REBOA - A Lifesaving Resuscitation Technique

Introduction

There is an increased incidence of traumatic injuries occurring all over the world. When associated with complications such as excessive bleeding, these traumatic injuries can lead to a person's death if not controlled immediately. The bleeding can be controlled if immediate hospitalization and appropriate measures are taken by the emergency department. The traumatic and extensive bleeding was initially prevented by using laparotomy (a surgical incision or cut made in the abdominal cavity) or thoracotomy (a surgical incision made in the chest wall), which stops the bleeding. The REBOA is an advancement in the resuscitation procedure to control hemorrhage and is less invasive than laparotomy and thoracotomy.

What Is REBOA?

REBOA refers to resuscitative endovascular balloon occlusion of the aorta. Endovascular means using long tubes called catheters inserted into the incisions made on the body and passed through the blood vessels. This technique inserts an endovascular balloon into the aorta to occlude them and control the hemorrhage. It is most useful in reducing non-compressible hemorrhage in traumatic injury patients. Hemorrhage in traumatic injuries is broadly divided into two types:

• Compressible Hemorrhage: Bleeding can be stopped by applying enough pressure or compression.

• Non-compression Hemorrhage: They are difficult to control just by applying pressure. They cause high-grade injury to various organs like the kidney, liver, spleen, and chest region and fractures in the pelvic area. The use of REBOA has benefitted patients by providing a minimally invasive measure of controlling non-compressible injuries.

What Are the Indications of REBOA?

The indications for the use of REBOA include persons within the age group of 18 to 69 years with the following conditions:

• In cases of PEA (pulseless electrical activity), arrest due to excessive blood loss from the femoral vessels (blood vessel supplying the thigh) or non-compressible hemorrhage, wherein the electrical activity within the heart is too weak, and the person does not have a pulse. REBOA can be used in this situation when the PEA is identified immediately on ultrasound imaging.

• In patients with severe hypovolemic shock, the heart cannot pump enough blood to the body due to severe blood loss. It is an emergency situation that requires immediate treatment.

• Those with non-compressible injuries with hemorrhage within the abdomen, pelvis fracture, and pelvic area injury with uncontrollable hemorrhage from the femoral artery.

What Are the Contraindications of REBOA?

The following are the situations that contraindicate the use of REBOA:

• In elderly persons above the age of 70 years.

• In patients with PEA arrests that are not identifiable on ultrasound imaging and when the condition lasts more than ten minutes.

• Patients with terminal medical conditions.

What Is the Technique for Using REBOA?

REBOA technique involves placing a flexible catheter into the femoral artery and passing it to the aorta, where the balloon attached to the catheter is inflated. This technique is temporary management to prepare a patient for a surgical procedure.

• The femoral artery is located precisely using the femoral artery introducer along with ultrasound guidance. Access to the femoral artery is the most critical step in this technique, and expertise is required in this procedure for a correct location.

• There are several balloons that can be used in REBOA. But the most frequently used is the ER-REBOA type of balloon. It has a flexible tip and an arterial monitoring port used to measure pre-occlusion blood pressure and the arterial response to REBOA. Other balloon types include Coda, Reliant, and the Berenstein.

• Next, the REBOA catheter is placed into the aorta and is made to occlude. The site or the zone at which the catheter is inserted into the aorta must be decided before performing the procedure. The aorta has the following zones:

  1. Zone 1- Thoracic aorta.

  2. Zone 2- Between the celiac and the renal arteries.

  3. Zone 3- Below the renal artery.

Zone 1 is employed for patients with hemorrhage within the abdomen, and zone 3 is for patients with pelvic fractures.

• The balloon is inflated using a sterile saline solution or an iodinated contrast solution. The balloon is continuously inflated until the blood pressure increases and the femoral pulse at the opposite side has stopped. The recommended volumes for inflation are eight milliliters for zone 1 and three milliliters for zone 3. Overinflation of the balloon is avoided, which might lead to the rupture of the balloon or the blood vessel.

• The position of the inflated balloon is confirmed using an X-ray or fluoroscopy. Fluoroscopy is a procedure wherein an X-ray is passed through a body part for a period of time, and the movement occurring at that moment is recorded and displayed on a monitor.

• After the balloon inflation is complete, the patient is taken to the operation theater, where the required surgical procedure is performed. When the hemorrhage has been totally controlled, the balloon is deflated, and the catheter is removed.

• Once the procedure of controlling the hemorrhage is complete, the patient is observed to see if there is a re-emergence of bleeding. The surgical team must be ready to overcome such problems and manage them appropriately.

What Are the Complications of Using REBOA?

The following are the complications associated with the use of REBOA:

• The main complications due to the REBOA catheter insertion are the injuries to the blood vessel, such as their rupture, perforation, and embolization (spread of the blood clot).

• Lower limb ischemia, which refers to the reduced blood supply to the lower part of the legs. This might lead to the death of the cells and tissues of the lower leg and, ultimately, its surgical removal.

• Complications can also arise due to balloon deflation, which causes the release of inflammatory cells, embolization, metabolic acidosis (accumulation of acid in the body), and bleeding in the previously controlled area.

Since the complications arise mainly causing injury to the blood vessels, the REBOA must be performed by trained professionals with adequate knowledge and experience in using REBOA as a resuscitation technique. The surgeon must also be skilled enough to intervene in the complications that may arise.

Conclusion

REBOA is the resuscitative endovascular balloon occlusion of the aorta, which serves as a temporary procedure to stop the bleeding in patients with traumatic injuries. It involves inflating a balloon within the aorta that occludes the vessel and stops the bleeding. The procedure may seem simple, but the technique is quite complex. For a successful outcome, the technique is performed by trained professionals with expertise in the field of REBOA. The use of REBOA is increasing in the emergency department due to its beneficial and minimally invasive technique.