Hemorrhage is the leading cause of preventable death following trauma. Non-compressible hemorrhage is of particular concern as these patients require emergent intervention and many will die prior to anatomic hemostasis. For years, left anterior thoracotomy, the “ED thoracotomy”, was the standard of care for temporary proximal aortic occlusion, but survival remained dismal. Endoluminal aortic occlusion which was actually first described in the 1950s. With the increasing use of endovascular therapies for a wide variety of vascular disease, the “REBOA” (Resuscitative Endovascular Balloon Occlusion of the Aorta) began to be reported for use for ruptured abdominal aneurysms in the 2000s. Since that time, interest in its use in trauma has been increasing with a variety of basic science studies and early clinical series and case reports documenting potential benefits. Although no large randomized trials, or even large observational studies, are available, use of the REBOA is considered standard of care in many centers. Typically the REBOA is placed via the femoral artery either percutaneously or via a cut down and the aorta is occluded with a balloon placed over a wire by standard Seldinger-type technique. The balloon can be placed in “zone 1” just above the diaphragm to provide occlusion to the abdominal viscera and pelvic vasculature or in “zone 3” at the aortic bifurcation to provide inflow control to the pelvis and lower extremities. Injuries are then addressed and the balloon is carefully deflated taking care to avoid metabolic collapse from reperfusion. One main limitation of this technique is that the currently approved device in the United States requires a 12F sheath which requires an open femoral artery repair which obvious can be associated with significant complications. There are a huge number of unanswered questions about the use of REBOA in 2015: 1. Who are the appropriate patients in whom use may be beneficial? 2. How long can a balloon be inflated and the aorta be occluded before irreversible ischemic damage to the viscera occurs? 3. How long can the aorta be occluded before the metabolic consequences of reperfusion are lethal? 4. What is the effect on cerebral and cardiac perfusion when a REBOA is placed and afterload is acutely increased? Is it favorable or “too much”? 5. Who are the appropriate providers to place a REBOA? Only surgeons? Emergency Medicine physicians? Medics in the field? 6. How do we best train providers to place the REBOA? 7. How to we assure competency of providers? 8. Will lower profile devices make the technique more accessible and be associated with fewer complications?

1. REBOA: WHO, WHAT
AND WHY? (AND HOW)
Deborah M. Stein, MD, MPH
Chief of Trauma, R Adams Cowley Shock Trauma Center

2. The “why”

4. Leading Causes of Death
Following Injury?
#2
Hemorrhage
#3
Sepsis/MODS
#1 Traumatic
Brain Injury

5. …is the
leading
cause of
potentially
preventable
death
Hemorrhage

6. “The only weapon with which
the unconscious patient can
immediately retaliate upon the
incompetent surgeon is
hemorrhage.”
- Halstead

7. Direct Manual Pressure

8. Topical Hemostatic Agents
 QuikClot®
 Modified Rapid Deployment Hemostatic
Dressing
 WoundStat™
 HemCon
 Etc…

9. Tourniquets

10. • Non-compressible bleeding accounts for
approximately 85% of preventable
deaths on the battlefield, 80% of which
include acute hemorrhage within the
abdomen/torso.
Noncompressible
hemorrhage

11. Guiding Principle - Proximal Aortic
Control

12. Ledgerwood AM, et al. J Trauma. 1976
Advantages to aortic occlusion prior to
laparotomy:
1. Continued cerebral/coronary
perfusion
2. Avoid catastrophic CV collapse with
laparotomy
3. Proximal aortic control decreases
blood loss

