REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta)

1. Definition

REBOA = temporary endovascular aortic occlusion using an inflatable balloon inserted via the femoral artery to control non-compressible torso hemorrhage (NCTH).

It provides:

• Proximal control of bleeding
• Augmentation of coronary and cerebral perfusion
• Bridge to definitive hemorrhage control (OR / IR / damage control surgery)

It is a less invasive alternative to resuscitative thoracotomy with aortic cross-clamping.

2. Historical Perspective

• First described in the 1950s (Korean war)
• Modern resurgence with low-profile catheters (~7 Fr)
• Now incorporated in trauma algorithms (EAST, WSES, ACS TQIP, ELSO in select ECMO contexts)

3. Physiological Basis 

Aortic Occlusion Causes:

↑ Proximal MAP

• Improves coronary perfusion pressure
• Improves cerebral perfusion

↓ Distal Flow

• Reduces hemorrhage distal to balloon
• Produces ischemia below occlusion

Hemodynamic Effects:

4. Aortic Zones 

🔴 Zone 1

• For severe abdominal bleeding
• Maximum ischemic burden

🟢 Zone 3

• For pelvic fracture bleeding
• Lower ischemic risk

Zone 2 = No man’s land

5. Indications 

Primary Indication:

Hemorrhagic shock due to non-compressible torso hemorrhage

Trauma:

• Blunt abdominal trauma
• Pelvic fracture with massive hemorrhage
• Junctional bleeding not controllable

Non-Trauma (Selective):

• Ruptured abdominal aortic aneurysm
• Massive GI bleed (bridge)
• Postpartum hemorrhage (rare but described)

Hemodynamic Criteria:

• SBP < 90 mmHg despite resuscitation
• Transient responder
• Cardiac arrest from hemorrhage (before thoracotomy)

6. Contraindications

Absolute:

• Thoracic bleeding proximal to occlusion
• Unsalvageable injury
• Aortic injury proximal to balloon

Relative:

• Severe traumatic brain injury (afterload increase risk)
• Prolonged CPR (>10–15 min no ROSC)
• Aortic dissection

7. Procedure Steps 

Step 1: Femoral Artery Access

• Ultrasound-guided
• Prefer common femoral artery (above bifurcation)
• 7 Fr sheath (modern systems)

Step 2: Catheter Advancement

• External landmark-based measurement OR fluoroscopy
• Zone 1: ~45 cm
• Zone 3: ~25 cm

Step 3: Balloon Inflation

• Inflate with saline + contrast
• Monitor MAP response
• Confirm by:
• Loss of femoral pulse
• Radiography if available

Step 4: Secure & Prepare for Definitive Control

8. Occlusion Strategies 

1. Complete Occlusion

• Full balloon inflation
• Maximum hemodynamic support
• High ischemia risk

2. Partial REBOA (pREBOA)

• Controlled partial inflation
• Allows minimal distal perfusion
• Reduces ischemia-reperfusion injury
• Current preferred strategy

3. Intermittent REBOA

• Deflate periodically
• Used when prolonged occlusion unavoidable

9️⃣ Time Limits 

After 60 min:

• Severe metabolic acidosis
• Reperfusion injury
• Multiorgan failure

10. Complications 

1️⃣ Ischemic Complications

• Limb ischemia
• Bowel ischemia
• Renal failure
• Spinal cord ischemia

2️⃣ Reperfusion Injury

• Massive acidosis
• Hyperkalemia
• Hypotension on deflation
• Ventricular arrhythmias

3️⃣ Vascular Injury

• Femoral artery thrombosis
• Dissection
• Pseudoaneurysm

4️⃣ Balloon Rupture

5️⃣ Compartment Syndrome

11. REBOA vs Resuscitative Thoracotomy

Thoracotomy preferred in:

• Penetrating cardiac injury
• Cardiac tamponade

12. REBOA in Cardiac Arrest

• Used in traumatic cardiac arrest from hemorrhage
• Can restore coronary perfusion
• If no ROSC within short time → poor outcome

Not indicated in:

• Medical cardiac arrest
• Non-hemorrhagic arrest

13. REBOA in Pelvic Fracture

Zone 3 preferred

• Reduces pelvic arterial bleeding
• Bridge to:
• Angioembolization
• Pelvic packing
• External fixation

14. Metabolic Consequences After Deflation 

Sudden deflation causes:

• ↓ SVR
• ↓ MAP
• Acidosis washout
• Hyperkalemia
• Myocardial depression

Management During Deflation:

• Gradual deflation
• Calcium
• Bicarbonate (selective)
• Vasopressors ready
• Massive transfusion ongoing

15. Evidence & Outcomes 

• Improves short-term hemodynamics
• Survival benefit unclear in all-comers
• Best benefit in:
• Severe pelvic hemorrhage
• Transient responders

Poor outcomes in:

• Prolonged occlusion
• Delayed definitive control
• Severe TBI

16. Integration in Trauma Algorithm

REBOA sits between:

Massive transfusion protocol
⬇
Persistent hypotension
⬇
REBOA (if NCTH suspected)
⬇
Damage control surgery / IR

17. Monitoring in ICU After REBOA

• Serial lactate
• ABG every 30–60 min
• Limb perfusion checks hourly
• Doppler pulses
• CK levels
• Renal function
• Compartment pressure if needed