Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): update and insights into current practices and future directions for research and implementation

Abstract

Background In this review, we assess the state of Resuscitative Endovascular Occlusion of the Aorta (REBOA) today with respect to out-of-hospital (OOH) vs. inhospital (H) use in blunt and penetrating trauma, as well as discuss areas of promising research that may be key in further advancement of REBOA applications. Methods To analyze the trends in REBOA use, we conducted a review of the literature and identified articles with human or animal data that fit the respective inclusion and exclusion criteria. In separate tables, we compiled data extracted from selected articles in categories including injury type, zone and duration of REBOA, setting in which REBOA was performed, sample size, age, sex and outcome. Based on these tables as well as more detailed review of some key cases of REBOA usage, we assessed the current state of REBOA as well as coagulation and histological disturbances associated with its usage. All statistical tests were 2-sided using an alpha=0.05 for significance. Analysis was done using SAS 9.5 (Cary, NC). Tests for significance was done with a t-test for continuous data and a Chi Square Test for categorical data. Results In a total of 44 cases performed outside of a hospital in both military and civilian settings, the overall survival was found to be 88.6%, significantly higher than the 50.4% survival calculated from 1,807 cases of REBOA performed within a hospital (p<.0001). We observe from human data a propensity to use Zone I in penetrating trauma and Zone III in blunt injuries. We observe lower final metabolic markers in animal studies with shorter REBOA time and longer follow-up times. Conclusions Further research related to human use of REBOA must be focused on earlier initiation of REBOA after injury which may depend on development of rapid vascular access devices and techniques more so than on any new improvements in REBOA. Future animal studies should provide detailed multisystem organ assessment to accurately define organ injury and metabolic burden associated with REBOA application. Overall, animal studies must involve realistic models of injury with severe clinical scenarios approximating human trauma and exsanguination, especially with long-term follow-up after injury.

Development of a computational fluid dynamic model to investigate the hemodynamic impact of REBOA

“…As hemorrhagic shock remains a leading cause of potentially preventable deaths in both civilian and military populations aged 18–45 years, REBOA has emerged as a promising technique to minimize internal bleeding ( Eastridge et al, 2019 ). However, there is growing evidence that full aortic occlusion (i.e., f-REBOA) is not only challenging to implement but can also impose I/R injury, endothelial damage, acute coagulation changes, and has been associated with poor patient outcomes ( Markov et al, 2013 ; Doucet and Coimbra, 2017 ; Thrailkill et al, 2021 ). As a result, partial aortic occlusion strategies have been proposed.…”

“…There have even been some reports of endothelial damage either directly from the balloon catheter or subsequent hemodynamic or ischemia alterations after REBOA. However, the direct cause of these endothelial dysfunctions and acute coagulopathy is not well understood ( Thrailkill et al, 2021 ). Pre-clinical large animal studies suggest that Zone 1 REBOA (proximal to diaphragm, Figure 1 ) is survivable for up to 60 min and Zone 3 (distal to renal artery, Figure 1 ) for 90 min.…”

The use of Resuscitative Endovascular Balloon Occlusion of the Aorta in a pregnant woman with a ruptured splenic aneurysm and haemorrhagic shock: A case report

“…Contemporary studies also suggest that REBOA reduces mortality in trauma patients with sub‐diaphragmatic haemorrhagic shock, 3 and is associated with improved survival in trauma patients with non‐compressible torso haemorrhage treated in a high‐volume centre 4 . Still, the indications for REBOA remain poorly defined, and there is conflicting evidence regarding the safety and efficiency of the procedure 5 . We present a case of splenic artery aneurism in a pregnant woman, where REBOA was introduced late and standard surgical procedures failed to prevail, but provided a vital bridge to definitive treatment.…”

“… 4 Still, the indications for REBOA remain poorly defined, and there is conflicting evidence regarding the safety and efficiency of the procedure. 5 We present a case of splenic artery aneurism in a pregnant woman, where REBOA was introduced late and standard surgical procedures failed to prevail, but provided a vital bridge to definitive treatment. We suggest that this technique should be used more frequently and be on the repertoire for anesthesiologists.…”

A survey of resuscitative endovascular balloon occlusion of the aorta (REBOA) program implementation in Canadian trauma centres

“…Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a temporizing procedure for hemodynamically unstable patients with suspected sub-diaphragmatic hemorrhage prior to definitive surgical management or angiography [1]. Despite mixed evidence for REBOA clinical utilization [2,3], trauma centres continue to implement REBOA programs.…”