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REBOA

Dr. Norling PGY-2 , Dr. Pistell PGY-4

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Resuscitative Endovascular Balloon Occlusion of Aorta

Hemorrhage is the leading cause of death in trauma. 40%²
Resource intensive option for treating critical, non-compressible torso hemorrhage (NCTH)

ACS-COT and ACEP Joint Statement 2019: “REBOA should only be placed by a surgeon or interventionalist responsible for definitive hemorrhage control or by a physician trained and qualified in REBOA in direct consultation with the physician who will provide definitive hemorrhage control.”

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When to REBOA

18-69 years with:

Traumatic life threatening sub-diaphragm hemorrhage

Abdominal hemorrhage
Junctional/ lower extremity hemorrhage

Ability to identify femoral vessels on US/cutdown
PEA arrest <10 minutes from sub-diaphragmatic exsanguination
Causes of obstructive shock excluded

“N-A-V-L”

Common femoral artery. 1 cm below the midpoint of the inguinal ligament.

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When NOT to REBOA

Supra-diaphragmatic injury/hemorrhage
Obstructive shock
Concerns for increased BP to brain/upper extremity/torso such as proximal aortic bleeding, neck hemorrhage, etc
Ischemia time projected to be >30 mins (Zone 1) or max of 60 minutes (Zone 3)
Special Populations: overall lacking data

Age >70y
Pregnant patients
Pediatric- research ongoing with pulsatile flow models, 3D printed aortas with 4fr-6fr sheaths^5,6

Age >70 since no studies did this on anyone over 70

Timing is based off animal studies

P-REBOA: Pediatric Resuscitative Endovascular Balloon Occlusion of the Aorta, A Model for Potential Pediatric Trauma Use�Louis Carrillo, MD, MPh; Max Skibber, BS; Akshita Kumar, MD. MS; Mitchell George, MD; Charles Cox, MD�University of Texas Health Science Center Houston Dept of Pediatric Surgery, Houston, TXBackground- The Resuscitative Endovascular Balloon Occlusion (REBOA) device is becoming more widespread in adult trauma but is not FDA approved for pediatric patients. Reports of their use in pediatric patients have been published but no guidelines currently exist. 3D printed aortic models present a method to test occlusion in different sized vessels spanning the sizes of pediatric patients.

Methods- A circulatory system was constructed using 3D printed aortas made of TangoPlus FullCure 930¨R). The diameters of the aorta at the xyphoid process and umbilicus for the 5 largest broselow size categories were used to create the vessels. The system included thoracic and cerebral vascular pathways with sonographic flow meters placed distal to the aorta sample as well as on the cerebral pathway. Pressure monitors were placed at the pump exit and in the cerebral and thoracic pathways. Flow and pressure readings were recorded as a REBOA device was inflated at .2cc/sec in the aorta.

Results- Distal flow and pressure decreased while cerebral perfusion increased with REBOA deployment. The distal flow measurements and REBOA volumes to occlude 50% and 25% of flow are seen in the attached graph.

Conclusions- Pediatric patients present with a wide range of vessel sizes that occlude with different REBOA infusions. This study provides a basis to establish initial infusion volumes for REBOA deployment in select pediatric patients.

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Zones of Aortic Occlusion�

Zone 1

From the left subclavian artery to the celiac trunk
External landmark: mid-sternum
Targets intra-abdominal bleeding below the diaphragm

Zone 3

From the lowest renal artery to the aortic bifurcation
External landmark: umbilicus
Targets bleeding at the groin junction, pelvis, or lower extremities

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But what about zone 2?

