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Current Surgery Reports

, 5:23 | Cite as

The Current Status of REBOA in Traumatic Shock

  • Jacob GlaserEmail author
  • Megan Brenner
Trauma Surgery (J. Diaz, Section Editor)
Part of the following topical collections:
  1. Trauma Surgery

Abstract

Purpose of Review

Hemorrhagic shock remains a major cause of potentially preventable death in civilian and military trauma. Balloon occlusion of the aorta has emerged as a viable technique to address non-compressible torso hemorrhage. The purpose of this review is to describe the current state of translational and clinical data on REBOA and help define its role in modern trauma algorithms.

Recent Findings

Recent findings suggest that REBOA is feasible in many clinical areas including prehospital. Robust animal data define a reasonable safety profile and current clinical data suggest that there are subset(s) of patients who may benefit from REBOA over traditional EDT and/or in conjunction with other resuscitation measures.

Summary

Although enthusiasm for the technique may have outpaced high-quality clinical data, ongoing efforts through multicenter trials seek to identify the ideal clinical scenario for REBOA. We also discuss future translational and clinical series for the next generation of REBOA.

Keywords

Trauma Hemorrhage Shock Proximal control Aortic occlusion REBOA pREBOA 

Notes

Funding

None.

Compliance with Ethics Guidelines

Conflict of interest

M.B. is a Clinical Advisory Board member for Prytime Medical Inc. J.G. declares no conflicts of interest relevant to this manuscript.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Kelly JF, Ritenour AE, et al. Injury severity and causes of death from operation Iraqi Freedom and operation enduring freedom: 2003–2004 versus 2006. J Trauma. 2008;64(2 Suppl):S21–6.CrossRefPubMedGoogle Scholar
  2. 2.
    Kauvar DS, Lefering R, et al. Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations. J Trauma. 2006;60(6 Suppl):S3–11.CrossRefPubMedGoogle Scholar
  3. 3.
    Morrison JJ, Rasmussen TE. Noncompressible torso hemorrhage: a review with contemporary definitions and management strategies. Surg Clin North Am. 2012;92(4):843–58, vii.Google Scholar
  4. 4.
    Rossaint R, Bouillon B, et al. Management of bleeding following major trauma: an updated European guideline. Crit Care. 2010;14(2):R52. doi: 10.1186/cc8943 (Epub 2010 Apr 6).
  5. 5.
    Eastridge BJ, Mabry RL, et al. Death on the battlefield (2001–2011): implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012;73(6 Suppl 5):S431–7.CrossRefPubMedGoogle Scholar
  6. 6.
    Stannard A, Morrison JJ, et al. The epidemiology of noncompressible torso hemorrhage in the wars in Iraq and Afghanistan. J Trauma Acute Care Surg. 2013;74(3):830–4.CrossRefPubMedGoogle Scholar
  7. 7.
    Kisat M, Morrison JJ, et al. Epidemiology and outcomes of non-compressible torso hemorrhage. J Surg Res. 2013;184(1):414–21.CrossRefPubMedGoogle Scholar
  8. 8.
    http://stopthebleedingcoalition.org/. Last Accessed 10 May 2017.
  9. 9.
    US Army Joint Trauma System Clinical Practice Guidelines. http://www.usaisr.amedd.army.mil/pdfs/TCCCGuidelinesforMedicalPersonnel170131Final.pdf. Last accessed 10 May 2017.
  10. 10.
    White JM, Stannard A, et al. The epidemiology of vascular injury in the wars in Iraq and Afghanistan. Ann Surg. 2011;253(6):1184–9.CrossRefPubMedGoogle Scholar
  11. 11.
    Kragh JF Jr, Walters TJ, et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg. 2009;249(1):1–7.CrossRefPubMedGoogle Scholar
