Written by: Andew Cunningham, MD (NUEM PGY-4) Edited by: Bill Burns, MD (NUEM Alum ‘17) Expert commentary by: Zaffer Qasim, MBBS, FRCEM, FRCPC(EM), EDIC
REBOA: Ready for Prime Time?
For years, the resuscitative thoracotomy has been the sole weapon in the physician’s arsenal against a loss of a perfusing pressure in the crashing trauma patient. With the advent of new endovascular technologies, novel methods to control hemorrhage are being refined, among them Resuscitative Endovascular Balloon Occlusion of the Aorta or REBOA. With this newer method getting a lot of attention in the emergency and trauma communities, it’s time to take a look at what it is, how successful it is, and where we are going with it.
What Is It?
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a possible alternative to resuscitative thoracotomy in cases of non-compressible torso hemorrhage (NCTH) that present to the Emergency Department in extremis.1
REBOA works via the insertion of a catheter through the femoral artery to allow an endovascular balloon to be deployed within the aorta, allowing for bleeding control and augmentation of afterload in hemorrhagic shock.2
REBOA can be deployed in Zone III of the Aorta, as depicted in the image below, for pelvic hemorrhage, or in Zone I of the Aorta for abdominal hemorrhage.3
Borrowed from Reference 3
The primary indications for REBOA include:
PEA arrest secondary to abdominal or pelvic hemorrhage within 10 minutes of the onset of arrest
Severe hypovolemic shock secondary to abdominal or pelvic hemorrhage
Unstable hemodynamics refractory to volume resuscitation in patients with abdominal or pelvic hemorrhage2
The major contraindications include age older than 70, significant comorbidities, prolonged PEA arrest (lasting longer than 10 minutes), or high suspicion for proximal aortic injury (REBOA may exacerbate bleeding from thoracic sources).2
Does It Work?
A study at U of Arizona showed that 45% of patients who received thoracotomy may have benefited from REBOA based on autopsy results, but only 32% of the patients receiving a thoracotomy did not have a contraindication for it, and of those who did not have a contraindication, only roughly half would have potentially benefited. Compared to prior literature, this may suggest that REBOA is not as useful in patients in extremis.1
Although the literature does suggest that REBOA reduces the amount of overall hemorrhage, there is still no definitive evidence in humans of a decrease in mortality.4
There are still risks of complications in humans, including arterial injury and limb ischemia.3 In animal models, REBOA has also resulted in renal failure, liver failure, intestinal ischemia, and multiple other injuries which result from occlusion of the aorta.5
Given that REBOA still obstructs distal flow, just like cross-clamping the aorta in a resuscitative thoracotomy, it is still reserved as a last resort maneuver. The effects of aortic occlusion can be reviewed below6:
Borrowed from Reference 6
Where Is It Going?
An alternative to REBOA may be Selective Aortic Arch Perfusion (SAAP); in this similar yet separate endovascular approach, a catheter that has two ports is utilized instead of the single-port REBOA catheter. This allows for both occlusion of the aorta and selective administration of blood, pressors, or other medications directly to the heart and brain. Where REBOA may be useful for exclusively shock, SAAP may have advantages in cardiac arrest secondary to trauma.7
A new, smaller REBOA catheter, the 7 French ER-REBOA, may cause fewer injuries and also allows for simultaneous blood pressure monitoring.8
Partial REBOA, or P-REBOA, allows for controlled blood flow to the body distal to the area of occlusion, in efforts to limit ischemia.5
Is It Feasible for ER Docs to Perform?
Yes! Some of the larger studies performed in Japan required placement by either a surgical or emergency medicine-trained attending.9
In England, there are case of REBOA being deployed in the pre-hospital setting to act as a bridging method for resuscitation during transport.7 As the relay between the hospital and Emergency Medical Services, it is an EM physician’s responsibility to be aware of this method and its utility in her area.
Take-Home Points
REBOA is a newer up-and-coming method of controlling hemorrhage secondary to abdominopelvic trauma that may act as an alternative to resuscitative thoracotomy.
Although more data still needs to be collected, REBOA has not yet shown to clearly improve mortality, and does come with certain risks and complications.
There are more novel methods of REBOA undergoing research and development, including SAAP, ER-REBOA, and P-REBOA, which may strengthen the utility of REBOA and reduce some of the complication risks.
