The future of resuscitative endovascular balloon occlusion in combat operations

Abstract

Damage control resuscitation and early thoracotomy have been used to increase survival after severe injury in combat. There has been a renewed interest in resuscitative endovascular balloon occlusion of the aorta (REBOA) in both civilian and military medical practices. REBOA may result in visceral and limb ischaemia that could be harmful if use of REBOA is premature or prolonged. The purpose of this paper is to align our experience of combat injuries with the known capability of REBOA to suggest an implementation strategy for the use of REBOA in combat care. It may replace the resuscitative effect of thoracotomy; can provide haemostasis of non-compressible torso injuries such as the junctional and pelvic haemorrhage caused by improvised explosive devices. However, prehospital use of REBOA must be in the context of an overall surgical plan and should be restricted to deployment in the distal aorta. Although REBOA is technically easier than a thoracotomy, it requires operator training and skill to add to the beneficial effect of damage control resuscitation and surgery.

Deployment of second-generation resuscitative endovascular balloon occlusion of the aorta for unresponsive hypotension in a polytrauma patient

“…4 Although the first patients succumbed to their wounds, the potential for use as a resuscitative method was confirmed and is now showing promise to improve survival through temporary occlusion of the aorta, thereby restoring perfusion to the brain and heart. 5 The technique of REBOA in trauma with off-label endovascular catheters has been used, but large arterial sheaths of up to 14-French has limited their use. 5 To our knowledge, this is the first report of use of the ER-REBOA catheter in Canada since it obtained Health Canada approval in October 2017, and we have since placed a second device for a junctional hemorrhage due to a gunshot wound to the proximal superficial femoral artery.…”

“…5 The technique of REBOA in trauma with off-label endovascular catheters has been used, but large arterial sheaths of up to 14-French has limited their use. 5 To our knowledge, this is the first report of use of the ER-REBOA catheter in Canada since it obtained Health Canada approval in October 2017, and we have since placed a second device for a junctional hemorrhage due to a gunshot wound to the proximal superficial femoral artery. The ER-REBOA system offers a compliant aortic balloon on 5-French catheters with an integral arterial line.…”

REBOA at Role 2 Afloat: resuscitative endovascular balloon occlusion of the aorta as a bridge to damage control surgery in the military maritime setting

“…REBOA offers a bridge to damage control surgery 22. If initial stabilisation fails or cardiac arrest ensues, presence of an aortic catheter extends the options to include therapies such as selective aortic arch perfusion (SAAP) with blood or novel resuscitation fluids 23.…”

Management of intra-abdominal vascular injury in trauma laparotomy: a South African experience

“…22 This innovation was prompted by the recent military experience, and reports on its use are limited. 23 This technique could be instrumental in facilitating proximal control while allowing endovascular intervention in vessels that are difficult to access without recourse to massive retroperitoneal dissections. The exact place of these techniques is yet to be defined.…”