images Vol. 6, No. 1; 2022; pp 8–13
DOI: 10.26676/jevtm.v6i1.221

 

 

Indication of Resuscitative Endovascular Balloon Occlusion of the Aorta in Trauma Patients

Kenichiro Ishida1, Satomi Seno2, Takaaki Maruhashi3 and Yosuke Matsumura4

1Department of Acute Medicine and Critical Care Medical Center, Osaka National Hospital, National Hospital Organization, Osaka City, Osaka, Japan

2Department of Emergency and Critical Care Center, Saiseikai Yokohamashi Tobu Hospital, Yokohama City, Kanagawa, Japan

3Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan

4Department of Intensive Care, Chiba Emergency Medical Center, Chiba City, Chiba, Japan

 

 

In trauma bays, resuscitation as a bridge to definitive hemorrhage control to avoid cardiac arrest is challenging. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a resuscitation procedure for refractory hemorrhagic shock. The REBOA procedure itself is simple compared to other endovascular procedures, such as angioembolization or stent graft placement. However, adequate REBOA implementation requires a complete understanding of its potential risks and simulation training. We should be aware that REBOA is not a hemostatic device, but a bridge to definitive hemorrhage control; furthermore, it is not a magical device that can improve the critical situation in trauma resuscitation. For appropriate use, we herein describe the indication of REBOA in trauma resuscitation based on existing evidence.

Keywords: Resuscitative Endovascular Balloon Occlusion of the Aorta; REBOA; Trauma; Hemorrhagic Shock; Indication

Received: 3 October 2021; Accepted: 16 December 2021

 

 

 

Corresponding author:

Kenichiro Ishida, Department of Acute Medicine and Critical Care Medical Center, Osaka National Hospital, National Hospital Organization, 2-1-14, Hoenzaka, Chuo-ku, Osaka, Japan.

Email: kenichiro1224@gmail.com

© 2022 CC BY-NC 4.0 – in cooperation with Depts. of Cardiothoracic/Vascular Surgery, General Surgery and Anesthesia, Örebro University Hospital and Örebro University, Sweden

 

 

INTRODUCTION

In trauma bays, resuscitation as a bridge to definitive hemorrhage control to avoid cardiac arrest is challenging. Resuscitative thoracotomy with an aortic cross-clamp (RTACC) is a resuscitation procedure in patients with life-threatening refractory hemorrhagic shock. However, RTACC itself is highly invasive, and sequelae such as bleeding from the chest wall, hypothermia, and empyema are known complications. As an alternative method, intra-aortic balloon occlusion catheters have been used since the latter half of the 1990s. In 2011, resuscitative endovascular balloon occlusion of the aorta (REBOA) was reported [1], and since then, it has been widely used worldwide.

However, the effectiveness of REBOA, such as its impact on life prognosis, is controversial [2,3]. A possible reason for this is that REBOA has not been appropriately implemented. In the absence of high-quality evidence regarding REBOA implementation, we herein describe the indications for REBOA in trauma resuscitation based on existing evidence.

Ethical Approval and Informed Consent

This is a review article and does not contain any original human or animal data, therefore ethical approval was not required and consent to participate was also not required.

THE ROLE OF REBOA

The Purpose of REBOA

In addition to its resuscitative use, REBOA is used as an intraoperative proximal control in massive bleeding cases. Furthermore, the degree of balloon occlusion can be adjusted depending on the blood pressure, which is known as partial REBOA. Moreover, it is possible to switch to REBOA from other aortic occlusion procedures, such as RTACC or manual compression of the aorta during laparotomy. REBOA is less invasive than RTACC and may have a similar physiological effect.

REBOA as a Bridge to Definitive Hemorrhage Control

REBOA is not a magical device that can improve the critical situation in trauma resuscitation. REBOA is not a hemostatic device, but a bridge to definitive hemorrhage control. Therefore, one should not be relieved with an apparent increase in blood pressure during aortic occlusion. Definitive hemorrhage control must not be delayed. The association of REBOA with life prognosis is not constant in observational studies using large databases [2,3]. Inappropriate use of REBOA can easily lead to complications and may lead to life-threatening situations. Therefore, it is essential to conduct REBOA with a strong risk awareness.

REBOA CATHETER PLACEMENT

Aortic Zones Related to REBOA

When performing REBOA, a balloon catheter is placed in the aorta after passing through the blood vessel via the femoral artery. The descending thoracic aorta is divided into three zones. Zone 1 extends from the origin of the left subclavian artery to the celiac artery. Zone 2 extends from the celiac artery to the lowest renal artery. Zone 3 extends from the lowest renal artery to the aortic bifurcation (Figure 1) [1].

