Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

• Consider in a patient suffering from non-compressible traumatic torso and/or pelvic bleeding who is near arrest or arrested despite resuscitative efforts
• Not indicated in tamponade or suspected tramatic aortic dissection

• Depending on site of suspected hemorrhage, balloon infated in Zone I, II or III (can confirm via ultrasound) 

• Helpful hint: Place central arterial line early in a potential REBOA candidate.  Helps facilitate subsequent REBOA catherization. 
• Be careful!  Balloon inflation time >45 minutes yields higher complications genernally secondary to ischemia, multiorgan dysfunction and refractory acidosis
• Courses currently available and designed to train EM physicians in placement of REBOA device 
• Important to coordinate protocols between EM, trauma and vascular physicians in addition to potential transfering institutions when considering implementation of REBOA for patient care 

Final thoughts: 

• REBOA literature is mixed
• Some indication of higher to equivalent survival with better neurologic outcome in REBOA patients 
• Research from AAST 2014 showed a survival rate of 37.5 vs 9.7% (n of 96 patients) 
• Other data (Japanese patient population) showed higher rates of procedural complications 
• Japan data may not be applicable to US patient population secondary to less in-house trauma team availability, longer balloon times, longer door to OR times and potentially less injured patient population 
• The largest trial to date, AORTA trial, is ongoing with published data on 114 patients prospectively observing survival rate was not statistically different despite it being 28.2% in REBOA vs 16.1% in resuscitative thoracotomy  

Sources: 

•  A systematic review of the use of resuscitative endovascular balloon occlusion of the aorta in the management of hemorrhagic shock Morrison, Jonathan James MD et. al.  Journal of Trauma and Acute Care Surgery. Issue: Volume 80(2), February 2016, p 324–334
• Evaluation of the safety and feasibility of resuscitative endovascular balloon occlusion of the aorta. Saito N et.al.  J Trauma Acute Care Surg. 2015 May;78(5):897-904
• Survival of severe blunt trauma patients treated with resuscitative endovascular balloon occlusion of the aorta compared with propensity score-adjusted untreated patients. Norii T, Crandall C, Terasaka Y. J Trauma Acute Care Surg. 2015 Apr;78(4):721-8
• The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: Data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA). DuBose, Joseph J. MD et. al.  The AAST AORTA Study Group. Journal of Trauma and Acute Care Surgery Issue: Volume 81(3), September 2016, p 409–419
•  Nonoperative management of hemodynamically unstable abdominal trauma patients with angioembolization and resuscitative endovascular balloon occlusion of the aorta. Ogura T, Lefor AT, Nakano M, Izawa Y, Morita H. J Trauma Acute Care Surg 2015;78:132–5