What are the outcomes and potential complications of using Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in hemodynamically unstable patients with a ruptured aorta?

REBOA Use in Ruptured Aorta: Outcomes and Complications

Based on the most recent high-quality evidence, REBOA in ruptured abdominal aortic aneurysm (rAAA) demonstrates excellent technical success and safety, with improved hemodynamic stability and reduced major adverse cardiovascular events, though mortality benefit remains uncertain. For traumatic aortic injury with hemorrhagic shock, current evidence does not support routine REBOA use due to lack of mortality benefit and significant complication risks 1.

Context-Specific Recommendations

For Ruptured Abdominal Aortic Aneurysm (rAAA)

REBOA should be considered as a bridge to definitive repair in hemodynamically unstable rAAA patients, particularly those with refractory shock 2. The 2026 propensity-matched study of 107 rAAA patients showed:

• 100% technical success rate with only one minor access site complication (4.5%)
• Significantly reduced major adverse cardiovascular events (4.5% vs 20.5%, p=0.043)
• Higher intraoperative diastolic blood pressure (mean +6.7 mmHg, p=0.031)
• No mortality difference (13.6% vs 22.7%, p=0.555), but improved cardiac protection 2

The mechanism appears to be augmented coronary perfusion during the critical resuscitation period. REBOA was used successfully in both open surgical repair (22.2%) and endovascular repair (19.4%) approaches 2.

For Traumatic Hemorrhage (Blunt Trauma)

Do not routinely use REBOA in arrested or peri-arrest blunt trauma patients 1. The 2024 American College of Emergency Physicians guideline, based on comprehensive review of 800 publications, found:

• No mortality benefit compared to resuscitative thoracotomy (HR 0.94,95% CI 0.60-1.48) in propensity-matched Japanese cohort 1
• Higher mortality with REBOA (35.7% vs 18.9%, p=0.01) in US ACS-TQIP dataset 1
• Increased complications: acute kidney injury (10.7% vs 3.2%, p=0.02) and lower extremity amputation (3.6% vs 0.7%, p=0.04) 1

The European guideline (2023) suggests REBOA only as a bridge in noncompressible life-threatening hemorrhage when definitive control cannot be immediately achieved, but acknowledges conflicting evidence and lack of quality data 3.

Technical Deployment Strategy

When REBOA is indicated (primarily rAAA):

Zone selection based on hemorrhage location:

• Zone 1 (left subclavian to celiac trunk): severe intra-abdominal or retroperitoneal hemorrhage
• Zone 3 (infrarenal to aortic bifurcation): pelvic hemorrhage 1, 3

Access approach considerations:

• Standard femoral artery access is typical
• Left brachial approach can provide safe Zone 1 occlusion when femoral access is problematic
• Consider transitioning from Zone 1 to Zone 3 with partial REBOA to minimize ischemia-reperfusion injury 4

Complication Profile

Major complications occur frequently and must be anticipated 5:

Vascular Complications (Most Common)

• Distal embolization and lower limb ischemia: 16% (range 4-52.6%)
• Access site complications: 1.2-11.1%
• Pseudoaneurysms: 2-14%
• Compartment syndrome requiring fasciotomy
• Lower limb amputation

Systemic Complications

• Acute kidney injury: 5.6-46% (most frequently documented systemic complication)
• Infection/sepsis: 2-36%
• Acute respiratory distress syndrome: 7.1-17.5%
• Multisystem organ failure: 7.1-17.5%
• Ischemia-reperfusion injury to abdominal organs

Critical Decision Algorithm

Use REBOA only when:

1. Ruptured AAA with hemodynamic instability → Proceed with REBOA as bridge to definitive repair (open or endovascular) 2

2. Traumatic noncompressible torso hemorrhage → REBOA only if:

   • Patient has NOT arrested (evidence shows no benefit in arrest) 1
   • Definitive hemorrhage control (OR/IR) immediately available
   • Part of institutional protocol with trained operators
   • No other temporizing options available 3

3. Pelvic fracture with ongoing hemorrhage → Consider Zone 3 REBOA as adjunct to pelvic packing if angioembolization cannot be achieved timely 3

Do NOT use REBOA when:

• Blunt trauma with cardiac arrest (use resuscitative thoracotomy instead) 1
• Definitive hemorrhage control not immediately available
• Lack of trained operators
• Penetrating thoracic trauma

Hemodynamic Expectations

Expect mean systolic blood pressure increase of approximately 50 mmHg following REBOA deployment 6. However, this hemodynamic improvement does not consistently translate to survival benefit in trauma populations 7.

Critical Pitfalls

The most important caveat: Early observational studies showing mortality benefit suffered from severe survival bias and bias by indication, as resuscitative thoracotomy patients typically had already arrested 1. These biases led to overestimation of REBOA benefit in trauma.

Avoid prolonged occlusion times to minimize ischemia-reperfusion injury. Use partial REBOA when possible to maintain some distal perfusion while achieving hemodynamic goals 4.

Monitor for compartment syndrome in all cases, as lower limb ischemia is the most common complication 5.

The divergence between rAAA outcomes (favorable) and trauma outcomes (unfavorable) likely reflects different pathophysiology: rAAA patients benefit from temporary proximal control during definitive repair, while trauma patients with arrest have already sustained irreversible injury 2, 7.