What is REBOA?
With the beginning of the new millennium, endovascular trauma management (EVTM) has been added to concepts such as Damage Control Resuscitation and Permissive Hypotension, which positively affect mortality in trauma1,2. EVTM includes a series of hemostatic methods, which is the most important target of traumatic resuscitation. These methods include angioembolization, stenting, and REBOA.
REBOA is the procedure of endovascular occlusion of the aorta by inflating the balloon by sending a special catheter with an externally inflatable balloon through the femoral artery to a suitable region within the aorta. REBOA was first performed on two soldiers with severe limb trauma by Lt. Col. Hughes, a military surgeon in the Korean War3. Soldiers in hemorrhagic shock survived but were lost due to sepsis that developed after surgical operations performed under the conditions of that period. Aortic occlusion with REBOA can total (tREBOA) or partial (pREBOA) or intermittent (iREBOA). Considering its historical development, REBOA was first defined as an indication for the temporary cessation of severe bleeding from a trauma-related non-compressible region (eg, thorax, abdomen, or pelvis). There are a considerable number of articles in the literature comparing resuscitative thoracotomy (RT) and cross-clamping of the aorta, which is another method for stopping severe bleeding from the above-mentioned regions, and REBOA. A recently published meta-analysis demonstrated lower mortality rates in trauma patients with REBOA compared to RT4. In addition, the fact that aortic occlusion can be achieved with a minimally invasive approach can be considered as an important advantage in terms of preventing the opening of a large additional surgical wound in a seriously injured patient (basically ISS>15).
In recent years, it has been observed that REBOA has been increasingly used in the treatment of bleeding in non-traumatic patients. In addition to massive upper gastrointestinal bleeding and post-partum hemorrhages, animal experiments published in recent years support the view that REBOA can be used in addition to conventional cardiopulmonary resuscitation (CPR) in non-traumatic cardiac arrest (R-CPR)5.
The results of the REBOARREST study, which is a multicenter study comparing standard conventional CPR and R-CPR in terms of mortality in out-of-hospital non-traumatic cardiac arrest patients who are currently recruiting, are planned to be published in a few years6. If the results of the study will be in support of R-CPR, I think that our routine clinical practice will change significantly and REBOA will be performed more widely in the EDs.
References
1. Waibel BH, Rotondo MMF. Damage control surgery: it’s evolution over the last 20 years. Rev Col Bras Cir. 2012;39(4):314-321. doi:10.1590/s0100-69912012000400012
2. Rossaint R, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care. 2016;20:100. doi:10.1186/s13054-016-1265-x
3. Hughes CW. Use of an intra-aortic balloon catheter tamponade for controlling intra-abdominal hemorrhage in man. Surgery. 1954;36(1):65-68.
4. Castellini G, Gianola S, Biffi A, et al. Resuscitative endovascular balloon occlusion of the aorta (REBOA) in patients with major trauma and uncontrolled haemorrhagic shock: a systematic review with meta-analysis. World J Emerg Surg. 2021;16(1):41. doi:10.1186/s13017-021-00386-9
5. Hutin A, Levy Y, Lidouren F, et al. Resuscitative endovascular balloon occlusion of the aorta vs epinephrine in the treatment of non-traumatic cardiac arrest in swine. Ann Intensive Care. 2021;11:81. doi:10.1186/s13613-021-00871-z
6. Brede JR, Skulberg AK, Rehn M, et al. REBOARREST, resuscitative endovascular balloon occlusion of the aorta in non-traumatic out-of-hospital cardiac arrest: a study protocol for a randomised, parallel group, clinical multicentre trial. Trials. 2021;22:511. doi:10.1186/s13063-021-05477-1
