Revisiting the promise, practice and progress of resuscitative endovascular balloon occlusion of the aorta

Abstract

Purpose of review The use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) to temporarily control bleeding and improve central perfusion in critically injured trauma patients remains a controversial topic. In the last decade, select trauma services around the world have gained experience with REBOA. We discuss the recent observational data together with the initial results of the first randomized control trial and provide a view on the next steps for REBOA in trauma resuscitation. Recent findings While the observational data continue to be conflicting, the first randomized control trial signals that in the UK, in-hospital REBOA is associated with harm. Likely a result of delays to haemorrhage control, views are again split on whether to abandon complex interventions in bleeding trauma patients and to only prioritize transfer to the operating room or to push REBOA earlier into the post injury phase, recognizing that some patients will not survive without intervention. Summary Better understanding of cardiac shock physiology provides a new lens in which to evaluate REBOA through. Patient selection remains a huge challenge. Invasive blood pressure monitoring, combined with machine learning aided decision support may assist clinicians and their patients in the future. The use of REBOA should not delay definitive haemorrhage control in those patients without impending cardiac arrest.

Selective aortic arch perfusion: a first-in-human observational cadaveric study

“…The REBOA balloon can be inflated either in the thoracic aorta (Zone 1) or distal aorta (Zone 3). REBOA provides both haemorrhage control distal to the balloon and cardiac resuscitation proximal to it [ 19 ]. SAAP is procedurally more complex as it adds to the occlusion balloon of REBOA a central catheter through which fluids can be infused directly into the aortic arch.…”

Prehospital Partial Resuscitative Endovascular Balloon Occlusion of the Aorta for Exsanguinating Subdiaphragmatic Hemorrhage

“…Balloon occlusion of the descending thoracic aorta (zone 1 [Z1], supraceliac) reduces distal blood loss while also improving coronary and cerebral perfusion . This intervention can temporarily delay cardiac arrest from exsanguination, potentially extending the time window to provide definitive treatment . However, in the UK, the average time taken to reach a hospital following major injury is 90 minutes, long after the window of potential benefit …”

“…However, this was limited to infrarenal placement (Z3) to avoid prolonged visceral ischemia . To further investigate this resuscitation strategy in this setting, it is important to establish whether it can be delivered in patients with more proximal hemorrhage in the abdomen (Z1 REBOA) and to achieve maximal increase in proximal blood pressure (BP) and therefore myocardial perfusion in patients with profound shock and traumatic cardiac arrest (TCA) caused by subdiaphragmatic exsanguinating hemorrhage . However, this comes with an increased risk of visceral ischemic injury.…”

“… This intervention can temporarily delay cardiac arrest from exsanguination, potentially extending the time window to provide definitive treatment. However, in the UK, the average time taken to reach a hospital following major injury is 90 minutes, long after the window of potential benefit. …”

Editorial: Acute trauma management in a changing environment

“…In any case, careful patient selection is key to minimize treatment failure which also expands to catheter- and stent-based endovascular modalities [9]. Marsden et al share interesting signals from the first randomized controlled trial on the add-on use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) to standard major trauma care in uncontrolled torso trauma hemorrhage [12]. The primary outcome was a reduction in 90-day- all-cause mortality but the trial was just recently stopped prematurely with 90 patients recruited due to evidence of harm in the REBOA treatment group.…”