REBOA in resuscitation

This page is largely based on the ACE  protocol developed at The Alfred Hospital by Robbie Lendrum and colleagues

OVERVIEW

REBOA is Resuscitative Endovascular Balloon Occlusion of the Aorta

• It involves placement of an endovascular balloon in the aorta to control haemorrhage and to augment afterload in traumatic arrest and haemorrhagic shock states
• Endovascular balloons have been used to control haemorrhage in other settings such as aortic aneurysm surgery, gastro-intestinal bleeding, postpartum haemorrhage and trauma
• Tends to cause less physiological disturbance and have higher rates of technical success than aortic cross clamping

ANATOMY

The aorta is divided into three separate zones for the purposes of REBOA (aortic length varies between individuals)

• Zone I of the aorta extends from the origin of the left subclavian artery to the coeliac artery (approx 20cm long in a young adult male)
• Zone II extends from the coeliac artery to the most caudal renal artery (approx 3cm long)
• Zone III extends distally from the most caudal renal artery to the aortic bifurcation (approx 10cm long)

The thoracic aorta is 20mm in diameter and the distal aorta 15mm in young adult males on average.

• averages 2mm narrower in females
• increases by 0.5 mm/y

Measured externally this is approximated by:

• Zone 1 is measured to the xiphoid
• Zone 3 is measured to just above the umbilicus

INDICATIONS

Selected adult patients (aged 18-69 years) with:

• PEA arrest (<10 minutes) secondary to exsanguination from sub-diaphragmatic haemorrhage and femoral vessels immediately identifiable on ultrasound (if not identifiable consider emergency thoracotomy), or
• severe hypovolaemic shock and a systolic blood pressure <70mmHg, or
• those in an agonal state due to non-compressible exsanguinating haemorrhage, who are non/partial responders to rapid volume resuscitation and have had causes of obstructive shock excluded, and:
  • suspected or diagnosed intra-abdominal haemorrhage due to blunt trauma or penetrating torso injuries (Zone I REBOA), or
  • blunt trauma patients with suspected pelvic fracture and isolated pelvic haemorrhage (Zone III REBOA), or
  • patients with penetrating injury to the pelvic or groin area with uncontrolled haemorrhage from a junctional vascular injury (iliac or  common femoral vessels) (Zone III REBOA)

CONTRA-INDICATIONS

• Age >70y
• PEA arrest (<10 minutes) secondary to exsanguination from sub-diaphragmatic haemorrhage and femoral vessels not immediately identifiable on ultrasound
• Cardiac arrest due to causes other than exsanguination due to severe subdiaphragmatic trauma
• PEA arrest >10 minutes
• High clinical/radiological suspicion of proximal traumatic aortic dissection
• Pre-existing terminal illness or significant comorbidities

DESCRIPTION

Equipment

• Cook arterial line kit
• Percutaneous entry thin-wall needle (Cook: 18G, 7cm)
• Cook 12 Fr sheath kit
• Amplatz Extra-Stiff guidewire (Cook: 0.035 inch, 180cm)
• Cook Coda Balloon Catheter 32mm, 9Fr shaft, 100cm in length
• 30ml syringe
• 3-way tap
• 0.9% saline 20mL, omnipaque contrast solution 10mL
• Sterile drape
• Grip-lock dressing
• Two large tegaderm dressings
• PPE (cap, gown, gloves, goggles, mask)

METHOD OF USE

Overview

• Standard trauma resuscitation is performed concurrently (avoid external cardiac compressions, provide volume resuscitation, decompress the chest, rule out tamponade)
• The procedure may be performed in:
  • trauma resuscitation areas
  • operating theatre for intra-operative haemorrhage control or facilitate transfer to the IR suite (e.g. for pelvic angioembolisation)
  • prehospital settings (e.g. London HEMS)
• identify potential REBOA patients prehospital to allow trauma team activation withe ‘REBOA alert’
• REBOA can be performed by a single operator with an untrained assistant, but we prefer a 3 person REBOA team:
  • REBOA operator (cannulator 1)
  • REBOA assistant (cannulator 2), and
    REBOA procedure team leader (provides oversight of REBOA procedure)
• apply pelvic binder and assess for effectiveness prior to REBOA if suspected pelvic fracture

Pre-REBOA phase

• PPE
• use contralateral CFA if suspected junctional vascular injury
• identify CFA 2 cm below the inguinal ligament at the mid-inguinal point (halfway between the pubic symphysis and the anterior superior iliac crest) using ultrasound
• Insert femoral arterial line via the common femoral artery (CFA) with pelvic binder in situ (if present)

