Discuss the role of resuscitative endovascular balloon occlusion of the aorta (REBOA) in resuscitation. Include in your answer: brief description, mechanism of action, potential indications, contraindications, and complications.


 


 

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College answer

Introduction/ Description

REBOA, by inflation of balloon at specific zones of the aorta to interrupt blood flow, haemorrhage below the level of the balloon can be controlled, while augmentation of the blood pressure cranial to the balloon. It allows temporary control of non-compressible intra-abdominal bleeding in order to proceed for definitive operation.

Has been used in many locations:

Intra-operatively, in the emergency department, interventional radiology and in the field.

Mechanism of action

Provides increase in afterload similar to a balloon pump. However, there is no deflation. Downstream stops haemorrhage by occlusion of vessel. Increases MAP during this time and consequently cerebral and myocardial perfusion.

Potential Indications of REBOA

  1. Non-compressible torso haemorrhage from trauma (alternative for resuscitative thoracotomy for direct clamping of aorta)
 
  1. Management of major exsanguination e.g.

-AAA rupture,

-Post-partum haemorrhage

- Abdominal or pelvic bleeding any cause i.e. elective surgical complication

  1. CPR: Non-traumatic out of hospital/prehospital cardiac arrest or medical cardiac arrest use is on exploration

Contraindication:

  1. Thoracic aortic injury and/or thoracic aortic diseases e.g. aneurysm
  2. Inability to obtain femoral access/peripheral vascular disease
  3. Penetrating thoracic trauma
  4. Not a candidate for resuscitative thoracotomy

Complications

  • Prolong occlusion of the aorta results in tissue ischemia- spinal, renal
  • Aortic or iliac artery injury including rupture, dissection, perforation
  • Arterial thrombosis
  • Compromised lower limb perfusion and ischemia. Amputation may be required
  • Metabolic complications including ischemic reperfusion injury, acute kidney injury, myocardial injury, lactic acidosis

Discussion

Brief description:

  • A patient is selected on the basis of having life-threatening noncompressible haemorrhage due to a torso or lower extremity injury
  • A balloon-tipped catheter is introduced into the aorta via a 10-14Fr femoral arterial sheath 
  • The balloon is then inflated with saline and its position is confirmed radiologically
  • The patient is then transferred for urgent damage control surgery
  • The balloon is deflated when haemostasis is achieved

Mechanism of action:

  • Basically, you block the blood flow to the lower body, and stop the blood loss thereby, buying some time for damage control surgery.
  • At the same time, cardiac output is redirected to the upper body, hopefully preserving the brain.  

Potential indications:

  • Blunt or penetrating trauma 
  • Exsanguinating subdiaphragmatic haemorrhage
  • Hypovolaemic shock with an SBP <70 mmHg or agonal state/ pulseless cardiac arrest with electrical activity of <10 min and
  • Non/partial responder to volume resuscitation

Absolute contraindications are:

  • Blunt cardiac injury
  • Aortic injury, eg. dissection
  • Penetrating neck or chest trauma
  • Untreated causes of obstructive shock
    (eg. cardiac tamponade or tension pneumothorax)
  • Inaccessible femoral vessels(if the pelvis is severely distorted or if pelvic trauma somehow otherwise decreases access to the femoral vessels).

Relative contraindications include:

  • Prolonged cardiac arrest due to exsanguination (arbitrarily, 10 minutes)
  • Significant comorbidities

Complications:

  • Aortic injury and femoral vessel injury
  • Haematoma at the insertion site
  • Thrombotic and ischaemic complications of the ipsilateral distal limb
  • Ischaemia with prolonged inflation time
  • Reperfusion injury
  • Delay of definitive management

References

Fitzgerald, Mark, et al. "Feasibility study for implementation of resuscitative balloon occlusion of the aorta in peri‐arrest, exsanguinating trauma at an adult level 1 Australian trauma centre." Emergency Medicine Australasia (2019).

Manning, James E. "Selective aortic arch perfusion." U.S. Patent No. 5,437,633. 1 Aug. 1995.

Kutcher, Matthew E., Raquel M. Forsythe, and Samuel A. Tisherman. "Emergency preservation and resuscitation for cardiac arrest from trauma." International Journal of Surgery 33 (2016): 209-212.

Stannard, Adam, Jonathan L. Eliason, and Todd E. Rasmussen. "Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock." Journal of Trauma and Acute Care Surgery 71.6 (2011): 1869-1872.

Hughes, Carl W. "Use of an intra-aortic balloon catheter tamponade for controlling intra-abdominal hemorrhage in man." Surgery 36.1 (1954): 65-68.

Ledgerwood, ANNA M., M. A. R. I. S. Kazmers, and CHARLES E. Lucas. "The role of thoracic aortic occlusion for massive hemoperitoneum." The Journal of trauma 16.08 (1976): 610-615.

Napolitano, Lena M. "Resuscitative endovascular balloon occlusion of the aorta: indications, outcomes, and training." Critical care clinics 33.1 (2017): 55-70.

Low, Ronald B., et al. "Preliminary report on the use of the percluder® occluding aortic balloon in human beings." Annals of emergency medicine 15.12 (1986): 1466-1469.

Gupta, Bhupendra K., et al. "The role of intra-aortic balloon occlusion in penetrating abdominal trauma." The Journal of trauma 29.6 (1989): 861-865.

Martinelli, Thomas, et al. "Intra-aortic balloon occlusion to salvage patients with life-threatening hemorrhagic shocks from pelvic fractures." Journal of Trauma and Acute Care Surgery 68.4 (2010): 942-948.

Patel, Jigarkumar A., and Joseph M. White. "REBOA-Induced Ischemia-Reperfusion Injury." Endovascular Resuscitation and Trauma Management. Springer, Cham, 2020. 121-133.

Stannard, Adam, Jonathan L. Eliason, and Todd E. Rasmussen. "Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock." Journal of Trauma and Acute Care Surgery 71.6 (2011): 1869-1872.

Cannon, Jeremy, et al. "Resuscitative endovascular balloon occlusion of the aorta (REBOA) for hemorrhagic shock." Military medicine 183.suppl_2 (2018): 55-59.

Chung, Jae Sik, et al. "resuscitative Endovascular Balloon occlusion of the aorta in Impending Traumatic arrest: Is It Effective?." Journal of Trauma and Injury (2020).

Yamamoto, Ryo, et al. "Resuscitative endovascular balloon occlusion of the aorta (REBOA) is associated with improved survival in severely injured patients: A propensity score matching analysis." The American Journal of Surgery 218.6 (2019): 1162-1168.

Bekdache, Omar, et al. "Resuscitative endovascular balloon occlusion of the aorta (REBOA): a scoping review protocol concerning indications—advantages and challenges of implementation in traumatic non-compressible torso haemorrhage." BMJ open 9.2 (2019): e027572.

Nunez, Ramiro Manzano, et al. "A meta-analysis of resuscitative endovascular balloon occlusion of the aorta (REBOA) or open aortic cross-clamping by resuscitative thoracotomy in non-compressible torso hemorrhage patients." World Journal of Emergency Surgery 12.1 (2017): 30.

van der Burg, BLS Borger, et al. "A systematic review and meta-analysis of the use of resuscitative endovascular balloon occlusion of the aorta in the management of major exsanguination." European Journal of Trauma and Emergency Surgery 44.4 (2018): 535-550.