REBOA is within an EM physician’s scope of practice, and may play a role in EMS in the future. As such, it is our duty to be aware of it and follow along with its developments.
Expert Commentary
Thanks for a great post on an evolving temporary hemorrhage control concept. Hemorrhage, and torso hemorrhage in particular, remains the largest cause of death in trauma in the first 24 hours. In the right patient, REBOA can be another effective procedure in the emergency physician’s toolbox. Some additional points to consider:
1. Access is key! The rate limiting step is early common femoral artery (CFA) access. It’s important to emphasize accessing the common as placing the sheath in one of the smaller branch vessels could increase the risk of iatrogenic injury. I advocate using ultrasound to define the anatomy and routinely placing a CFA arterial line in your “big sick” patients to maintain skills. As you state, this step is well within the wheelhouse of the Emergency Physician, and the foundation to build on to train in placing REBOA
2. Patient selection is critical! The available data generally has the inclusion/exclusion criteria listed, but definitions on who is “unstable” vary. In my opinion, an arbitrary blood pressure cutoff of <90mmHg in someone with torso hemorrhage should not automatically trigger REBOA. I think these patients should get a CFA line, and then proceed to REBOA only if not responding to initial resuscitative measures or rapidly deteriorating to imminent arrest.
3. Placement before arrest will likely lead to better outcomes. The evolving data shows that the group that benefits most in terms of mortality are the nonresponders who will imminently arrest unless they have a lifesaving procedure. In the arrested patient, as mentioned, determining the time of arrest is crucial. This can certainly be challenging with prehospital arrest.
4. While the data does not show improved mortality compared to thoracotomy, there does seem to be a trend to improved neurologically intact survival – this is our ultimate goal and speaks to the ability to use REBOA proactively, before traumatic arrest happens
5. It is absolutely critical that REBOA is used in a system that can rapidly deliver these patients to definitive care (OR/IR). The consequences of prolonged balloon occlusion as listed are dire. Based on collective clinical experience and translational animal data, I would not recommend occluding beyond 45 minutes to 1 hour in Zone 1.
6. REBOA in the US is currently used only at level 1 and 2 trauma centers. I think (as the British have shown), the biggest benefit is likely at smaller centers and ultimately prehospital. Success here will be based on procedural considerations (like p-REBOA to prolong safe inflation times), appropriate training, and systems issues (expedited transfer to definitive care).
Zaffer A. Qasim, MBBS, FRCEM, FRCPC(EM), EDIC
Assistant Professor of Clinical Emergency Medicine
UPenn Medicine
How to Cite This Post
[Peer-Reviewed, Web Publication] Cunningham A, Burns W (2019, January 7). REBOA [NUEM Blog. Expert Commentary by Qasim Z]. Retrieved from http://www.nuemblog.com/blog/REBOA
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References
Joseph B, Ibraheem K, Haider AA, et al. Identifying potential utility of resuscitative endovascular balloon occlusion of the aorta: An autopsy study. J Trauma Acute Care Surg. 2016;81:S128-S132.
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). Vol 2016. LIFTL.
Napolitano LM. Resuscitative Endovascular Balloon Occlusion of the Aorta: Indications, Outcomes, and Training. Crit Care Clin. 2017;33:55-70.
Morrison JJ, Galgon RE, Jansen JO, Cannon JW, Rasmussen TE, Eliason JL. A systematic review of the use of resuscitative endovascular balloon occlusion of the aorta in the management of hemorrhagic shock. J Trauma Acute Care Surg. 2016;80:324-334.
Perkins ZB, Lendrum RA, Brohi K. Resuscitative endovascular balloon occlusion of the aorta: promise, practice, and progress? Curr Opin Crit Care. 2016;22:563-571.
Russo RM, Neff LP, Johnson MA, Williams TK. Emerging Endovascular Therapies for Non-Compressible Torso Hemorrhage. Shock. 2016;46:12-19.
Bebarta V. REBOA - Ready for Prime Time? ACEP EM Education.
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Saito N, Matsumoto H, Yagi T, et al. Evaluation of the safety and feasibility of resuscitative endovascular balloon occlusion of the aorta. J Trauma Acute Care Surg. 2015;78:897-903; discussion 904.