Resuscitative endovascular balloon occlusion of the aorta

doi:10.1016/j.resuscitation.2015.09.003

Resuscitation

Volume 96, November 2015, Pages 275-279

https://doi.org/10.1016/j.resuscitation.2015.09.003 Get rights and content

Abstract

The management of non-compressible torso hemorrhage can be problematic. Current therapy requires either open or interventional radiologic control of bleeding vessels and/or organs. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a new tool to stabilize patients in shock by achieving temporary inflow occlusion of non-compressible torso hemorrhage. This proactive technique represents a paradigm shift in achieving hemodynamic stability in patients as a bridge to definitive hemostasis. REBOA is applicable by trauma professionals, including emergency physicians, at the bedside in the emergency department, but its use needs to be considered within the context of available evidence and a robust system encompassing training, accreditation, multidisciplinary involvement and quality assurance. We review the evolving role of REBOA and discuss unanswered questions and future applications.

Introduction

Uncontrolled hemorrhagic shock is a significant contributor to early mortality.¹ In particular, non-compressible torso hemorrhage (NCTH) is not amenable to local hemostatic maneuvers such as direct pressure. Controlling NCTH requires either an open approach or in selected cases, radiologic intervention of the bleeding vessels.

Techniques previously employed in the operating room (OR) have now migrated to the emergency department (ED) and the prehospital care arena. The use of tourniquets is a good example of potentially lifesaving therapy, now commonly used much earlier in a patient's care than in the past.² Endovascular techniques to treat hemorrhage in the pelvis, spleen, liver and kidney also continue to evolve. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is the newest endovascular technique of achieving inflow control to temporarily slow NCTH. It involves placing a balloon occlusion catheter into the aorta via the common femoral artery (CFA). Commonly employed in the OR in the setting of repair of abdominal aortic aneurysms (AAA), it has recently evolved into a proactive means of hemorrhage control in the ED. As improvements in REBOA design and use continue, the emergency physician (EP) will need to become familiar with the indications and technical aspects of its use. This article explores the evolution of REBOA, outlines training in the procedure, and explores future applications and implications for the EP as they help bring this new technique to the bedside as part of a multidisciplinary resuscitation team.

Section snippets

Defining the problem

Hemorrhagic shock is a leading cause of early death after injury. Mortality is likely to be highest in the first six hours after injury, especially in patients with hemorrhage in the chest, abdomen or pelvis.3, 4 Every effort must be made to diagnose the cause of torso hemorrhage early and provide rapid hemostasis.

Laparotomy is the primary method for arresting intra-abdominal hemorrhage, allowing identification and treatment of all bleeding sites. Interventional radiologic methods have proved

History and evolution of REBOA

Hughes described use of endovascular aortic occlusion techniques during the Korean War, applying this method to three critically injured soldiers.⁷ Although two survived to surgery, all died from major injuries. He suggested earlier deployment of the device might have proved more beneficial.

The next several decades saw only scattered reports, primarily small case series, of REBOA use in various forms. Low et al. reported on outcomes in 23 patients with either traumatic or non-traumatic NCTH.⁸

Technique, current limitations, and complications of REBOA

REBOA technique for trauma is deliberately modified from that employed in vascular surgery due to the lack of ready access to fluoroscopy. We describe our institutional technique below.

The CFA is identified by palpation, ultrasound, or direct cutdown techniques, and accessed using a standard arterial line catheter. A stiff wire with a floppy tip, such as the Amplatz Super Stiff wire (Boston Scientific, MA, USA) is inserted to the level of the proximal descending thoracic aorta (identified by

Considerations for training in REBOA

Adequate and appropriate training in REBOA is critical to its successful implementation within a trauma system. Non-surgical specialties do not benefit from a common pathway or guidance to develop competency in peripheral endovascular techniques such as those needed for REBOA. Although surgical training programs do provide formal general didactics, we feel these may not be adequate.

Holcomb et al. suggest several steps in establishing competence amongst non-traditional users of REBOA.²⁶ These

Future directions for research and implementation

Although the existing animal and human data is very promising, it does also raise some conflicting issues and concerns about the use of REBOA. Nevertheless, we feel with continued use within well-established trauma systems and collaborative data sharing, these concerns will continue to be addressed. The following discussion reviews what we feel are some key unanswered questions about the implementation and evolving role of REBOA, and represents current best available evidence and our consensus

Conclusion

REBOA presents an exciting paradigm shift for the proactive management of critically ill patients with torso hemorrhage. Continuing research and technologic development will further identify and expand its possible uses while outlining incidence and consequence of complications. Practitioners will need to attain and maintain the required skills, carefully consider the currently available evidence, and coordinate the implementation and use of REBOA within a collaborative multidisciplinary

Conflicts of interest statement

None declared by any author.

Assistance obtained

We declare this is the original work of the authors and no other assistance was attained in producing this manuscript.

Acknowledgements

We report there was no internal or external funding source involved in the preparation of this manuscript.

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^☆: A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2015.09.003.

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Review articleResuscitative endovascular balloon occlusion of the aorta☆

Abstract

Introduction

Section snippets

Defining the problem

History and evolution of REBOA

Technique, current limitations, and complications of REBOA

Considerations for training in REBOA

Future directions for research and implementation

Conclusion

Conflicts of interest statement

Assistance obtained

Acknowledgements

J Emerg Med

J Am Coll Surg

Ann Emerg Med

J Surg Res

Am J Emerg Med

Surgery

Surgery

Int J Obstet Anest

Anaesth Crit Care Pain Med

J Surg Res

Ann Vasc Surg

Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations

J Trauma

Preventable deaths from hemorrhage at a level I Canadian trauma center

J Trauma

Damage control resuscitation: the new face of damage control

J Trauma

Emergency department thoracotomy: still useful after abdominal exsanguination?

J Trauma

Use of an intra-aortic balloon catheter tamponade for controlling intra-abdominal hemorrhage in man

Surgery

The role of intra-aortic balloon occlusion in penetrating abdominal trauma

J Trauma

An endoluminal method of hemorrhage control and repair of ruptured abdominal aortic aneurysms

J Endovasc Ther

Balloon occlusion of the aorta during endovascular repair of ruptured abdominal aortic aneurysm

J Endovasc Ther

Review article
Resuscitative endovascular balloon occlusion of the aorta☆