2. Retrograde Endovascular Balloon Occlusion of the Aorta (REBOA)
Resuscitative
Retrograde Endovascular Balloon Occlusion of the Aorta (REBOA)
Hi, I’m Dr Jim Vretis and today I’m going to talk to you about REBOA. REBOA used to be called Retrograde Endovascular Balloon Occulsion of the Aorta, but the term I like best, and the one you see most often in the Trauma literature, is Resuscitative Endovascular Balloon Occlusion of the Aorta

3. REBOA is an adjunct in the setting of hemorrhagic shock and an alternative to thoracotomy with aortic compression
REBOA is an adjunct in the setting of hemorrhagic shock and an alternative to thoracotomy with aortic compression

4. Objectives Review background Explain rationale Establish indications
Itemize resources
Describe technique for REBOA
During this presentation we will review the background, explain the rationale, discuss indications, review the resources available and describe the technique for REBOA

5. Background
Truncal hemorrhage is the leading cause of preventable death on the battlefield and in motor vehicle collisions.
Background: Truncal hemorrhage is the leading cause of preventable death on the battlefield and in motor vehicle collisions.

6. Background
Balloon occlusion of the aorta is not a new intervention. The technique was described as a resuscitative intervention by Hughes in 1954.
Balloon occlusion of the aorta as a resuscitative adjunct is not a new or novel intervention.
The technique was described in 1954 by Hughes as a resuscitative intervention in a review of three cases in which it was utilized in moribund Korean War casualties undergoing pre-operative resuscitation.

7. Rationale and Indications
Non-Compressible Torso Hemorrhage (NCTH) is defined as hemorrhage arising from trauma to the torso vessels, pulmonary parenchyma, solid abdominal organs and / or a disruption of the bony pelvis.
Rationale and Indications. Non-Compressible Torso Hemorrhage (NCTH) is defined as hemorrhage arising from trauma to the torso vessels, pulmonary parenchyma, solid abdominal organs and / or a disruption of the bony pelvis.

8. Rationale and Indications
External cardiac compression has not proven beneficial in the setting of NCTH with cardiac arrest, hypotension or shock.
Rationale and Indications: External cardiac compression has not proven beneficial in the setting of NCTH with cardiac arrest, hypotension or shock.

9. Rationale and Indications
Resuscitative aortic occlusion (RAO) for NCTH:
mitigates hemorrhage
increases afterload
increases central aortic pressure
buys time until surgical / IR hemostasis can be achieved
Resuscitative aortic occlusion (RAO) for NCTH: mitigates hemorrhage. It increases afterload. It also increases central aortic pressure. And most importantly, it buys time until surgical / IR hemostasis can be achieved

10. RAO Indications In pulseless patients determine the following:
1. Mechanism and pattern of injury
2. Duration of CPR
3. Presence of an organized, narrow-complex cardiac rhythm and / or organized cardiac activity by FAST exam
Prior to RAO in pulseless patients you must determine the following: Mechanism and pattern of injury. The duration of CPR. The presence or absence of an organized, narrow-complex cardiac rhythm on a cardiac monitor and / or organized cardiac activity by FAST exam

11. RAO Indications
If RAO is to be performed, closed chest cardiac massage can continue while the surgeons are preparing for this procedure.
If RAO is not to be performed, resuscitative efforts should cease unless there is a compelling reason to consider a non- traumatic cause of the arrest.
If resuscitative aortic occlusion is to be performed, closed chest cardiac massage can continue while the surgeons are preparing for this procedure. If RAO is not to be performed, all resuscitative efforts should cease unless there is a compelling reason to consider a non- traumatic cause of the arrest; i.e. cardiac arrest from myocardial infarction while driving to the hospital for chest pain.

12. RAO Indications
Early identification of patients with pulses who are at risk for profound shock or traumatic arrest is essential.
Early application of RAO / REBOA prior to arrest can lead to improved outcomes.
More RAO indications: Early identification of patients with pulses who are at risk for profound shock or traumatic arrest is essential. Early application of RAO / REBOA prior to arrest can lead to improved outcomes. Obviously the best treatment for cardiac arrest is to avoid the arrest in the first place.