When there is impending cardiac arrest due to refractory hemorrhagic shock or the bleeding source cannot be detected, a REBOA catheter is placed in zone 1 first. Subsequently, partial REBOA (pREBOA) or repositioning to zone 3 is considered depending on the response to resuscitation and the assumed bleeding source.

How to Confirm REBOA Placement

Due to downstream migration or blood vessels with excessive tortuosity, the REBOA catheter may become dislocated proximally or distally from the target zones 1 and 3. On the other hand, resuscitation may be delayed by using portable X-rays many times in a non-fluoroscopic environment. Therefore, after confirming the guidewire’s position using ultrasound or X-rays, repetitive imaging can be omitted before balloon inflation. After balloon inflation, it is necessary to confirm the balloon catheter position using portable radiography or fluoroscopy.

Training

The REBOA procedure itself is simple compared to other endovascular procedures, such as angioembolization or stent graft placement. Therefore, it should be performed by emergency physicians and surgeons who are at the frontline of trauma care. However, adequate REBOA implementation requires a complete understanding of its potential risks and simulation training. In addition, REBOA is not usually carried out frequently. For this reason, it is not easy to learn about REBOA in a clinical setting. Inexperienced people need repeated training to establish their knowledge [4].

THE CLINICAL INDICATIONS OF REBOA

Physiological Indications

In the absence of high-quality evidence regarding REBOA implementation, there is some expert consensus that REBOA is now widely used in acute sub-diaphragmatic hemorrhage [5]. Physiological indications for REBOA include refractory hemorrhagic shock, systolic blood pressure below 90 mmHg despite fluid resuscitation or transfusion, and advanced trauma life support (ATLS) class IV (Table 1) [6]. ATLS class III is not an indication.

Figure 1 Aortic zones related to REBOA and the anatomical and external landmark. The approximate aortic diameter in zone 1 and zone 3 is 20 mm, and 10 mm in younger males. In older people, the catheter may not follow well in the aorta due to the excessive arteriosclerotic tortuosity of blood vessels. Thus, the external measurement method may cause a significant measurement deviation compared to X-rays.

Table 1 Advanced Trauma Life Support classification (ATLS) of hemorrhagic shock.

Evidence regarding the bleeding volume and blood transfusion volume for REBOA implementation remains insufficient. Arterial access is an essential step in REBOA; however, it may be more challenging to obtain femoral artery access because the artery may not be palpable due to the circulatory collapse and spasm in hemorrhagic shock. The frequency of complications can also increase accordingly. Therefore, when REBOA is considered, femoral arterial access should be obtained using a 4-Fr, 5-Fr sheath, or 18-gauge arterial line. Afterwards, upsizing the sheath will be suitable when the decision is made to perform REBOA.

Anatomical Indications

Table 2 shows the indications for REBOA classified by zone [7,8]. Sub-diaphragmatic trauma is mainly an anatomical indication, and distal blood flow can be controlled by balloon inflation in zone 1. In pelvic fractures or lower limb trauma, REBOA may be placed in zone 3. It should be noted that although the placement in zone 3 maintains organ blood flow, the support for hemodynamics is inferior compared to that in zone 1 [9].

Indications Considering Facilities and Transportation System

It is considered that complete aortic balloon occlusion by REBOA for more than 30 minutes in zone 1 is associated with ischemic complications and death. In principle, definitive hemostasis should be initiated within 15 minutes after aortic balloon occlusion. Thus, a trauma management system in which definitive hemostasis can be performed at the same facility after REBOA implementation is ideal [7]. On the other hand, patients should be transferred to higher-level medical institutions if definitive hemostasis is not available at their institution. However, adequate monitoring is complex with REBOA during patient transfer. Downstream migration of balloon catheters is also a concern.

Therefore, surgery in patients transferred to another hospital after REBOA must be performed with careful consideration of the risks and benefits of REBOA. From the viewpoint of organ ischemia, zone 3 occlusions for a pelvic fracture or fatal obstetric bleeding may lead to definitive hemostasis after transfer to another hospital. However, if it is unavoidable to maintain zone 1 occlusion, lifesaving may be difficult due to subsequent intestinal ischemia and necrosis. When transferring to another hospital after zone 1 occlusion, pREBOA with massive blood transfusion to maintain organ perfusion may be lifesaving.