13.  Examine role of laparotomy in ED for
abdominal hemorrhage
 51 patients
 All had EDT prior to laparotomy
Survival 0%

14. It is all about exposure!

18. Is there a better way?

19. Pubmed “REBOA” 2 years
ago….

20. The “what”

21. REBOA – Resuscitative
Endovascular Balloon Occlusion of
the Aorta

22. Not a New Concept
Hughes CW. Surgery, 1954

23. Pre-Endovascular Era
 Low RB et al. Preliminary report on the
use of the Percluder occluding aortic
balloon in human beings.
 Annals of emergency medicine. 1986 Dec;15(12):1466–9.
 13% survival in 15 trauma patients after REBOA
 Gupta BK et al. The Role of Intra-aortic
Balloon Occlusion in Penetrating
Abdominal Trauma.
 The Journal of Trauma. 1989;29(6):861–5.
 35% survival in 20 trauma patients after REBOA

24. Endovascular Era
 Greenberg RK et al. An endoluminal
method of hemorrhage control and repair
of ruptured AAA.
 J Endovasc Ther 2000
 Malina M, Veith F. Balloon occlusion of the
aorta during endovascular repair of
ruptured abdominal aortic aneurysm.
 J Endovasc Ther. 2005 Oct;12(5):556–9.

25. Translational Research
 Endovascular balloon occlusion of the aorta is superior
to resuscitative thoracotomy with aortic clamping in a
porcine model of hemorrhagic shock.
 White et al. Surgery 2011;150:400-9.
 REBOA vs EDT + clamping
 REBOA group:
 Less acidotic
 Lower serum lactate
 Lower pCO2 level
 Required less fluid and pressor during resuscitation

26. Translational Research
 Forty-minute Endovascular Aortic Occlusion Increases
Survival in an Experimental Model of Uncontrolled
Hemorrhagic Shock caused by Abdominal Trauma.
 Avaro et al. J Trauma. 2011;71:720-5
 REBOA vs fluid resuscitation
 REBOA group:
 More survivors
 Higher MAP
 Lower lactate levels
 No difference in bowel/renal ischemia between no
REBOA and REBOA groups at 40 or 60 minutes

27. Morrison JJ, et al. J Sur Research. 2

28. Translational research
 Same group has looked at
 Effect on inflammatory cascades
 Survivability up to 90 minutes of occlusion
 Functional outcomes and paraplegia rates
 Continuous vs. intermittent use
 Novel systems without fluoroscopy and smaller
sheaths
Morrison JJ, et al. J Surg Research. 2014
Markov NP, et al. Surgery 2013
Long KN, et al. Ann Vasc Surg. 2015
Morrison JJ, et al. Shock. 2014
Scott DJ, et al. J Trauma. 2013

29. Case Series - Trauma
 13 patients with pelvic fracture, refractory hypotension
 Aortic occlusion performed by IR – in-house
 46% survival
Martinelli T, et al. J Trauma 2010 Apr;68(4):942-8

30. Brenner ML, et al. J Trauma Acute Care Surg. 2013

31. Overall (N = 96) Resuscitative Thoracotomy
(n=72)
REBOA
(n=24)
p value
Age, Median (P25,P75) 30.5(23.5, 48) 41 (24,62) 0.33
Male %(n) 87.5% (63) 79.2%(19) 0.33
Blunt %(n) 44.4% (32) 66.7% (16) 0.10
ISS, Median (P25,P75) 34 (22,59) 29 (19,41) 0.17
AIS Head, Median (P25,P75) 3 (0,5) 4 (3,5) 0.29
AIS Chest, Median (P25,P75) 3 (3,4) 3.5 (3,4) 0.91
AIS Abdomen, Median (P25,P75) 2 (0,4) 3 (2,4) 0.26
AIS Extremity, Median (P25,P75) 1.5 (0,3) 4 (3,4) <0.001
Survival Rate % (n) 9.7% (7) 37.5% (9) 0.003
Moore LJ, et al. AAST, 2014