Lies between zones 1 and 3

A non-inflation zone due to numerous branch vessels arising in this area and the potential to miss the actual bleeding vessel

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Literature Overview

Initial animal studies showing promise in canines, swine models when looking at mortality (100%->25%)
Compared to aortic cross clamping-studies suggesting improved mortality^3,4
Per ACS- Improved survival with REBOA in studies between level 1 trauma centers however they were compared to pts who underwent RT... ^{JTACS 2019}
Systematic review of 41 studies showing no clear reduction in mortality with REBOA usage ^{JTACS 2016}, but meta-analysis of ~1200 pts showing improvement in mortality ^{WJES 2017}
Japanese reviews of 45,000 pts (1% getting REBOA) painted REBOA in negative light (76% mortality vs 16%)^8,9

Last ditch effort- sicker patients

Looking Ahead: UK REBOA Trial- ongoing goal to recruit 120 patients across 10 major trauma centers- RCT, primary outcome: 90 day mortality

Confoudning variables comparing pts who got REBOA vs thoracotomy: 2019 Journal TACS: Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage

Manzano Nunez R, Naranjo MP, Foianini E, et al. A meta-analysis of resuscitative endovascular balloon occlusion of the aorta (REBOA) or open aortic cross-clamping by resuscitative thoracotomy in non-compressible torso hemorrhage patients. World J Emerg Surg. 2017;12:30. Published 2017 Jul 14. doi:10.1186/s13017-017-0142-5
Abe T, Uchida M, Nagata I, Saitoh D, Tamiya N. Resuscitative endovascular balloon occlusion of the aorta versus aortic cross clamping among patients with critical trauma: a nationwide cohort study in Japan [published correction appears in Crit Care. 2017 Feb 22;21(1):41]. Crit Care. 2016;20(1):400. Published 2016 Dec 15. doi:10.1186/s13054-016-1577-x
DeSoucy, E. S., Trappey, A. F., Davidson, A. J., Dubose, J. J., Williams, T. K., Johnson, M. A., & Stephenson

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REBOA for Hemorrhagic Shock (CPG ID:38) MAR 2020

Utilizes ER-REBOA

Zone I REBOA: placement of aortic balloon in the thoracic aorta (insert catheter to 46 cm, or measure the balloon to mid sternum, or /P-tip to the sternal notch)
Zone III REBOA: placement of aortic balloon directly above the aortic bifurcation (insert catheter to 27 cm or measure the balloon to the umbilicus or P-tip to the xyphoid process).

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Cook Medical CODA - (9-10 Fr catheters, 100-140 cm length, requiring 12-14 Fr sheaths)

Prytime “ER-REBOA”-(6 Fr catheter, 72 cm length, 7 Fr sheath)

Distal Arterial Line Port
Peel away sheath for “P-tip” ^TM

COBRA-OS- Frontline Medical. 4 fr

No distal arterial line
Re-usable J tip

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NMCP REBOA

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Take Home Points

“8 is great”- 8cc’s of NS/Gastrografin= 20mm balloon dilation with a maximum of 24cc’s for NMCP’s Prytime ER-REBOA
Look at your device’s package to determine proper inflation amounts+ markers
“28-46”= Zone 3, Zone 1 distances in cm
Resuscitate your patients who have lost blood…
Basic Endovascular Skills for Trauma (BEST Course) available at NMCP to EM physicians
Future studies looking at non-compressible non-traumatic hemorrhage (PPH, GI bleed⁸, non-traumatic CA, etc)

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ER-REBOA Steps:

A-line in place-> replace with larger Fr introducer sheath (with dilator) using wire.
Remove dilator-> slide peel-away sheath toward catheter distal tip to fully enclose/straighten P-tip
Connect and flush the arterial line via the 3-way stopcock
Insert peel-away sheath (fully distal to flatten P tip) and catheter into the 7 Fr introducer sheath ~5 mm or until the peel-away sheath stops
Advance the catheter 10–20 cm, then slide peel-away sheath away from the catheter
Advance catheter to appropriate position Zone 1 or Zone 3, inflate balloon, watch waveform. Get to the OR.