CONTRAINDICATIONS OF REBOA

Anatomical Contraindications

REBOA regulates sub-diaphragmatic bleeding via aortic balloon occlusion. In other words, it is impossible to control bleeding proximal to the balloon catheter, but this rather worsens the bleeding. For example, REBOA is not indicated for bleeding due to massive cervical or axillary bleeding. RTACC should be generally considered in patients with severe chest injuries, including penetrating trauma and cardiac tamponade. Moreover, REBOA is not indicated for patients with suspected aortic injury based on clinical findings or diagnostic imaging [10]. Although not all bleeding proximal to the balloon catheter is contraindicated for REBOA, it must be performed cautiously. For example, splenectomy with occlusion of the aorta in zone 1 may be a reasonable choice for patients with hemorrhagic shock with severe splenic injury and multiple rib fractures. However, it should be noted that bleeding from the intercostal arteries can exacerbate a hemothorax.

Table 2 Indications for REBOA classified by zones.

Contraindications of REBOA in Clinical Practice

In trauma resuscitation, the REBOA procedure will be performed as rapidly as possible, and is often performed using X-rays or ultrasound before a detailed evaluation of the injury. REBOA is contraindicated for a bleeding source proximal to the zones of aortic balloon occlusion. However, to maintain organ perfusion (for the brain and heart, for example), REBOA might be considered simultaneously with definitive hemostasis in patients with massive cervical bleeding with impending cardiac arrest. Some studies have reported that pREBOA can control bleeding while avoiding ischemic complications [11]. However, there is no clear consensus on the implementation of REBOA in these situations.

Moreover, there is still insufficient evidence for bleeding and transfusion volumes that require REBOA deployment. It should be noted that the implementation of REBOA may lead to complications in older people with excessive arteriosclerotic tortuosity of blood vessels, terminal conditions due to malignant tumors, and severe comorbidities. Therefore, in trauma resuscitation, the patient’s risk and benefit must be evaluated based on limited time and clinical information. In such difficult situations, prompt and careful decisions to implement REBOA are required. In addition, it is essential to establish a trauma management system that includes resuscitation, hemostasis, and intensive care after REBOA to bring out the potential of REBOA as a means of resuscitation.

CURRENT CONTROVERSIAL TOPICS AND FUTURE DIRECTION ABOUT REBOA

Chest Trauma

REBOA regulates blood flow distal to zones 1 or 3 by aortic occlusion. Thus, REBOA is not indicated for bleeding control proximal to the left subclavian artery. However, there are varied degrees of chest trauma. There are some opinions that REBOA may be feasible in chest trauma, although mild lung contusion, pneumothorax, and rib fractures may exacerbate bleeding from the chest [12,13]. Besides, there are various management strategies for REBOA, such as combined use with thoracotomy and partial REBOA [11,14]. Currently, the implementation of REBOA for chest trauma is controversial.

Intracranial Hemorrhage

In patients with head trauma, an increase in the proximal blood pressure may exacerbate intracranial hemorrhage. However, REBOA may not always be harmful to the brain. Secondary brain damage may occur due to insufficient cerebral perfusion in the presence of traumatic brain injury with hemorrhagic shock. In such cases, pREBOA may increase the proximal blood flow and maintain cerebral perfusion.

RESCUE Balloon (Tokai Medical Products, Aichi, Japan) and IABO Block Balloon (Senko Medical Instrument Mfg. Co., Ltd., Tokyo, Japan) are widely used REBOA catheters in Japan. According to these package inserts, REBOA is contraindicated in the presence of intracranial hemorrhage. However, whether intracranial hemorrhage is present before REBOA implementation cannot be evaluated in the trauma bay. In several countries, REBOA is not always contraindicated in the presence of intracranial hemorrhage [5]. Thus, the decision on whether to perform REBOA may vary depending on the management system of intracranial hemorrhage.

REBOA implementation is hesitant when intracranial hemorrhage is apparent. However, it is necessary to evaluate patients’ risks and benefits from limited circumstances, time, and clinical information. In such limited situations, prompt and careful decisions to implement REBOA are required.

Pediatric Trauma

REBOA is rarely performed in children compared to adults. Retrospective observational studies using large databases suggest that REBOA is feasible for pediatric trauma [15]; however, this is not high-quality evidence, as REBOA is rarely performed in children.

The commercially available REBOA catheters in Japan are 7 Fr (Rescue Balloon, Tokai Medical Products, Aichi, Japan), and 10 Fr (IABO Block Balloon, Senko Medical Instrument Mfg. Co., Ltd., Tokyo, Japan) for adult patients. In adult patients, a small diameter sheath (7 Fr) is associated with reduced complications of REBOA use [11]. However, it is not easy to perform REBOA in children because of the difficulty of femoral artery access and the risk of lower limb ischemia. Some studies have examined the appropriate balloon volume and catheter insertion length using computed tomography (CT) data of pediatric trauma patients [16]. However, the proper use of REBOA in children has not yet been established [17].