32. Norii T, et al. J Trauma and Acute Care Surg, 2015

33. The “how”

34. Proximal Aortic Control –
Aortic Occlusion Balloon (REBOA)

35. Stannard A, et al. J Trauma. 2011

36. The “who”

37. REBOA

39. Case
 26 year old male with GSW to abdomen and
SBP of 60
 Resus lines and R femoral A line placed
 + FAST
 To OR

40. Case
 In OR, has cardiac arrest
 REBOA placed through R femoral access
 SBP to 95
 At ex lap:
 Shattered right kidney
 Grade IV liver injury
 Multiple mesenteric and bowel injuries
 Rapid hemorrhage control/nephrectomy/packed
 Angio through R femoral sheath
 AE of R hepatic artery
 Repair of R CFA
 Left open and packed

41. Case
 Taken back to OR on POD #2
 Unpacked, closed
 Extubated POD #5/7
 D/Ced home POD #11/13

42. Hybrid ORs

43. Biffl WL, et al. J Trauma Acute Care Surg. 20

44. Unanswered Questions
 Who should be performing REBOA? What
should be the standards for training,
credentialing, and competency?
 What about open cardiac massage?
 Is the technology appropriate?

45. Brenner ML, et al. J Trauma Acute Care Surg. 2014

46. Brenner ML, et al. J Trauma Acute Care Surg. 2014

47. What about open cardiac
massage?
Table. EtCO2 Values for CCC and OCCM periods
CCC Only*
(n=18)
OCCM after CCC
(n=17)
CCC vs.
OCCM
First Min Total p CCC† OCCM p p
Initial 6.1±9.4 8.2±10.6 0.53 3.4±3.4 8.5±5.7 0.007 0.92
Final 6.4±6.9 16.2±12.1 0.01 7.2±6.9 14.8±12.1 0.03 0.73
Peak 9±9.7 27.4±16.5 0.003 10.4±10.4 28.8±22.2 0.004 0.83
Mean 6.8±7.4 12.4±6.1 0.02 6.8±6.4 13.1±8.7 0.02 0.78
*CCC-only data separated into first minute and the remainder of CCC period for comparison to
OCCM
†Mean CCC period duration prior to OCCM = 66.3 ± 33.1 seconds

48. Adjunct for Nonoperative
Mangement?

49. Case Reports - Nontrauma
 Paull JD et al. Balloon occlusion of the abdominal aorta during caesarean
hysterectomy for placenta percreta. Anaes int care. 1995 Dec;23(6):731–4.
 Bell-Thomas, SM et al. Emergency use of a transfemoral aortic occlusion
catheter to control massive haemorrhage at caesarean hysterectomy.
BJOG 2003 Dec;110(12):1120–2.
 Tang X et al. Use of aortic balloon occlusion to decrease blood loss during
sacral tumor resection. J Bone Joint Surg 2010 Jul 21;92(8):1747–53.
 Søvik E et al. The use of aortic occlusion balloon catheter without
fluoroscopy for life-threatening post-partum haemorrhage. Acta Anaes Scand.
2012 Mar;56(3):388–93.
 Elective orthopedics?
 Elective urological procedures?

50. Nothing is for free!
Biffl WL, et al. J Trauma Acute Care Surg. 20

51. Nothing is for free!

52. “Pre-hospital REBOA would appear to be well suited to the
geography of Scotland, which includes a spectrum of
topography ranging from major urban lowland regions to
rural Northern and island territories.
The use of this technique in patients with haemorrhagic
shock, who are injured in remote areas, would facilitate an
extension of the window for salvage, and in turn permit
Morrison JJ. The Surgeon. 20

53. REBOA in the field?
How London Air Ambulance
saved life of cyclist who lost leg
in skip lorry crash
A young cyclist who was
miraculously saved by Air
Ambulance medics and hospital
surgeons after being run over by a
skip lorry today told how she felt
“lucky to be alive”.
Victoria Lebrec, 24, only survived
because a London’s Air Ambulance
doctor performed a life-saving
procedure successfully at the
roadside for only the second time in
the world to stop her bleeding to
death.
05 January 2015

54. Still to be answered
Many questions…

55. Work to be done…

57. Thank you