  12. 12.
    Cothren CC, Osborn PM, et al. Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma. 2007;62(4):834–9; discussion 839–42.Google Scholar
  13. 13.
    Tötterman A, Madsen JE, et al. Extraperitoneal pelvic packing: a salvage procedure to control massive traumatic pelvichemorrhage. J Trauma. 2007;62(4):843–52.CrossRefPubMedGoogle Scholar
  14. 14.
    Seamon MJ, Pathak AS, et al. Emergency department thoracotomy: still useful after abdominal exsanguination? J Trauma. 2008;64:1–7.CrossRefPubMedGoogle Scholar
  15. 15.
    Khorsandi M, Skouras C, Shah R. Is there any role for resuscitative emergency department thoracotomy in blunt trauma? Interact Cardiovasc Thoracic Surg. 2013;16(4):509–16.CrossRefGoogle Scholar
  16. 16.
    Seamon MJ, Fisher CA, et al. Emergency department thoracotomy: survival of the least expected. World J Surg. 2008;32(4):604–12.CrossRefPubMedGoogle Scholar
  17. 17.
    Branney SW, Moore EE, et al. Critical analysis of two decades of experience with postinjury emergency department thoracotomy in a regional trauma center. J Trauma. 1998;45(1):87–94; discussion 94–5.Google Scholar
  18. 18.
    Ledgerwood AM, Kazmers M, Lucas CE. The role of thoracic aortic occlusion for massive hemoperitoneum. J Trauma. 1976;16(08):610–5.CrossRefPubMedGoogle Scholar
  19. 19.
    Burlew CC, Moore EE, et al. Western Trauma Association critical decisions in trauma: resuscitative thoracotomy. J Trauma Acute Care Surg. 2012;73(6):1359–63.CrossRefPubMedGoogle Scholar
  20. 20.
    Hathaway E, Glaser JJ, et al. Exploratory laparotomy for proximal vascular control in combat-related injuries. Mil Med. 2016;181(5 Suppl):247–52.CrossRefPubMedGoogle Scholar
  21. 21.
    Rhee PM, Acosta J, et al. Survival after emergency department thoracotomy: review of published data from the past 25 years. J Am Coll Surg. 2000;190(3):288–98.CrossRefPubMedGoogle Scholar
  22. 22.
    Moore LJ, Brenner M, et al. Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage. J Trauma Acute Care Surg. 2015;79(4):523–30.CrossRefPubMedGoogle Scholar
  23. 23.
    Brenner M, Teeter W, et al. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a feasible option for proximal aortic control in severe hemorrhage and arrest. JAMA Surg. 2017 (In revisions).Google Scholar
  24. 24.
    Bradley M, Bonds B, et al. Open chest cardiac massage offers no benefit over closed chest compressions in patients with traumatic cardiac arrest. JTACS. 2016;81(5):849–54.Google Scholar
  25. 25.
    Brenner M, Teeter WA, et al. “End tidal carbon dioxide (EtCO2) before and after Resuscitative Endovascular Balloon Occlusion of the Aorta with Closed Chest Compression (REBOACCC) is higher compared to Open Chest Cardiac Massage with Aortic Cross-Clamp (OCCMACC)”. Quick shot presentation, Southwestern Surgical Congress, April 2017, manuscript in preparation.Google Scholar
  26. 26.
    Brenner, M, Aiolfi A, et al. REBOA is superior to resuscitative thoracotomy in select patients with hemorrhagic shock: early results from the AAST AORTA Registry. Accepted for Podium presentation AAST 2017.Google Scholar
  27. 27.
    Hughes CW. Use of intra-aortic balloon catheter tamponade for controlling intra-abdominal hemorrhage in man. Surgery. 1954;36(1):65–8.PubMedGoogle Scholar
  28. 28.
    Low RB, Longmore W, et al. Preliminary report on the use of the Percluder occluding aortic balloon in human beings. Ann Emerg Med. 1986;15(12):1466–9.CrossRefPubMedGoogle Scholar
  29. 29.
