REBOA: Resuscitative Endovascular Balloon Occlusion of the Aorta
About
REBOA is a technique used in trauma for patients that are rapidly bleeding to death from injuries to their chest, abdomen or pelvis. This technique involves rapidly placing a flexible catheter into the femoral artery, maneuvering it into the aorta and inflating a balloon at its tip. This stops blood flow beyond the balloon, essentially halting any bleeding, while also stopping all blood flow distal to the balloon. This is a very temporary maneuver and is merely a bridge to get the severely injured patient to the Operating Room or Angiographic Suite.
Because it has only recently been applied in the clinical setting, the indications are still being established. There is strong agreement that it is useful in cases of non-compressible torso and pelvic bleeding, when the patient has either arrested, or is about to arrest, and only in the pre-hospital or trauma bay. Less clear indications would include immediately pre-op with abdominal trauma to decrease bleeding during the immediate exploration, or as a bridge to embolization in the transient responder.
Technique
The balloon can either be maneuvered into the chest region for thoracic or abdominal bleeding, or just above the pelvis for suspected pelvic exsanguination. It is essential that cardiac tamponade, and tension pleural physiology be excluded prior to initiating REBOA therapy.
Training, Credentialing and Team Preparation
Since REBOA is a new technique, it is most commonly performed by a trauma surgeon that has taken a course, and has participated in a formal mentorship with a vascular/endovascular surgeon in order to practice endovascular techniques in a controlled setting, and with the benefit of angiography, which is not available in the initial placement of the REBOA catheter. A partnership with the Vascular Surgery service is essential since some of the approaches require formal groin dissection, and arterial closure when removing the catheter.
The trauma team needs to be prepared for using REBOA, and simulated REBOA scenarios are extremely helpful in this regard. In addition, there are numerous protocols that need to be established. These range from the specific indications and provider credentialing to a formal deflation protocol, since the reperfusion injury has the potential for fatal acidosis.