Resuscitative endovascular balloon occlusion of the aorta

Traumatic injury Severe hemorrhagic shock caused by non-compressible traumatic injury to the torso and junctional regions remains a major cause of death among civilian and military trauma victims. REBOA is performed by gaining access to the common femoral artery and inserting a small endovascular catheter with an inflatable balloon within the aorta. Ongoing investigation The safety and efficacy of REBOA in the treatment of severe hemorrhagic shock is an area of ongoing research. Early studies reported conflicting data regarding mortality and failed to establish any clear benefit of REBOA when compared to emergency thoracotomy with aortic cross clamping. However, design improvements of the REBOA device and continuously evolving patient selection criteria have subsequently improved REBOA outcomes. Current literature demonstrates a survival benefit of REBOA deployment in patients with severe hemorrhagic shock who do not require cardiopulmonary resuscitation (CPR). However, despite REBOA demonstrating its greatest efficacy when deployed prior to cardiovascular collapse, recent data has also shown promise when deployed during CPR. Closed cardiopulmonary compressions with the REBOA device deployed has demonstrated improved cardiac compression fraction and end-tidal when compared to emergency thoracotomy with aortic cross clamping and cardiac massage. Additionally, some centers have promoted REBOA deployment in patients with hypotension at risk for progression to severe hemorrhagic shock but who do not yet meet criteria for emergency thoracotomy with aortic cross clamping. The variability in REBOA outcomes likely reflects the variability in institutional patient selection and indications criteria which highlights the need for ongoing evaluation. == Key procedural steps ==

Access to the common femoral artery is first achieved using ultrasound guided, open, or percutaneous technique. The REBOA device is then positioned either within Zone 1 (descending thoracic aorta) or Zone 3 (infrarenal abdominal aorta) before the occluding balloon is inflated with saline. Upon successful definitive hemorrhage control, the occluding balloon is slowly deflated and the patient is monitored for recurrent bleeding or metabolic derangement. Finally, the REBOA sheath is removed and the patient is monitored for access site complications or potential ischemic complications. == Potential complications ==

Despite the minimally invasive nature of the REBOA device, there are significant risks associated with its use. Although occlusion of the aorta may temporarily augment cardiac index to preserve cardiac and coronary perfusion, there is a significant risk of downstream ischemia which may lead to local ischemic changes or systemic metabolic derangement. Significant complications such as limb amputation, metabolic acidosis, and severe reperfusion injury have all been reported with REBOA use and are the subjects of ongoing research. Although there is no definitive consensus within the academic or surgical communities, many centers recommend balloon occlusion times of less than 30 minutes whenever possible to minimize the risk of clinically significant ischemia. Alternatively, some institutions have recommended partial aortic occlusion or intermittent balloon deflation to minimize the effect of downstream ischemia. Although intermittent balloon deflation is less technically difficult to perform, partial occlusion of the aorta has been demonstrated to reduce uncontrolled hemorrhage while simultaneously limiting distal ischemia and extending safe occlusion times. Additional potential complications are listed below: • Access site hematoma • Arterial injury • Pseudo-aneurysm • Aortic injury • Local Ischemia • Metabolic derangement • Acidosis • Limb amputation • Renal infarct • Thrombosis == See also ==