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

2. 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

3. 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

4. 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

5. ER REBOA
Difference between CODA and ER REBOA

6. 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?

7. 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

8. Anatomy
Zone 1
Zone 2
Zone 3

9. 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

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

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

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

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

14. 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 )

15. 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%

16. 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 Apr;80(4):559-66

17. 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, doi: /jamasurg
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.

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

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

20. 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

21. 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, doi: /jamasurg
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 May;226(5):
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 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