notch
        • Approximately 46 cm
      • Zone III: Insertion to Umbilicus or Xiphoid Process
        • Approximately 26 cm
  • Insert Guidewire & Then Catheter
  • Inflate Balloon to Moderate Resistance
  • Use X-Ray to Confirm Placement
  • Secure Catheter & Expediate OR/IR for Definitive Control
  • *Always Note Insertion Length & Have a Person Dedicated to Manning the Catheter as Pulsation of Aorta Can Cause Migration

Complications

  • Extremity Ischemia from Catheter
  • Aortic Injury, Dissection or Perforation
  • Embolization of Aortic Plaque
  • Mesenteric Ischemia
  • Ischemia-Reperfusion Injury
    • Some Promote Intermittent or Partial Occlusion to Limit

Aortic Zones 2

XR Confirming REBOA Position 3

References

  1. Weltz AS, Harris DG, O’Neill NA, O’Meara LB, Brenner ML, Diaz JJ. The use of resuscitative endovascular balloon occlusion of the aorta to control hemorrhagic shock during video-assisted retroperitoneal debridement or infected necrotizing pancreatitis. Int J Surg Case Rep. 2015;13:15-8. (License: CC BY-NC-ND-4.0)
  2. Lee J, Kim K, Jo YH, Lee JH, Kim J, Chung H, Hwang JE. Use of resuscitative endovascular balloon occlusion of the aorta in a patient with gastrointestinal bleeding. Clin Exp Emerg Med. 2016 Mar 31;3(1):55-58. (License: CC BY-NC-3.0)