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REBOA for Non-Compressible Torso Hemorrhage:

History and the Way Forward

REBOA for Non-Compressible Torso Hemorrhage:

History and the Way Forward

J.R. Taylor III MD

Assistant Professor of Surgery, University of Arkansas for Medical Sciences

@11A2TraumaMD

Disclosure

• I have served as a consultant for PrytimeMedical Inc

Objectives

• Describe the history of REBOA

• Discuss the progression of the technology and its evolution in clinical care

• Discuss the way forward implementing REBOA for trauma and acute care surgery

What is REBOA?

Resuscitative

Endovascular

Balloon

Occlusion of the

Aorta

PAST

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Korean War Medical Advances

• MASH Unit

• Helicopter as flying ambulance

• Blood collection and distribution using plastic containers

• Body armor

• First attempted during the Korean War

• Two patients with intra-abdominal hemorrhage

• Placed AFTER patients received >10 units blood

• Catheter placed through femoral artery

• Balloon inflated at level of diaphragm

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PRESENT

OIF / OEF / GWOT Medical Advances

• Tourniquets

• Improved body armor

• Golden hour

• Damage control resuscitation

Five Steps:1.Obtain femoral arterial access2.Balloon selection and positioning3.Balloon inflation4.Balloon deflation5.Sheath removal

– Closure of arteriotomy– Confirm distal pulses

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Aortic Occlusion Zones• Select zone of occlusion

based upon injury pattern

• Zones I and III preferred

• Avoid occlusion in Zone II

• Confirm zone of occlusion on plain x ray or fluoroscopy

Conclusions from this series

• REBOA is a feasible and effective means of proactive aortic control for patients in end-stage shock from blunt and penetrating mechanisms

• Can be safely placed by Acute Care Surgeons with some, but no formal, vascular training

• More studies necessary to define population where REBOA is truly beneficial

Overall (N = 96) Resuscitative 

Thoracotomy (n=72)

REBOA 

(n=24)

p value

Age

Median (P25,P75)30.5(23.5, 48) 41 (24,62) 0.33

Male %(n) 87.5% (63) 79.2%(19) 0.33

Blunt %(n) 44.4% (32) 66.7% (16) 0.10

ISS

Median (P25,P75)34 (22,59) 29 (19,41) 0.17

AIS Head

Median (P25,P75)3 (0,5) 4 (3,5) 0.29

AIS Chest

Median (P25,P75)3 (3,4) 3.5 (3,4) 0.91

AIS Abdomen

Median (P25,P75)2 (0,4) 3 (2,4) 0.26

AIS Extremity

Median (P25,P75)1.5 (0,3) 4 (3,4) <0.001

Survival Rate % (n) 9.7% (7) 37.5% (9) 0.003

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Among Deaths 

(N=80)Resuscitative 

Thoracotomy 

Deaths (n=65)

REBOA Deaths

(n=15) p value

All Deaths%(n) 90.3% (65) 62.5% (15) 0.003

Died in ED%(n) 69.2% (45) 26.7% (4) <0.001

Died in OR%(n) 9.2% (6) 20% (3) 0.69

Died in ICU%(n) 21.6% (14) 53.3% (8) 0.17

Age Median 

(P25,P75)31 (24,46) 40.5 (24,66) 0.41

Male%(n) 87.7% (57) 73.3% (11) 0.22

Blunt%(n) 44.6% (29) 73.3% (11) 0.08

ISS Median 

(P25,P75)35.5 (22,67) 34 (20,45.5) 0.39

Comparison of Cause of ICU Death

RT ICU Deaths (n=14) REBOA ICU Deaths 

(n=8)

Early death from hemorrhage 

%(n)

71.4% (10) 0% (0)

Multiple organ failure %(n) 14.3% (2) 12.5% (1)

Head injury %(n) 14.3% (2) 87.5% (7)

Comparison of Survivors

Among 

Survivors 

(N=16)

Resuscitative 

Thoracotomy 

Alive (n=7)

