The pitfalls of resuscitative endovascular balloon occlusion of the aorta: Risk factors and mitigation strategies

Abstract

Despite technological advancements, REBOA is associated with significant risks due to complications of vascular access and ischemia-reperfusion. The inherent morbidity and mortality of REBOA is often compounded by coexisting injury and hemorrhagic shock. Additionally, the potential for REBOA-related injuries is exaggerated due to the growing number of interventions being performed by providers who have limited experience in endovascular techniques, inadequate resources, minimal training in the technique, and who are performing this maneuver in emergency situations. In an effort to ultimately improve outcomes with REBOA, we sought to compile a list of complications that may be encountered during REBOA usage. To address the current knowledge gap, we assembled a list of anecdotal complications from high-volume REBOA users internationally. More importantly, through a consensus model, we identify contributory factors that may lead to complications and deliberate on how to recognize, mitigate, and manage such events. An understanding of the pitfalls of REBOA and strategies to mitigate their occurrence is of vital importance to optimize patient outcomes.

Effect of resuscitative endovascular balloon occlusion of the aorta in hemodynamically unstable patients with multiple severe torso trauma: a retrospective study

“…Despite technological advancements, REBOA is associated with significant risks due to complications of vascular access and reperfusion ischemia [26, 27]. The serious complication of lower limb ischemia, which may lead to amputation, occurred with high frequency (3/24 patients) in a previous study [28].…”

Emergency Department Thoracotomy: Development of a Reliable, Validated Checklist for Procedural Training

“…However, for cardiac or thoracic injuries particularly with the suspicion for cardiac tamponade, myocardial injury, or other thoracic vascular injury resulting in cardiac arrest, the resuscitative EDT remains the standard of care. Any suspected thoracic injury is a contraindication for the use of endovascular balloon therapy . In addition, recent joint statements American College of Surgeons Committee on Trauma and the American College of Emergency Physicians have recommended that EM physicians without critical care training should not perform REBOA .…”

Management of High-Risk Obstetrical Patients with Morbidly Adherent Placenta in the Age of Resuscitative Endovascular Balloon Occlusion of the Aorta

“…From the trauma literature, access site complications are similar to those encountered during other forms of arterial puncture, but may be severe, including limb ischemia requiring amputation [51,52]. Balloon malposition into an aortic branch vessel or migration into a higher or lower position within the aorta has also been described, sometimes resulting in uncontrolled arterial rupture and death [45,51]. In animal models, proximal hypertension resulting from aortic occlusion has led to acute heart failure, cerebral edema, and respiratory failure [53,54].…”

“…Potential complications from REBOA include those related to arterial access, balloon positioning and inflation, and the physiologic changes that result from inflation and deflation of the device (Table 4). From the trauma literature, access site complications are similar to those encountered during other forms of arterial puncture, but may be severe, including limb ischemia requiring amputation [51,52]. Balloon malposition into an aortic branch vessel or migration into a higher or lower position within the aorta has also been described, sometimes resulting in uncontrolled arterial rupture and death [45,51].…”