    Gupta BK, Khaneja SC, et al. The role of intra-aortic balloon occlusion in penetrating abdominal trauma. J Trauma. 1989;29(6):861–5.CrossRefPubMedGoogle Scholar
  30. 30.
    Propper BW, Alley JB, et al. Endovascular treatment of a blunt aortic injury in Iraq: extension of innovative endovascular capabilities to the modern battlefield. Ann Vasc Surg. 2009;23(5):687.e19–22.Google Scholar
  31. 31.
    Mayer D, Pfammatter T, et al. 10 years of emergency endovascular aneurysm repair for ruptured abdominal aortoiliac aneurysms: lessons learned. Ann Surg. 2009;249(3):510–5.CrossRefPubMedGoogle Scholar
  32. 32.
    • White JM, Cannon JW, et al. Endovascular balloon occlusion of the aorta is superior to resuscitative thoracotomy with aortic clamping in a porcine model of hemorrhagic shock. Surgery. 2011;150(3):400–9. This is the first animal model in the trauma literature to describe the benefits of balloon aortic occlusion and suggest it as an alternative to open occlusion for non compressible torso hemorrhage. Google Scholar
  33. 33.
    Morrison JJ, Ross JD, et al. Use of resuscitative endovascular balloon occlusion of the aorta in a highly lethal model of non-compressible torso hemorrhage. Shock. 2014;41(2):130–7.CrossRefPubMedGoogle Scholar
  34. 34.
    Suzuki A, Taki K, et al. Cerebral blood flow during open-chest cardiac massage with occlusion of the descending aorta in dogs. Resuscitation. 1985;13(1):69–75.CrossRefPubMedGoogle Scholar
  35. 35.
    Spence PA, Lust RM, et al. Transfemoral balloon aortic occlusion during open cardiopulmonary resuscitation improves myocardial and cerebral blood flow. J Surg Res. 1990;49(3):217–21.CrossRefPubMedGoogle Scholar
  36. 36.
    Sesma J, Labandeira J, et al. Effect of intra-aortic occlusion balloon in external thoracic compressions during CPR in pigs. Am J Emerg Med. 2002;20(5):453–62.CrossRefPubMedGoogle Scholar
  37. 37.
    Avaro JP, Mardelle V, et al. Forty-minute endovascular aortic occlusion increases survival in an experimental model of uncontrolled hemorrhagic shock caused by abdominal trauma. J Trauma. 2011;71(3):720–5; discussion 725–6.Google Scholar
  38. 38.
    • Scott DJ, Eliason JL, et al. A novel fluoroscopy-free, resuscitative endovascular aortic balloon occlusion system in a model of hemorrhagic shock. J Trauma Acute Care Surg. 2013;75(1):122–8. This translational work established the technology of the first fluoroscopy free REBOA device, as well as one that can be placed though a 7Fr sheath. This animal work describes the device and opened the door for a broader application of REBOA (without requiring a definitive vascular repair from the sheath). Google Scholar
  39. 39.
    White JM, Cannon JW, et al. A porcine model for evaluating the management of noncompressible torso hemorrhage. J Trauma. 2011;71(1 Suppl):S131–8.CrossRefPubMedGoogle Scholar
  40. 40.
    Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma. 2011;71(6):1869–72.PubMedGoogle Scholar
  41. 41.
    Markov NP, Percival TJ, et al. Physiologic tolerance of descending thoracic aortic balloon occlusion in a swine model of hemorrhagic shock. Surgery. 2013;153(6):848–56.CrossRefPubMedGoogle Scholar
  42. 42.
    Lallemand MS, Moe DM, et al. Resuscitative Endovascular balloon Occlusion of the Aorta (REBOA) for major abdominal venous injury in a porcine hemorrhagic shock model. J Trauma Acute Care Surg. 2017 Apr 28.Google Scholar
  43. 43.
    Johnson MA, Williams TK, et al. The effect of REBOA, partial aortic occlusion and aggressive blood transfusion on traumatic brain injury in a swine polytrauma model. J Trauma Acute Care Surg. 2017. doi: 10.1097/TA.0000000000001518.Google Scholar
