What is a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)?

From the Guidelines

REBOA stands for Resuscitative Endovascular Balloon Occlusion of the Aorta, a minimally invasive emergency procedure used to control severe internal bleeding in trauma patients, particularly those with non-compressible torso hemorrhage. The procedure involves inserting a balloon catheter through the femoral artery and inflating it in the aorta to temporarily stop blood flow below the balloon, thereby reducing bleeding and maintaining blood pressure to vital organs like the heart and brain.

Key Points

• REBOA is typically performed in two zones: Zone 1 (between the left subclavian artery and celiac artery) for abdominal bleeding, or Zone 3 (between the lowest renal artery and aortic bifurcation) for pelvic bleeding 1.
• The balloon is only inflated for a limited time, usually less than 30-60 minutes, to prevent ischemic complications to tissues downstream.
• This technique serves as a bridge to definitive surgical repair, buying critical time for patients who might otherwise bleed to death.
• REBOA requires specialized training and equipment but has become increasingly important in trauma centers as it can be performed more quickly than traditional open surgical approaches for aortic occlusion.

Clinical Application

• In hemodynamic unstable patients with suspected pelvic bleeding, REBOA in zone III should be considered as a bridge to definitive treatment 1.
• Partial-REBOA or/and intermittent-REBOA should be considered to decrease occlusion time and ischemic insult 1.
• The usage of REBOA is increasing worldwide, especially in the USA, despite the lack of high-quality evidence and prospective trials 1.

Recent Evidence

• A recent study published in 2024 in the Annals of Emergency Medicine found that REBOA has been proposed as an alternative to resuscitative thoracotomy (RT) in hemodynamic unstable trauma patients 1.
• The study highlights the importance of REBOA as a method of temporary hemorrhage control as a bridge to definitive treatment.

From the Research

Definition of REBOA

• Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an endovascular procedure where a blocking balloon is introduced into the aorta to reduce bleeding situated distal to the balloon and simultaneously improve cardiac and cerebral oxygenation 2.
• REBOA is a minimally invasive technique used to treat hemorrhage in critically ill patients, providing a temporizing measure to prevent exsanguination and allow for transition to definitive hemorrhage control 3.

Indications for REBOA

• REBOA is used in trauma surgery for controlling non-compressible torso hemorrhages, as a less invasive option compared to an invasive emergent thoracotomy for aortic cross-clamping 4.
• It is also used to prevent hemodynamic collapse in patients with severe hemorrhagic shock, maintaining perfusion of the brain and heart while decreasing distal bleeding until hemorrhage control can take place 4.
• REBOA has been used for select non-traumatic cases, including postoperative abdominal or gynecological bleeding, and as a possible adjunct to cardiopulmonary resuscitation for non-traumatic cardiac arrest 2, 4.

Procedure and Complications

• The procedure involves arterial access, positioning the initial sheath, balloon preparation and positioning, balloon inflation, securing the balloon/sheath, subsequent hemorrhage control, balloon deflation, and balloon/sheath removal 5.
• Major complications reported include acute kidney injury, lower leg amputations, and even death 4.
• The complication rate of the procedure is approximately 5%, with access complications being the most common 2.

Placement of REBOA

• Standardized distances for placement of REBOA in patients with aortic stenosis have been measured using computer tomographic (CT) scans, with a potentially safe interval for placement in Zone 1 calculated to be between 43 and 48 cm from the site of insertion into the common femoral artery 6.