COMPLICATIONS of REBOA and WHAT TO DO?

• Duygu Ege
• 03 June, 2022
• 2948 Person Viewed

First, let's start by emphasizing that, like every procedure, a good preparation phase is mandatory for a successful REBOA.

Since REBOA is mostly used as a tool for unstable patients to save time, we can say that for these patients, time is life. So, some parts of the preparation phase should have been arranged long before the patient arrives.

We recommend creating a REBOA kit. Just like we have intubation boxes, and emergency carts, creating a REBOA kit like the image in Çağaç Yetiş's article will make your procedure much smoother.

Even after the preparation phase, we may face different complications at each step of the procedure. To avoid that, mental exercises, skill development studies in various models, and round table talks to strengthen teamwork will facilitate the smooth introduction of REBOA into your resuscitation arsenal. As a result, we must foresee that only REBOA will not be applied to the unstable patient at the time of resuscitation and that every resuscitative procedure may have to be performed almost simultaneously.

While securing the arterial access, vessel dissection may occur due to atheroma plaques or punctures where the vessel wall cannot be fully penetrated. The best thing to do for not experiencing this is to follow the “rule of no resistance”. If you encounter any resistance as you advance the wire in, do not ever try to push the wire into the vessel, just carefully pull it back and redo the puncture if necessary.

Ultrasonography will also play an important role in minimizing the complications of the REBOA procedure. Because of vasoconstriction secondary to catecholamine release, successful access may not be achieved with a single wall puncture in a patient who is in shock. In that case, the double-wall puncture technique can be used. If this also does not work, after the injection of lidocaine for local anesthetic purposes into the anatomical position, a small incision is made, and the skin is bluntly dissected with oblique forceps. You can puncture where the pulse is felt at the incision site. (Modified Seldinger method).

List of other complications that may occur secondary to puncture: Retroperitoneal hematoma or bleeding, Femoral hematoma, Pseudoaneurysm, AV Fistula, Neuropathy, Arterial occlusion…

If the puncture point is above the inguinal ligament – high puncture – this means entering into the pelvis, and it may be more difficult for the hematoma to be self-limiting here. There is a possibility of distal occlusion if the entrance is made from a lower level. It will be most convenient for the patient to enter from that area which is 3 cm in height – between the inguinal ligament and the bifurcation – shown in the picture.

Another complication might be the missing guidewire: Care must be taken that the entire length of the wire should not remain inside the catheter. Care should always be taken to ensure that the distal end of the wire is safe either with the non-dominant hand or with the second assisting person throughout the entire procedure. In case of handing over the distal end of the wire to another person, this should be done with a verbal warning and verbal feedback “– I'm leaving the wire”. “– I’ve got the wire”.

Another situation, which may seem simple or insignificant, can stress you in a way that you cannot understand at the time of resuscitation: the “bent wire”. Wires can be bent more easily according to their quality. The provided access pathway makes a significant angulation at the point where it 1- passes through the skin and 2- enters into the arterial lumen. While passing through these areas, the wire may bend and cause you to encounter a sort of non-vascular resistance while sliding all other catheters that you will pass over. Here the stress begins: we violated the rule of no resistance. So, is “this” resistance vascular or nonvascular?

To prevent this from happening, a little SF and a few sponges in a sterile bowl prepared in advance may help you. When working with wire, you should always take care to keep it slightly taut and straight. Before and after each passing over the wire, the wire can be “washed” with a wet sponge. In addition, replacing the bent guide wire with a stiffer guide wire such as “Amplatz” can also help overcome this problem.

Inflation of the REBOA balloon will create resistance to the cardiac beat, and with each cardiac beat, the balloon may slide down from the original area which is called migration. In this situation, which is more common, especially in REBOA applications in Zone 1, the balloon may slide into Zone 2 unintentionally and of course undesirably. Resolving this situation requires experienced manipulations or surgical intervention. It is important to know the characteristics of the catheter you are using so that it does not happen. The person inflating the REBOA balloon should treat the balloon as his/her “best friend”. There are points to be considered, such as knowing the required volume of the balloon to be fully inflated, exchanging the guidewire with a stiff wire before inflating the balloon (like with the Tokai Rescue Balloon), and always keeping an eye on the patient's monitor, and noting the depth of the guide wire inside the patient. After inflating the balloon, the catheter can be sutured to the skin if necessary. In addition, a longer introducer sheath may be preferred to increase the strength of the catheter shaft.

Complications can be minimized with meticulous preparation, careful application, following up-to-date information, and asking for help when needed.

Hope nothing goes wrong...

References:

1. Hörer T.M. (ed). (2017). Top Stent; The art of endovascular hybrid trauma and bleeding management. Örebro University Hospital, c/o KärlThorax kliniken.
2. Ribeiro Junior, M., Feng, C., Nguyen, A., Rodrigues, V. C., Bechara, G., de-Moura, R. R., & Brenner, M. (2018). The complications associated with Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). World journal of emergency surgery : WJES, 13, 20. https://doi.org/10.1186/s13017-018-0181-6
3. Matsumura, Y., Matsumoto, J., Kondo, H., Idoguchi, K., Ishida, T., Kon, Y., Tomita, K., Ishida, K., Hirose, T., Umakoshi, K., Funabiki, T., & DIRECT-IABO Investigators (2017). Fewer REBOA complications with smaller devices and partial occlusion: evidence from a multicentre registry in Japan. Emergency medicine journal : EMJ, 34(12), 793–799. https://doi.org/10.1136/emermed-2016-206383
4. Long, B., Hafen, L., Koyfman, A., & Gottlieb, M. (2019). Resuscitative Endovascular Balloon Occlusion of the Aorta: A Review for Emergency Clinicians. The Journal of emergency medicine, 56(6), 687–697. https://doi.org/10.1016/j.jemermed.2019.03.030
5. Cantle P. M. (2022). REBOA utility. Surgery open science, 8, 50–56. https://doi.org/10.1016/j.sopen.2022.03.002
6. Shoji, T., Tarui, T., Igarashi, T., Mochida, Y., Morinaga, H., Miyakuni, Y., Inoue, Y., Kaita, Y., Miyauchi, H., & Yamaguchi, Y. (2018). Resuscitative Endovascular Balloon Occlusion of the Aorta Using a Low-Profile Device is Easy and Safe for Emergency Physicians in Cases of Life-Threatening Hemorrhage. The Journal of emergency medicine, 54(4), 410–418. https://doi.org/10.1016/j.jemermed.2017.12.044