  44. 44.
    Long KN, Houston R 4th, et al. Functional outcome after resuscitative endovascular balloon occlusion of the aorta of the proximal and distal thoracic aorta in a swine model of controlled hemorrhage. Ann Vasc Surg. 2015;29(1):114–21.CrossRefPubMedGoogle Scholar
  45. 45.
    Madurska MJ, Jansen JO, et al. The compatibility of CT scanning and partial-REBOA: a large animal pilot study. J Trauma Acute Care Surg. 2017. doi: 10.1097/TA.0000000000001574.PubMedGoogle Scholar
  46. 46.
    Reva VA, Hörer T, et al. Field and en route REBOA: a feasible military reality? J Trauma Acute Care Surg. 2017. doi: 10.1097/TA.0000000000001476.Google Scholar
  47. 47.
    CDMRP award W81XWH-16-1-0116. Physiologic response to prolonged resuscitative Endovascular balloon occlusion of the thoracic aorta in swine.Google Scholar
  48. 48.
    Biffl WL, Fox CJ, Moore EE. The role of REBOA in the control of exsanguinating torso hemorrhage. J Trauma Acute Care Surg. 2015;78(5):1054–8.CrossRefPubMedGoogle Scholar
  49. 49.
    • Brenner ML, Moore LJ, et al. A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation. J Trauma Acute Care Surg. 2013;75(3):506–11. This is the first clinical series published on REBOA, with 6 patients and 4/6 survivors. This article established REBOA a clinically viable option in US trauma centers. Google Scholar
  50. 50.
    Moore LJ, Martin CD, et al. Resuscitative endovascular balloon occlusion of the aorta for control of noncompressible truncal hemorrhage in the abdomen and pelvis. Am J Surg. 2016;212(6):1222–30.CrossRefPubMedGoogle Scholar
  51. 51.
    Aso S, Matsui H, et al. Resuscitative endovascular balloon occlusion of the aorta or resuscitative thoracotomy with aortic clamping for noncompressible torso hemorrhage: a retrospective nationwide study. J Trauma Acute Care Surg. 2017;82(5):910–4.CrossRefPubMedGoogle Scholar
  52. 52.
    Saito N, Matsumoto H, et al. Evaluation of the safety and feasibility of resuscitative endovascular balloon occlusion of the aorta. J Trauma Acute Care Surg. 2015;78(5):897–903; discussion 904.Google Scholar
  53. 53.
    Norii T, Crandall C, Terasaka Y. Survival of severe blunt trauma patients treated with resuscitative endovascular balloon occlusion of the aorta compared with propensity score-adjusted untreated patients. J Trauma Acute Care Surg. 2015;78(4):721–8.CrossRefPubMedGoogle Scholar
  54. 54.
    Tsurukiri J, Akamine I, et al. Resuscitative endovascular balloon occlusion of the aorta for uncontrolled haemorrahgic shock as an adjunct to haemostatic procedures in the acute care setting. Scand J Trauma Resusc Emerg Med. 2016;24:13.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Morrison JJ, Ross JD, et al. Resuscitative endovascular balloon occlusion of the aorta: a gap analysis of severely injured UK combat casualties. Shock. 2014;41(5):388–93.CrossRefPubMedGoogle Scholar
  56. 56.
    Sadek S, Lockey DJ, et al. 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.CrossRefPubMedGoogle Scholar
  57. 57.
    Qasim Z, Brenner M, et al. Resuscitative endovascular balloon occlusion of the aorta. Resuscitation. 2015;96:275–9.CrossRefPubMedGoogle Scholar
  58. 58.