REBOA phase

• Scrub, drape, prepare sheath
• Insert short guidewire into femoral arterial-line or use percutaneous entry thin-wall needle (Cook: 18G, 7cm)
• Sequential dilatation
  • Assistant ensures guidewire moves freely during sequential dilatation
• 12Fr sheath insertion (load onto appropriate dilator and ensure that the sheath’s side-port is in the “off” position)
  • an assistant is tasked with maintaining sheath position (subsequently secured with a grip-lock following balloon inflation)
• Mix saline/contrast (20mL saline/10mL contrast)
• Measure guidewire insertion depth + mark (sternal angle via umbilicus, approx 60cm)
• Measure catheter insertion depth + mark
  • Zone I – Xiphoid (approx 50cm)
  • Zone III – Umbilicus (approx 40cm)
• Insert long guidewire to mark
• X-ray — J-tip approximately level with T4
• Insert catheter to mark
  • assistant holds guidewire ensuring not to advance/withdraw while REBOA operator inserts catheter
• X-ray — 2 radiopaque bands positioned at:
  • Zone I – T4 to L1
  • Zone III – L2 to L4
• Prompt assistant to hold catheter shaft at exit from sheath during inflation
• Inflate balloon until moderate resistance (document time)
  • Zone I – 20 to 25 mL
  • Zone III – 15 to 20 mL
• X-ray – confirmation balloon positioning
• Secure catheter with grip lock
• Expedite departure to OR/IR (no CT post-REBOA)

CONTROVERSIES AND EVIDENCE

• High quality evidence for the efficacy of REBOA in clinical settings is currently lacking – in particular, an improvement in haemorrhage-related mortality has not been demonstrated
• Inclusion and exclusion criteria are likely to evolve
• REBOA may be better suited to prehospital/ remote settings lacking immediate access to definitive surgical therapy
• Using propensity analysis, Inoue et al (2015) found an association between use of REBOA and excess mortality in patients with haemodynamically unstable torso trauma that had a median door-to-primary-surgery time of 97 minutes

References and Links

FOAM and web resources

• EMCrit — Podcast 121 – REBOA (2014)
• HQMEDED — REBOA (2014)
• SMACC — REBOA: Who, What, Why? by Deborah Stein (2015)

Journal articles

• Biffl WL, Fox CJ, Moore EE. The role of REBOA in the control of exsanguinating torso hemorrhage. The journal of trauma and acute care surgery. 78(5):1054-8. 2015. [pubmed]
• Brenner M, Hoehn M, Teeter W, Stein D, Scalea T. Trading scalpels for sheaths: Catheter-based treatment of vascular injury can be effectively performed by acute care surgeons trained in endovascular techniques. The journal of trauma and acute care surgery. 2016. [pubmed]
• Chaudery M, Clark J, Morrison JJ, Wilson MH, Bew D, Darzi A. Can contrast-enhanced ultrasonography improve Zone III REBOA placement for prehospital care? The journal of trauma and acute care surgery. 80(1):89-94. 2016. [pubmed]
• Inoue J, Shiraishi A, Yoshiyuki A, Haruta K, Matsui H, Otomo Y. Resuscitative endovascular balloon occlusion of the aorta might be dangerous in patients with severe torso trauma: a propensity score analysis. The journal of trauma and acute care surgery. 2016. [pubmed]
• Morrison JJ, Galgon RE, Jansen JO, Cannon JW, Rasmussen TE, Eliason JL. A systematic review of the use of resuscitative endovascular balloon occlusion of the aorta in the management of hemorrhagic shock. The journal of trauma and acute care surgery. 80(2):324-34. 2016. [pubmed]
• Park TS, Batchinsky AI, Belenkiy SM. Resuscitative endovascular balloon occlusion of the aorta (REBOA): Comparison with immediate transfusion following massive hemorrhage in swine. The journal of trauma and acute care surgery. 79(6):930-6. 2015. [pubmed]
• Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma. 2011 Dec;71(6):1869-72. doi: 10.1097/TA.0b013e31823fe90c.[pubmed]
• Tsurukiri J, Akamine I, Sato T. Resuscitative endovascular balloon occlusion of the aorta for uncontrolled haemorrahgic shock as an adjunct to haemostatic procedures in the acute care setting. Scandinavian journal of trauma, resuscitation and emergency medicine. 24(1):13. 2016. [pubmed]