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References

https://www.emrap.org/corependium/chapter/recU4wDIZSTnsjsh8/Prehospital-Hemorrhage-and-Invasive-Therapies#h.4o31yzid9kyg
Curry N, Hopewell S, Dorée C, Hyde C, Brohi K, Stanworth S. The acute management of trauma hemorrhage: a systematic review of randomized controlled trials. Crit Care. 2011;15(2):R92. doi:10.1186/cc10096
Manzano Nunez R, Naranjo MP, Foianini E, et al. A meta-analysis of resuscitative endovascular balloon occlusion of the aorta (REBOA) or open aortic cross-clamping by resuscitative thoracotomy in non-compressible torso hemorrhage patients. World J Emerg Surg. 2017;12:30. Published 2017 Jul 14. doi:10.1186/s13017-017-0142-5
Abe T, Uchida M, Nagata I, Saitoh D, Tamiya N. Resuscitative endovascular balloon occlusion of the aorta versus aortic cross clamping among patients with critical trauma: a nationwide cohort study in Japan [published correction appears in Crit Care. 2017 Feb 22;21(1):41]. Crit Care. 2016;20(1):400. Published 2016 Dec 15. doi:10.1186/s13054-016-1577-x
DeSoucy, E. S., Trappey, A. F., Davidson, A. J., Dubose, J. J., Williams, T. K., Johnson, M. A., & Stephenson, J. T. (2021). Pediatric Sized REBOA Catheter Testing in a Pulsatile Aortic Flow Model. Journal of Endovascular Resuscitation and Trauma Management, 4(2). https://doi.org/10.26676/jevtm.v4i2.141
https://pediatrictraumasociety.org/meeting/abstracts/2018/4.cgi
Garrett PD, Eckart RE, Bauch TD, Thompson CM, Stajduhar KC. Fluoroscopic localization of the femoral head as a landmark for common femoral artery cannulation. Catheter Cardiovasc Interv. 2005;65(2):205-207. doi:10.1002/ccd.20373
https://www.uptodate.com/contents/image?imageKey=SURG%2F116317
Qasim Z, Brenner M, Menaker J, Scalea T. Resuscitative endovascular balloon occlusion of the aorta. Resuscitation. 2015;96:275-279. doi:10.1016/j.resuscitation.2015.09.003
Bulger EM, Perina DG, Qasim Z, et al
Manzano Nunez R, Naranjo MP, Foianini E, et al. A meta-analysis of resuscitative endovascular balloon occlusion of the aorta (REBOA) or open aortic cross-clamping by resuscitative thoracotomy in non-compressible torso hemorrhage patients. World J Emerg Surg. 2017;12:30. Published 2017 Jul 14. doi:10.1186/s13017-017-0142-5
Clinical use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in civilian trauma systems in the USA, 2019: a joint statement from the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, the National Association of Emergency Medical Services Physicians and the National Association of Emergency Medical Technicians. Trauma Surgery & Acute Care Open 2019;4:e000376. doi: 10.1136/tsaco-2019-000376
https://www.tamingthesru.com/blog/procedural-education/the-anatomy-of-femoral-vascular-access
https://litfl.com/reboa-in-resuscitation/
https://www.facs.org/for-medical-professionals/news-publications/journals/case-reviews/issues/v3n6/chipman-reboa/
Saito N, Matsumoto H, Yagi T, et al. Evaluation of the safety and feasibility of resuscitative endovascular balloon occlusion of the aorta. J Trauma Acute Care Surg. 2015;78(5):897-904. doi:10.1097/TA.0000000000000614
Norii T, Crandall C, Terasaka Y. 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;78(4):721-728. doi:10.1097/TA.0000000000000578
https://w3.abdn.ac.uk/hsru/reboa/public/public/index.cshtml
https://thetraumapro.com/2021/01/22/reboa-a-comparison-of-the-hardware-from-two-companies/

https://jts.health.mil/assets/docs/cpgs/Resuscitative_Endovascular_Balloon_Occlusion_of_the_Aorta_(REBOA)_for_Hemorrhagic_Shock_31_Mar_2020_ID38.pdf

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Quiz

https://docs.google.com/forms/d/e/1FAIpQLScYWWGyA0S0tH7wKLXqWfa5qwUYp4YAQtAbXc-DVTzJISEXww/viewform?usp=sf_link