    • DuBose JJ, Scalea TM, et al.; AAST AORTA Study Group. The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA). J Trauma Acute Care Surg. 2016;81(3):409–19. This is the most recent data from the US multicenter aortic occlusion study group. It describes data from 114 prospectively collected patients. Comparable outcomes are seen between REBOA and open occlusion in terms of survival and recover of blood pressure. Sustained improvement in blood pressure was higher in the REBOA group. Approximately 50% of REBOAs were placed via a cut down and average time to balloon occlusion was 6.6 minutes. Complications rates were acceptable. Google Scholar
  59. 59.
    Søvik E, Stokkeland P, et al. The use of aortic occlusion balloon catheter without fluoroscopy for life-threatening post-partum haemorrhage. Acta Anaesthesiol Scand. 2012;56:388–93.CrossRefPubMedGoogle Scholar
  60. 60.
    Harma M, Kunt AS, et al. Balloon occlusion of the descending aorta in the treatment of severe post-partum haemorrhage. Aust N Z J Obstet Gynaecol. 2004;44:170–1.CrossRefPubMedGoogle Scholar
  61. 61.
    Stensaeth KH, Haakon K, et al. Fluoroscopy-free Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for controlling life threatening postpartum hemorrhage. PLoS ONE. 2017;12(3):e0174520. doi: 10.1371/journal.pone.017452.CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    Paull JD, Smith J, et al. Balloon occlusion of the abdominal aorta during caesarean hysterectomy for placenta percreta. Anaesth Intensive Care. 1995;23:731–4.PubMedGoogle Scholar
  63. 63.
    Masamoto H, Uehara H, et al. Elective use of aortic balloon occlusion in cesarean hysterectomy for placenta previa percreta. Gynecol Obstet Invest. 2009;67:92–5.CrossRefPubMedGoogle Scholar
  64. 64.
    Bell-Thomas SM, Penketh RJ, et al. Emergency use of a transfemoral aortic occlusion catheter to control massive haemorrhage at caesarean hysterectomy. BJOG Int J Obstet Gynaecol. 2003;110(12):1120–2.CrossRefGoogle Scholar
  65. 65.
    Rosenthal MD, Raza A, et al. The novel use of resuscitative endovascular balloon occlusion of the aorta to explore a retroperitoneal hematoma in a hemodynamically unstable patient. Am Surg. 2017;83(4):337–40.PubMedGoogle Scholar
  66. 66.
    Tang X, Guo W, et al. Use of aortic balloon occlusion to decrease blood loss during sacral tumor resection. J Bone Joint Surg Am. 2010;92(8):1747–53.CrossRefPubMedGoogle Scholar
  67. 67.
    Matsuoka S, et al. Temporary percutaneous aortic balloon occlusion to enhance fluid resuscitation prior to definitive embolization of post-traumatic liver hemorrhage. Cardiovasc Intervent Radiol. 2001;24(4):274–6.CrossRefPubMedGoogle Scholar
  68. 68.
    Sano H, et al. Resuscitative endovascular balloon occlusion of the aorta for uncontrollable nonvariceal upper gastrointestinal bleeding. World J Emerg Surg. 2016;11:20.CrossRefPubMedPubMedCentralGoogle Scholar
  69. 69.
    Greenberg RK, et al. An endoluminal method of hemorrhage control and repair of ruptured AAA. J Endovasc Ther. 2000;7(1):1–7.CrossRefPubMedGoogle Scholar
  70. 70.
    Malina M, Veith F. Balloon occlusion of the aorta during endovascular repair of ruptured abdominal aortic aneurysm. J Endovasc Ther. 2005;12(5):556–9.CrossRefPubMedGoogle Scholar
  71. 71.
    Guliani S, Amendola M, et al. Central aortic wire confirmation for emergent endovascular procedures: as fast as surgeon-performed ultrasound. J Trauma Acute Care Surg. 2015;79(4):549–54.CrossRefPubMedGoogle Scholar
  72. 72.
    Pezy P, Flaris AN, et al. Fixed-distance model for balloon placement during fluoroscopy-free resuscitative endovascular balloon occlusion of the aorta in a civilian population. JAMA Surg. 2017;152(4):351–8.CrossRefPubMedGoogle Scholar
  73. 73.
