INDICATIONS & CONTRAINDICATIONS for REBOA
To facilitate proper balloon placement, three functional regions of the aorta have been identified. Zone 1; It is the region extending from the left subclavian artery to the celiac trunk. It is recommended for all intra-abdominal, retroperitoneal bleeding and traumatic arrest cases (Figure 1). Zone 3; region of the infrarenal aorta. Visceral and renal perfusion can be maintained. Its use is recommended in patients with severe pelvic and proximal lower extremity bleeding (Figure 2). Zone 2 is; Between the celiac and renal arteries is the paravisceral aorta. It is where the visceral arteries that supply the gastrointestinal tract, liver and kidneys are located. It is traditionally considered to be a non-congested region and its use is not recommended (1,2).
Figure 1
Figure 2
In Advanced Trauma Life Support guidelines (ATLS); The use of reboa is recommended in trauma patients in hypovolemic shock (systolic blood pressure < 90 mmHg) who do not respond or partially respond to fluid and blood product resuscitation (3). In the joint algorithm of the American College of Surgeons Committee on Trauma (ACS COT) and the American College of Emergency Physicians (ACEP); It is recommended to be used in patients with subdiaphragmatic traumatic hemorrhagic shock who do not respond or temporarily respond to resuscitation, in cases of arrest due to subdiaphragmatic traumatic hemorrhagic shock, and especially in patients with severe pelvic and proximal lower extremity bleeding (4). After evaluating with FAST (Focused assessment with sonography in trauma), especially in subdiaphragmatic traumatic hemorrhagic shock diseases, Zone I occlusion is recommended for patients with hypotension and positive abdominal FAST, while Zone 3 occlusion is recommended for patients with negative FAST and pelvis fractures (3) . It is also used in severe abdominal bleeding, including ruptured abdominal aortic aneurysm, severe post-partum and gastrointestinal bleeding (5). In the case series about the prehospital use of REBOA; It was performed prehospital in 19 trauma patients and two non-trauma patients for pelvic bleeding. Prehospital Zone III REBOA has been shown in a case series to significantly improve blood pressure and reduce the risk of prehospital hypovolemic arrest and premature death due to blood loss (6).
We must remember that REBOA can make some injuries worse. REBOA is contraindicated, especially in penetrating neck and chest trauma, and first choice should be resusative thoracotomy. At the same time, resusative thoracotomy is recommended for major bleeding chest injuries detected by X-ray and USG or requiring bilateral chest tube. The most important research and discussion point starts here. As an alternative to conventional resuscitative thoracotomy, REBOA has been shown to preserve myocardial and cerebral tissue perfusion in a less invasive way (1,2). REBOA has the advantage of being less invasive than open thoracotomy and can be performed more quickly in skilled hands compared to resuscitative thoracotomy (7). In other studies, the total interruption time of cardiac compressions is shorter in patients who underwent REBOA compared to resuscitative thoracotomy (8). In the large multicenter AORTA 2 study, when investigated in a more selective patient group, it was shown that REBOA can provide a significant survival advantage over resusative thoracotomy, especially in patients who do not require CPR (9).
REBOA is contraindicated when there is a high suspicion for thoracic aortic injury. Tourniquet and resuscitation are also recommended in cases with major extremity trauma (1). A relative contraindication to REBOA is the lack of femoral vascular access. It may be a problem for patients who have had previous femoral vascular procedures or who have significant peripheral vascular disease (10).
Although the potential of REBOA to dangerously increase intracranial pressure in patients with traumatic brain injury was theoretically a concern at first, traumatic brain injury is no longer considered a contraindication for REBOA, especially in the United States (7).
Resources
1. Duman A. Acil vasküler girişim: Aortun resüsitatif endovasküler balon oklüzyonu. Söğüt Ö, Çolak Ş, Kapçı M, Güven R, editörler. Hibrit Acil Servis Modeli. 1. Baskı. Ankara: Türkiye Klinikleri; 2021. p.72-6.
2. Hörer T.(2017). Endovasküler Hibrid Travma ve Kanama Yönetimi Sanatı 1. (Çev. Avcil M, Özlüer YE). İstanbul: Hiperlink yayınları. 2020.p85-109.
3. Marciniuk p, pawlaczyk R, Rogowski J, Wojciechowski J, Znaniecki Ł. REBoA - new era of bleeding control, literature review. Pol przegl Chir. 2019;92(2):42-47.
4. Brenner M, Bulger EM, perina DG, Henry S, Kang CS, Rotondo MF et al. Joint statement from the American College of Surgeons Committee on Trauma (ACS CoT) and the American College of Emergency physicians (ACEp) regarding the clinical use of Resuscitative Endovascular Balloon occlusion of the Aorta (REBoA). Trauma Surg Acute Care open. 2018;13:3(1):e000154.
5. Samuels JM, Sun K, Moore EE, Coleman JR, Fox CJ, Cohen MJ, et al. Resuscitative endovascular balloon occlusion of the aorta-Interest is widespread but need for training persists. J Trauma Acute Care Surg. 2020;89(4):e112-e116.
6. Sadek S, lockey DJ, lendrum RA, perkins Z, price J, Davies GE. Resuscitative endovascular balloon occlusion of the aorta (REBoA) in the pre-hospital setting: An additional resuscitation option for uncontrolled catastrophic haemorrhage. Resuscitation. 2016;107:135-8.
7. Ribeiro Júnior MAF, Brenner M, Nguyen ATM, Feng CYD, DE-Moura RR, Rodrigues VC, et al. Resuscitative endovascular balloon occlusion of the aorta (REBoA): an updated review. Rev Col Bras Cir. 2018;26:45(1):e1709.
8.Teeter W, Romagnoli A, Wasicek p, Hu p, Yang S, Stein D, et al. Resuscitative Endovascular Balloon occlusion of the Aorta Improves Cardiac Compression Fraction Versus Resuscitative Thoracotomy in patients in Traumatic Arrest. Ann Emerg Med. 2018;72(4):354-60.
9. Brenner M, Inaba K, Aiolfi A, DuBose J, Fabian T, Bee T, et al. AAST AoRTA Study Group. Resuscitative Endovascular Balloon occlusion of the Aorta and Resuscitative Thoracotomy in Select patients with Hemorrhagic Shock: Early Results from the American Association for the Surgery of Trauma's Aortic occlusion in Resuscitation for Trauma and Acute Care Surgery Registry. J Am Coll Surg. 2018;226(5):730-40.
10. Manzano Nunez R, Naranjo Mp, Foianini E, Ferrada p, Rincon E, García-perdomo HA, et al. A meta-analysis of resuscitative endovascular balloon occlusion of the aorta (REBoA) or open aortic cross-clamping by resuscitative thoracotomy in non-compressible torso hemorrhage patients. World J Emerg Surg. 2017;14:12:30.
