What is the role of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in managing severe hemorrhagic shock?

Role of REBOA in Managing Severe Hemorrhagic Shock

REBOA should be considered in patients with noncompressible life-threatening traumatic hemorrhage as a bridge between hemodynamic collapse and definitive hemorrhage control, particularly in hemodynamically unstable patients with suspected pelvic bleeding. 1

Indications and Patient Selection

• REBOA is indicated for:

  • Hemodynamically unstable patients with suspected pelvic bleeding (systolic blood pressure <90 mmHg or non-responders to direct blood products transfusion) 2
  • Patients with noncompressible torso hemorrhage requiring temporary control 1
  • As an alternative to resuscitative thoracotomy in selected patients in extremis 2, 1

• REBOA serves as a temporizing measure to:

  • Prevent exsanguination
  • Allow transition to definitive hemorrhage control
  • Preserve heart and brain perfusion while minimizing distal hemorrhage 3

Deployment Zones

REBOA can be deployed in different aortic zones depending on the injury pattern:

1. Zone 1 (Descending thoracic aorta):

   • Used for severe intra-abdominal/retroperitoneal hemorrhage
   • Extends from left subclavian artery to celiac trunk 1
   • Provides highest blood pressure augmentation but highest risk of ischemic complications

2. Zone 3 (Infrarenal aorta):

   • Preferred for isolated pelvic hemorrhage
   • Extends from infrarenal aorta to aortic bifurcation 1
   • Allows longer occlusion times (4-6 hours) with less ischemic insult to visceral organs 2
   • Provides similar neuro/cardioprotection as Zone 1 but with less organ dysfunction and coagulopathy 4

3. Zone 2 (Para-renal):

   • Generally avoided due to risk of visceral organ ischemia 2, 1

Technique and Implementation

• Early arterial vascular access via femoral artery should be established in major trauma patients with suspected pelvic trauma 2
• REBOA can be placed using both direct cutdown and percutaneous approaches 5
• Partial-REBOA or intermittent-REBOA should be considered to decrease occlusion time and ischemic insult 2, 1
• Mean increase in systolic blood pressure after REBOA deployment ranges from 55-60 mmHg 5, 6

Complications and Considerations

• Procedure-related complications include:

  • Distal embolization and lower limb ischemia (incidence 4-52.6%) 3
  • Vascular and access site complications (1.2-11.1%) 3
  • Acute kidney failure (5.6-46%) 3
  • Infection and sepsis (2-36%) 3
  • Pulmonary complications including ARDS (7.1-17.5%) 3

• Important considerations:

  • REBOA should be deployed early, ideally within 3 hours of injury 1
  • Aortic occlusion time should be minimized to reduce ischemia-reperfusion injury
  • Zone 3 REBOA may be preferable over Zone 1 for isolated pelvic trauma as it provides similar hemodynamic support with less organ dysfunction 4

Alternative Approaches

When REBOA is not feasible or contraindicated:

• Temporary extra-peritoneal packing should be considered when bleeding is ongoing and/or when angioembolization cannot be achieved in a timely manner 2
• Traditional approaches like resuscitative thoracotomy with aortic cross-clamping may be necessary in patients "in extremis" 2

Decision Algorithm

1. Assess for noncompressible life-threatening hemorrhage with hemodynamic instability (SBP <90 mmHg)
2. Determine likely source of bleeding (abdominal vs. pelvic)
3. Establish arterial access via femoral artery
4. Deploy REBOA in appropriate zone:
   • Zone 1 for abdominal/multiple sources of bleeding
   • Zone 3 for isolated pelvic bleeding
5. Proceed to definitive hemorrhage control (surgery, angioembolization)
6. Consider partial or intermittent balloon deflation to minimize ischemic complications
7. Remove REBOA as soon as hemodynamic stability is achieved

REBOA represents an important advancement in the management of severe hemorrhagic shock, but careful patient selection and technique are essential to maximize benefits while minimizing complications.