What are the outcomes of using REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) in patients with ruptured aortas?

REBOA Outcomes in Ruptured Aortas

For ruptured abdominal aortic aneurysms (rAAA), REBOA is recommended in hemodynamically unstable patients with suitable anatomy as it reduces major adverse cardiovascular events and improves intraoperative hemodynamic stability, though it does not significantly reduce overall mortality compared to non-REBOA management.

Evidence-Based Outcomes for Ruptured AAA

Mortality and Survival

The most recent high-quality evidence from a propensity-matched cohort study 1 demonstrates that REBOA in rAAA repair achieves:

• 30-day mortality: 13.6% (REBOA) vs 22.7% (non-REBOA) - though this difference was not statistically significant (p=0.555)
• 100% technical success rate with excellent safety profile
• Long-term survival was similar between groups (log-rank p=0.375)

The 2022 ACC/AHA guidelines 2 emphasize that for hemodynamically stable rAAA patients, endovascular repair is recommended over open repair to reduce morbidity and mortality, with contemporary mortality rates as low as 18.5% when using an endovascular-first strategy.

Cardiovascular Protection

REBOA significantly reduces major adverse cardiovascular events (MACE):

• 4.5% MACE rate with REBOA vs 20.5% without REBOA (p=0.043) 1
• Mean intraoperative diastolic blood pressure was 6.7 mmHg higher with REBOA (p=0.031) 1
• This hemodynamic benefit likely occurs by augmenting coronary perfusion while controlling hemorrhage

Hemodynamic Stabilization

A systematic review and meta-analysis 3 showed:

• Mean systolic pressure increased by almost 50 mmHg following REBOA deployment
• 79.3% of patients presented in hemodynamic shock
• Overall mortality across all REBOA indications was 49.2%, with significant variation by clinical indication

Technical Considerations and Safety

Safety Profile

The most recent evidence 1 demonstrates excellent safety:

• Only one Clavien-Dindo grade I complication (4.5% - access site hematoma)
• Zero instances of aortic injury, distal embolization, limb ischemia, or balloon failure
• Blood loss, ICU length of stay, and costs were comparable between REBOA and non-REBOA groups

Zone Selection for Ruptured AAA

For rAAA specifically:

• Zone I (supra-celiac) is typically used initially for infrarenal AAA rupture to control hemorrhage above the rupture site
• A two-stage approach can be employed: Zone 1 REBOA via left brachial artery for initial control, then transition to Zone 3 via femoral artery 4
• Partial REBOA combined with blood transfusion prevents ischemia-reperfusion complications 4

Anesthesia Preference

The ACC/AHA guidelines 2 recommend local anesthesia over general anesthesia for endovascular rAAA repair to reduce perioperative mortality risk.

Clinical Algorithm for REBOA in Ruptured AAA

Step 1: Initial Assessment

• Hemodynamically unstable (SBP <90 mmHg or non-responder to transfusion)
• Confirmed or suspected rAAA on imaging

Step 2: Imaging Decision

• If hemodynamically stable enough: obtain CT angiography to assess anatomy 2
• If in extremis: proceed directly to intervention with fluoroscopic guidance

Step 3: REBOA Deployment

• Establish femoral artery access (5Fr introducer) 5
• Deploy balloon in Zone I for infrarenal AAA rupture
• Confirm position fluoroscopically
• Consider partial REBOA to minimize ischemic time 4

Step 4: Bridge to Definitive Repair

• REBOA serves as temporizing measure only
• Proceed immediately to endovascular or open repair
• Consider transition to Zone 3 if prolonged occlusion needed 4

Important Caveats and Pitfalls

Ischemic Time Management

• Avoid prolonged full occlusion - use partial or intermittent REBOA 5
• Zone I occlusion creates visceral ischemia risk
• Maximum safe occlusion time debated, but minimize duration

Patient Selection

• REBOA does not replace definitive hemorrhage control - it is a bridge only 5
• Most beneficial in patients with refractory shock despite resuscitation
• Less clear benefit in patients who respond to initial resuscitation

Comparative Evidence Limitations

The 2024 ACEP Clinical Policy 6 notes that for blunt trauma (not specifically rAAA), REBOA showed no mortality benefit versus resuscitative thoracotomy in propensity-matched analysis. However, this applies to traumatic arrest, not ruptured aneurysms.

Permissive Hypotension

The ACC/AHA guidelines 2 recommend permissive hypotension in rAAA to decrease bleeding rate until definitive control achieved - REBOA facilitates this strategy by preventing complete circulatory collapse.

Divergent Evidence

While the most recent rAAA-specific study 1 shows MACE reduction without mortality benefit, older systematic reviews 3 suggested mortality improvements in mixed populations. The target trial emulation study 7 in trauma patients found no mortality difference at 30 days but lower early mortality rates (3,6,24 hours) with REBOA. The key distinction is that rAAA represents a different pathophysiology than traumatic hemorrhage, and the cardiovascular protective effect appears more pronounced in the aneurysm population.