Korbin Haycock, MD, FACEP, RDMS, RDCS To REBOA or not to REBOA?

Prytime Medical loaned me the simulation model for this course Conflict of interest? Prytime Medical loaned me the simulation model for this course Otherwise, I have no other conflict of interest

Overview and Key Points What is REBOA and what is the idea(s) behind it? How do you place a REBOA catheter? What are the indications for REBOA and what is the evidence that it works? Possible non-trauma applications

What is Resuscitative Endovascular Balloon Occlusion of the Aorta? A minimally invasive procedure used in place of an emergency thoracotomy for traumatic arrest There are some contraindications and possible additional indications with the procedure Or a means to buy a bit of time to get definitive control of bleeding not responsive to resuscitative efforts Idea is to occlude the aorta proximal to the hemorrhage and maintain perfusion to the brain and heart. Balloon occlusion is the replacement for the aortic cross clamp-no cutting open the chest. CODA versus ER-REBOA

ER REBOA Difference between CODA and ER REBOA

Insertion Cannulate a femoral artery and drop a guidewire Insert a 7Fr introducer catheter Measure Evacuate Flush Insert Inflate Secure P-tip to sternal notch or xiphoid (45cm-28cm). Twist peel away. A-wave (8cc-3cc). 30 minute time. Partial deflation?

Anatomy The aorta (when talking REBOA) is divided into 3 zones Zone 1 Left subclavian artery to the celiac artery Segment about 20 cm long Zone 2 Celiac artery to the most distal renal artery Segment about 3 cm long Zone 3 Most distal renal artery to the aortic bifurcation Segment about 10 cm long

Anatomy Zone 1 Zone 2 Zone 3

Anatomy External landmarks for the zones are as follows: Zone 1: The Sternal Notch (45 cm) Zone 3: The Xiphoid (28 cm) We don’t put the balloon in Zone 2

Test 1 Test 2 or pelvic instability Test 3 (Brenner, 2015)

Contraindications Severe TBI Suspected traumatic proximal aortic transection Traumatic arrest due to tension PTX or pericardial tamponade

Traumatic Indications Trauma to the torso with uncontrolled hemorrhage and shock This includes solid organ injury Pelvic injuries

Complications Venous placement Placement in smaller arteries Vascular dissection Retroperitoneal hemorrhage Embolic clots Ischemia Lactic acidosis

Data from the AAST/AORTA registry (DeBuse, 2016) Data from 8 level 1 trauma centers 46 REBOA, 68 Open AO REBOA with higher SBP 90 mmHg vs 65 mmHg Similar Mortality 72% vs 84% (p=0.12) Adjusted Mortality REBOA vs Open AO (OR, 0.263; 95% CI 0.043-1.61)

Data from the AAST/AORTA registry (Brenner, 2018) 285 patients without penetrating thoracic injury In patients without pre- hospital CPR, REBOA had better survival to discharge RT 3.4% vs REBOA 22.2% And, if arrival with hypotension: RT 0% vs REBOA 44%

Norii et al. 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 Apr;78(4):721-8. Inoue et al. Resuscitative endovascular balloon occlusion of the aorta might be dangerous in patients with severe trauma: a propensity score analysis. The Journal of trauma and acute care surgery. 2016 Apr;80(4):559-66

Propensity matched retrospective analysis of REBOA vs no REBOA Nationwide Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta in Civilian Trauma Bellal Joseph, MD et al JAMA Surg. Published online March 20, 2019. doi:10.1001/jamasurg.2019.0096 Propensity matched retrospective analysis of REBOA vs no REBOA REBOA with higher rates of mortality at 24 hours, AKI, leg amputations However: SBP in REBOA 108 mmHg, Unknown inflation times, increased time to definitive management Zaf Qasim on RebelEM good critique. My comments: 12Fr, First analysis REBOA sicker, Those that died in REBOA group sicker than those didn’t die in REBOA group. Only initial vital signs. Unknown occlusion time.

What about non-trauma indications? No real evidence beyond some case reports and case studies In principle, REBOA does make sense in multiple scenarios

Non-Traumatic Indications Exsanguinating Ectopic Pregnancy Upper GI bleeding (non variceal) Gastroduodenal artery Ruptured AAA Cardiac Arrest

Summary REBOA is a new technology with potential harms, but also very promising benefits The technology is evolving and improving making REBOA safer and probably more effective Optimal indications for REBOA still need to be explored and worked out Ongoing research for both traumatic and non-traumatic uses of REBOA will help guide future use

References Bellal Joseph, MD et al,. Nationwide Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta in Civilian Trauma JAMA Surg. Published online March 20, 2019. doi:10.1001/jamasurg.2019.0096 Brenner et al., Resuscitative Endovascular Balloon Occlusion of the Aorta and Resuscitative Thoracotomy in Select Patients with Hemorrhagic Shock: Early Results from the American Association for the Surgery of Trauma's Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery Registry. J Am Coll Surg 2018 May;226(5):730-740. DeBose et al., 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 Sep;81(3):409-19 Inoue et al. Resuscitative endovascular balloon occlusion of the aorta might be dangerous in patients with severe trauma: a propensity score analysis. The Journal of trauma and acute care surgery. 2016 Apr;80(4):559-66 Norii et al. 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 Apr;78(4):721-8