Future accumulation of cases and the development of smaller diameter catheters may accelerate new knowledge of REBOA in children. Considering the risk of complications, the implementation of REBOA in pediatric patients should be done with caution. In summary, resuscitative thoracotomy may be safer and more reliable under current evidence.

Prehospital Setting

REBOA can be performed in various locations in hospitals, such as emergency rooms, operating suites, angiography suites, and intensive care units [5]. There has also been an attempt to implement REBOA in a prehospital setting. However, it is not easy to evaluate the indications for REBOA in a prehospital setting.

In the United Kingdom, REBOA in zone 3 for pelvic fractures has been reported in a prehospital setting [18]. However, this was a case series with no high-quality evidence. Under limited situations, prehospital REBOA may be feasible and valuable. However, the implementation of REBOA in the prehospital setting has not yet reached a clear consensus. In Japan especially, where there are many older people, the catheter may not fit well in the aorta due to the excessive arteriosclerotic tortuosity of blood vessels. Moreover, it is difficult to distinguish the presence or absence of aortic injury in a prehospital setting without chest radiography or CT in polytrauma patients.

On the other hand, ultrasound-guided arterial access in the prehospital setting may facilitate changes in REBOA after hospital arrival. Arterial lines can be used for continuous arterial pressure monitoring, even if REBOA is not performed. Thus, arterial access before the hospital is an advantage in trauma management.

Future Direction

In developing the novel REBOA catheter, it is crucial to avoid complications and perform effective aortic occlusion. When pREBOA is performed, it is possible to avoid an excessive increase in blood pressure and to regulate distal blood flow. From this, pREBOA is a valuable procedure for avoiding lower limb ischemia, which is a severe complication of REBOA. However, the implementation of pREBOA requires frequent adjustment of the balloon injection volume. The novel REBOA catheter, pREBOA-PRO (Prytime Medical, Boerne, TX, USA), is equipped with a mechanism for safely adjusting pREBOA. The pREBOA-PRO catheter has balloons of different diameters, regulating partial distal perfusion via dual flow channels. According to the results of animal experiments, the use of pREBOA-PRO may reduce ischemic complications compared to conventional catheters [19,20].

SUMMARY

REBOA is a resuscitation procedure for refractory hemorrhagic shock; however, inappropriate use of REBOA can easily lead to complications and may lead to life-threatening situations. We must fully understand the indications and contraindications for REBOA use. In addition, we must be well trained in REBOA and avoid complications.

Acknowledgments

We thank all founding members of the Japanese Society of Diagnostic and Interventional Radiology in Emergency Critical Care and Trauma (DIRECT): Takayuki Irahara (Aichi Medical University Hospital, Aichi), Tomohiro Funabiki (Fujita Health University, Aichi), Yosuke Matsumura (Chiba Emergency Medical Center, Chiba), Takuya Sugiyama (Chiba Emergency Medical Center, Chiba), Makoto Aoki (Japan Red Cross Maebashi Hospital, Gunma), Futoshi Nagashima (Toyooka Public Hospital, Hyogo), Takaaki Maruhashi, Satoshi Tamura, Ryoichi Kitamura, Yutaro Kurihara (Kitasato University school of Medicine, Kanagawa), Satomi Senoo (Saiseikai Yokohamashi Tobu Hospital, Kanagawa), Yuri Kon (St. Marianna University School of Medicine, Kanagawa), Ken Shinozuka (Kyoto University Graduate School of Medicine, Kyoto), Shinya Onishi (Osaka University Graduate School of Medicine, Osaka), Ryosuke Usui (Rinku General Medical Center, Izumisano City, Osaka), Suguru Hitomi (Saitama Red Cross Hospital, Saitama).

Ethics Statement

(1) All the authors mentioned in the manuscript have agreed to authorship, read and approved the manuscript, and given consent for submission and subsequent publication of the manuscript.

(2) The authors declare that they have read and abided by the JEVTM statement of ethical standards including rules of informed consent and ethical committee approval as stated in the article.

Conflicts of Interest

Yosuke Matsumura was a clinical advisory board member of Tokai Medical Products (2015–2017). The other authors declare that they have no conflicts of interest.

Funding

This research was supported in part by research grants from The General Insurance Association of Japan.

Author Contributions

KI was responsible for drafting, editing, and submission of the manuscript. YM critically appraised the manuscript. KI, SS, MT and YM contributed to the critical revision of the manuscript for important intellectual content and provided intellectual input to the research and manuscript. All authors read and approved the manuscript.

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