Overview
Definition:
REBOA is an endovascular technique used in emergency settings to temporarily occlude the descending thoracic aorta, aiming to redistribute blood flow to vital organs (brain, heart) and increase proximal aortic pressure in patients with severe hemorrhagic shock.
Epidemiology:
Hemorrhagic shock remains a leading cause of preventable death in trauma patients
REBOA is indicated in non-compressible torso hemorrhage (NCTH) where conventional resuscitation has failed or is insufficient
Its adoption is increasing globally, with growing evidence supporting its efficacy in select patient populations.
Clinical Significance:
REBOA offers a temporizing measure to stabilize hemodynamically unstable patients with life-threatening bleeding from truncal injuries
It buys time for definitive hemorrhage control, whether surgical or interventional radiology-based, thereby improving outcomes and reducing mortality in this critical patient group
It is an adjunct to, not a replacement for, source control.
Indications And Contraindications
Indications:
Hemodynamic instability (systolic blood pressure < 90 mmHg, requiring ongoing resuscitation) despite standard measures
Presence of non-compressible torso hemorrhage
Failure or delay in definitive hemorrhage control
Patients unsuitable for immediate thoracotomy/laparotomy or requiring transport to definitive care.
Contraindications:
Known severe aortic valve disease or insufficiency
Severe pre-existing coagulopathy refractory to correction
Penetrating cardiac injury
Blunt cardiac injury with significant contusion
Prolonged aortic occlusion time (>90 minutes, absolute contraindication due to ischemia)
Patient refusal or lack of capacity
Expected mortality too high even with REBOA
Injury distal to the diaphragm with bleeding that can be controlled non-invasively.
Diagnostic Approach
History Taking:
Focus on mechanism of injury (blunt vs
penetrating)
Time of injury
Vital signs at presentation and response to initial resuscitation
Previous medical history, especially cardiac and vascular conditions
Duration of hypotension
Pre-hospital interventions.
Physical Examination:
Assess for signs of hemorrhagic shock: hypotension, tachycardia, altered mental status, pallor, cool extremities
Examine for obvious external bleeding
Palpate peripheral pulses (diminished or absent distal to occluded segment)
Auscultate heart sounds for murmurs suggestive of aortic regurgitation.
Imaging And Investigations:
FAST (Focused Assessment with Sonography for Trauma) and eFAST scans to identify intra-abdominal or thoracic free fluid
CT angiography of chest, abdomen, and pelvis for source identification once stabilized
Complete blood count (Hb, Hct), coagulation profile (PT, aPTT, INR), lactate, arterial blood gases (ABGs)
Electrocardiogram (ECG) to assess for cardiac injury.
Differential Diagnosis:
Other causes of shock in trauma: neurogenic shock, septic shock (late), cardiogenic shock
Hemorrhage from extremities or pelvic fractures
Aortic dissection (may be a cause or complication)
Tamponade.
Reboa Procedure
Access And Insertion:
Percutaneous femoral artery access is most common, typically using a Seldinger technique with a guidewire
A 5F-7F sheath is inserted
A dedicated REBOA catheter with an inflatable balloon is advanced under fluoroscopic guidance.
Balloon Placement:
The balloon is typically positioned in Zone I (distal to left subclavian artery, proximal to celiac artery) for truncal hemorrhage control
Zone II (distal to left subclavian, proximal to renal arteries) may be used for lower abdominal injuries
Accurate placement is crucial to avoid compromising cerebral or cardiac circulation.
Inflation And Monitoring:
The balloon is inflated with sterile saline until adequate proximal aortic pressure is achieved (target systolic BP 100-120 mmHg) and distal pulses become absent
Inflation should be intermittent (e.g., 15 minutes on, 5 minutes off) to minimize ischemic complications
Continuous hemodynamic monitoring is essential.
Removal And Definitive Care:
REBOA is a temporizing measure
Definitive hemorrhage control (surgery or IR embolization) should be performed as soon as feasible
Balloon removal is done after source control is achieved or when patient is hemodynamically stable
Post-removal monitoring for complications is vital.
Complications
Early Complications:
Ischemia and reperfusion injury to lower extremities, kidneys, bowel, and spinal cord (paraplegia)
Aortic dissection or rupture
Catheter-related thrombosis or embolization
Bleeding at access site
Myocardial ischemia or stunning
Acute kidney injury.
Late Complications:
Aortic aneurysm formation or pseudoaneurysm at the site of insertion or dissection
Chronic limb ischemia
Organ dysfunction due to prolonged ischemia-reperfusion
Spinal cord injury leading to paraplegia (most feared).
Prevention Strategies:
Strict adherence to indications and contraindications
Minimize occlusion time and use intermittent inflation
Accurate balloon placement
Prompt definitive hemorrhage control
Meticulous surgical technique for access and closure
Careful patient selection and monitoring
Utilize advanced imaging when available
Consider anticoagulation judiciously if no contraindication.
Prognosis
Factors Affecting Prognosis:
Severity of hemorrhage, time to REBOA placement, duration of occlusion, success of definitive hemorrhage control, pre-existing comorbidities, development of complications (especially spinal cord ischemia), and overall patient physiology.
Outcomes:
When used appropriately as a temporizing measure, REBOA can significantly improve survival rates in patients with otherwise unsalvageable hemorrhagic shock
It allows for transfer to definitive care and successful hemorrhage control
However, significant morbidity can still occur if complications arise.
Follow Up:
Close hemodynamic monitoring post-removal
Serial assessment for signs of limb ischemia, abdominal compartment syndrome, or end-organ dysfunction
Neurovascular checks are paramount
Imaging of the aorta (e.g., CT angiography) may be required in the subsequent days to weeks to assess for late vascular complications.
Key Points
Exam Focus:
REBOA is a temporizing endovascular technique for non-compressible torso hemorrhage
Zone I occlusion for truncal injuries is standard
Minimize occlusion time
Complications include spinal cord ischemia and lower limb ischemia
Definitive hemorrhage control is essential.
Clinical Pearls:
Think REBOA when conventional resuscitation fails in a bleeding patient
Always have a plan for definitive source control before initiating REBOA
Monitor proximal and distal pulses closely
Intermittent inflation is crucial to prevent ischemia
The goal is time, not cure.
Common Mistakes:
Using REBOA without a clear indication or when definitive care can be immediately provided
Prolonged, continuous occlusion time
Incorrect balloon placement leading to neurological deficits or inadequate resuscitation
Failure to have a plan for source control
Overlooking significant aortic pathology as a contraindication.