REBOA 

Alive (n=9) p value

Survivors % (n) 9.7% (7) 37.5% (9) 0.003

Age Median 

(P25,P75)

29 (21,51) 43 (25,59) 0.71

Male % (n) 85.7% (6) 88.9% (8) 1.00

Blunt % (n) 42.9% (3) 55.6% (5) 1.00

ISS Median 

(P25,P75)

29 (16,34) 26 (17,29) 0.56

Conclusions from this series

• Use of REBOA in patient with noncompressible hemorrhage from abdomen and pelvis is feasible and effectively controls hemorrhage

• Patients undergoing REBOA have at least equivalent overall survival and fewer early deaths

• Any patient with a suspected or confirmed major intrathoracic injury and cardiovascular collapse should still undergo resuscitative thoracotomy

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Case Example 1

• 42 y/o male crushed between two cranes while at work

• Presented to the OSH with a GCS 15, hypotension intubated at OSH, hypotensive, placed in pelvic binder transferred to MHH

• VS @ presentation, SBP 60, HR 120, normal cxr, pelvis xray

Case Example 1

• Cordis placed, right femoral arterial line place, pelvic binder moved inferiorly

• Persistent hypotension right femoral REBOA placed SBP improved to 130

• Taken to the CT scanner and subsequently to the interventional radiology suite for angiography +/-embolization

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• Angiography without evidence of actively bleeding arterial source REBOA removed, sheath maintained in right groin

• RUG showed prostatic urethral injury, so percutaneous SP tube placed

• Taken to the operating room found to have mesenteric injury with devitalized small bowel segment x 2 small bowel resection with HS anastomosis x 2, no other injury, NJ feeding tube placed, fascia closed

• Sheath removed after hemodynamics normalized, coagulopathy corrected

Case Example 1

• POD 1 went for placement of uniplanar external fixator anterior pelvis, closed reduction percutaneous screw fixation of right SI joint disruption, closed reduction percutaneous screw fixation left sacral fracture

Case Example 1 Case Example 2

• 41 y/o male s/p auto-pedestrian with traumatic right lower extremity amputation below the knee

• OSH intubated patient, placed right lower extremity proximal tourniquet and transferred to MH

• At evaluation, BP 60/40 52/30 massive transfusion protocol started, right femoral arterial line placed, left subclavian cordis

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Case Example 2

• FAST initially negative then positive with massive transfusion

• 7FR sheath exchanged for right femoral arterial line REBOA deployed to Zone I

Case Example 2

• Taken to the OR for exploratory laparotomy• At laparotomy found to have multiple Grade

III liver lacerations that underwent hepatorraphy and packing wound vac placed

• Right lower extremity mangled and non-salvageable gigli amputation undertaken

• After liver packing and hepatorraphy balloon deflated, hemodynamics maintained, and balloon removed

Case Example 2

• Taken to STICU overnight for resuscitation

• 7FR sheath pulled at bedside once TEG normalized 72 hour post removal duplex showed no evidence of pseudoaneurysm

• Taken next day to OR for pack removal without evidence of further bleeding and formalization of AKA

• Discharged to rehab after 41 day hospital stay

Case Example 3

• 34 y/o male with GSW to left thigh

• Taken to OSH where improvised tourniquet was placed

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Case Example 3

• Given hasty tourniquet right femoral artery access was obtained, 7FR sheath placed and REBOA deployed but not inflated

• Tourniquet removed, vascular control obtained, and balloon removed without inflation

Case Example 3

• Destructive injury to SFA, shunt placed 2 hours after time of injury

• Artery repaired with reverse saphenous vein graft

• Discharged from hospital on POD 3

Future Prehospital REBOA

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Emergency Room UseNon‐Trauma

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Acute Care Surgery

Endovascular Training for Acute Care Surgeons

• BEST Basic Endovascular Skills for Trauma Course coordinated by the American College of Surgeons Committee on Trauma

• Endovascular procedures on vascular surgery rotations aren’t just for fellows / chiefs it is a skill that translates to other parts of surgery

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Questions?