    Taylor JR III, Harvin JA, et al. Vascular complications from resuscitative endovascular balloon occlusion of the aorta (REBOA): life over limb? J Trauma Acute Care Surg. 2017;83(1 Suppl 1):S120–3. doi: 10.1097/TA.000000000000151.CrossRefPubMedGoogle Scholar
  74. 74.
    Teeter WA, Matsumoto J, et al. Smaller introducer sheaths for REBOA may be associated with fewer complications. J Trauma Acute Care Surg. 2016;81(6):1039–45.CrossRefPubMedGoogle Scholar
  75. 75.
    Teeter W, Romagnoli A, et al. Resuscitative endovascular balloon occlusion of the aorta: pushing care forward. J Spec Oper Med. Spring. 2017;17(1):17–21.Google Scholar
  76. 76.
    • Manley JD, Mitchell BJ, et al. A modern case series of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in an out-of-hospital, combat casualty care setting. J Spec Oper Med. Spring 2017;17(1):1–8. This military based case series describes the first use of REBOA in the prehospital and austere setting. Four cases are described, all with normalization of blood pressure, 100% survival, and no REBOA related complications. Google Scholar
  77. 77.
  78. 78.
    Uchino H, Tamura N, et al. “REBOA”—is it really safe? A case with massive intracranial hemorrhage possibly due to Endovascular Balloon Occlusion of the Aorta (REBOA). Am J Case Rep. 2016;17:810–3.CrossRefPubMedPubMedCentralGoogle Scholar
  79. 79.
    Davidson AJ, Russo RM, et al. Incremental balloon deflation following complete REBOA results in steep inflection of flow and rapid reperfusion in a large animal model of hemorrhagic shock. J Trauma Acute Care Surg. 2017;83(1):139–43. doi: 10.1097/TA.0000000000001502.CrossRefPubMedGoogle Scholar
  80. 80.
    • Russo RM, Williams TK, et al. Extending the golden hour: Partial resuscitative endovascular balloon occlusion of the aorta in a highly lethal swine liver injury model. J Trauma Acute Care Surg. 2016;80(3):372–8; discussion 378–80. This article is a displays a translational swine model of partial balloon occlusion for hemorrhage. While systemic blood pressures were preserved with both partial and complete balloon occlusion, carotid flow was preserved at physiologic levels in the partial occlusion group, versus extreme overpressure in the complete group. Next generation balloon catheters are being designed informed by this data. Google Scholar
  81. 81.
    Johnson MA, Neff LP, et al. Partial resuscitative balloon occlusion of the aorta (P-REBOA): clinical technique and rationale. J Trauma Acute Care Surg. 2016;81(5 Suppl 2 Proceedings of the 2015 Military Health System Research Symposium):S133–7.Google Scholar
  82. 82.
    Davidson AJ, Russo RM, et al. Potential benefit of early operative utilization of low profile, partial resuscitative endovascular balloon occlusion of the aorta (P-REBOA) in major traumatic hemorrhage. Trauma Surg Acute Care Open 2016;1(1):e000028.Google Scholar
  83. 83.
    Williams TK, Neff LP, et al. Extending resuscitative endovascular balloon occlusion of the aorta: endovascular variable aortic control in a lethal model of hemorrhagic shock. J Trauma Acute Care Surg. 2016;81(2):294–301.CrossRefPubMedPubMedCentralGoogle Scholar
  84. 84.

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  1. 1.Uniformed Services University School of MedicineNaval Medical Research Unit San AntonioSan AntonioUSA
  2. 2.Division of Trauma/Surgical Critical Care, RA Cowley Shock Trauma Center, Division of Vascular SurgeryUniversity of Maryland School of MedicineBaltimoreUSA

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