When is Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) indicated?

Indications for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

REBOA should be considered in patients with noncompressible life-threatening traumatic hemorrhage to bridge the gap between hemodynamic collapse and definitive hemorrhage control. 1

Primary Indications

REBOA serves as a temporary hemorrhage control method in specific clinical scenarios:

1. Hemodynamically unstable patients with suspected pelvic bleeding:

   • Systolic blood pressure <90 mmHg or non-responders to direct blood products transfusion 1
   • Used as a bridge to definitive treatment (surgery or angioembolization)

2. Noncompressible torso hemorrhage:

   • Severe intra-abdominal or retroperitoneal hemorrhage (Zone 1 deployment)
   • Pelvic hemorrhage (Zone 3 deployment) 1

3. Patients in extremis:

   • Alternative to resuscitative thoracotomy in selected patients 1
   • Can be considered during ongoing cardiopulmonary resuscitation 2

Anatomical Considerations

REBOA deployment zones are critical for proper application:

• Zone 1: From left subclavian artery to celiac trunk - for severe intra-abdominal/retroperitoneal hemorrhage
• Zone 3: Infrarenal to aortic bifurcation - for pelvic hemorrhage 1
• Zone 2: Pararenal area - generally avoided due to risk of visceral organ ischemia 1

Clinical Decision Algorithm

1. Initial Assessment:

   • Identify suspected noncompressible torso hemorrhage
   • Assess hemodynamic status (SBP <90 mmHg or non-responder to initial resuscitation)
   • Determine source of bleeding (abdominal vs. pelvic)

2. Procedural Considerations:

   • In major trauma patients with suspected pelvic trauma, consider early arterial vascular access via femoral artery 1
   • Consider partial-REBOA or intermittent-REBOA to decrease occlusion time and ischemic insult 1

3. Timing:

   • REBOA should be deployed early, ideally within 3 hours of injury 1
   • Serves as a bridge to definitive hemorrhage control (surgery, angioembolization) 1

Effectiveness and Limitations

• REBOA can temporarily improve hemodynamics in patients with severe hemorrhage 1, 2
• Evidence demonstrating survival improvement is conflicting 1
• Return of spontaneous circulation has been reported in 59% of patients in arrest after REBOA inflation 2

Important Caveats and Contraindications

1. Technical limitations:

   • Potential vascular injury after pelvic trauma may limit catheter advancement 3
   • Procedural complication rate reported at 6.6% 2

2. Time constraints:

   • REBOA should not be kept inflated for prolonged periods due to ischemic complications
   • Zone 3 REBOA may allow longer occlusion time (4-6 hours) than Zone 1 1

3. Patient selection:

   • Only a small percentage (<3%) of severely injured patients may be candidates for REBOA 4
   • Quality evidence supporting clinical use is lacking 1

Alternative Approaches

When REBOA is not feasible or contraindicated, consider:

• Temporary extra-peritoneal packing when bleeding is ongoing 1
• Traditional approaches like cross-clamping the proximal aorta or pre-peritoneal pelvic packing 3

REBOA remains an evolving technique that requires specific training and should be performed within appropriate clinical settings. Current guidelines suggest it as a bridging intervention rather than a definitive treatment for traumatic hemorrhage.