13. RAO Indications
Resuscitative aortic occlusion (RAO) has traditionally required a thoracotomy or a laparotomy for aortic exposure.
This procedure usually occurs in the ER resuscitation bay where a left anteriolateral thoracotomy and direct aortic compression are performed.
Resuscitative aortic occlusion (RAO) has traditionally required a thoracotomy or a laparotomy for aortic exposure. For trauma patients in extremis, this procedure usually occurs in the Emergency Department resuscitation bay where a left anteriolateral thoracotomy is performed and direct aortic compression is attempted.

14. RAO Techniques Resuscitative thoracotomy
Trans-abdomoinal Aortic Occlusion
REBOA
RAO Techniques: The most common RAO technique is the left anterolateral thoracotomy. There is also Trans-abdomoinal Aortic Occlusion and of course, REBOA

15. 1. Resuscitative Thoracotomy
Aortic occlusion is best performed through a left anterolateral thoracotomy.
Resuscitative Thoracotomy with Aortic occlusion is best performed through a left anterolateral thoracotomy.

16. Resuscitative Thoracotomy
Resuscitative thoracotomy with RAO has:
high mortality rate
potential for casualty morbidity
potential for trauma team morbidity
high resource utilization
Resuscitative thoracotomy with RAO has a high mortality rate, great potential for casualty morbidity, moderate potential for trauma team morbidity and a high resource utilization. Nonetheless, recent military trauma data from Afghanistan and Iraq indicate that there is a reasonable probability of long-term survival and recovery following RAO in appropriately selected patients

17. 2. Trans-abdominal Aortic Occlusion
The aorta can also be occluded trans-abdominally at any point along its length. It can be occluded with the application of a clamp, compression with a retractor, or manually.
2. Trans-abdominal Aortic Occlusion: The aorta can also be occluded trans-abdominally at any point along its length. It can be occluded with the application of a clamp. By compression with a retractor, or manually. In obese patients a trans-thoracic approach to the aorta is sometimes preferable.

18. 3. REBOA
REBOA is an alternative to resuscitative thoracotomy in some cases of traumatic arrest.
An endo-aortic balloon can be placed preemptively in patients with high-risk injury patterns and unstable physiologic parameters
3. REBOA: REBOA is an alternative to resuscitative thoracotomy in some cases of traumatic arrest. An endo-aortic balloon can be placed preemptively in patients with high-risk injury patterns and unstable physiologic parameters. REBOA can be proactive rather than reactive in appropriately selected patients.

19. REBOA Indications
REBOA is performed using transfemoral arterial access for aortic occlusion and allows for monitoring and support of central circulation in patients at risk of imminent cardiovascular collapse.
REBOA is performed using transfemoral arterial access for aortic occlusion. REBOA allows for monitoring and support of central circulation in patients at risk of imminent cardiovascular collapse. Animal studies have demonstrated the benefit of REBOA in shock with occlusion times of up to 90 minutes.

20. Positioning of the Balloon (Zones of the Aorta)
Positioning of the Balloon (Zones of the Aorta): Zone I is the descending thoracic aorta between the origin of the left subclavian and celiac arteries. Zone II represents the paravisceral aorta between the celiac and the lowest renal artery. Zone III the infrarenal abdominal aorta between the lowest renal artery and the aortic bifurcation.
Zone I is the descending thoracic aorta
Zone II represents the paravisceral aorta
Zone III the infrarenal abdominal aorta

21. RAO algorithm

22. ALGORITHM FOR THE MANAGEMENT OF PROFOUND SHOCK IN PATIENTS WITH NCTH
REBOA I is placement of aortic balloon in the thoracic aorta typically 2-8 cm above the xyphoid
REBOA III is placement of aortic balloon directly above the aortic bifurcation usually 1-2 cm above the umbilicus
REBOA I: Placement of aortic balloon in the thoracic aorta
REBOA III: Placement of aortic balloon directly above the aortic bifurcation

23. REBOA Resources and Technique
Arterial access and positioning of sheath
Selection and positioning of the balloon
Inflation of the balloon
Deflation of the balloon
Sheath removal

24. Establishing Arterial Access
Access to the arterial circulation for REBOA for trauma should be obtained through the femoral artery using one of three techniques:
percutaneous,
open exposure (i.e., cut down)
exchange over a guide wire from an existing femoral arterial line.
Establishing Arterial Access: Access to the arterial circulation for REBOA for trauma should be obtained through the femoral artery using one of three techniques: percutaneous, open exposure (i.e., cut down) or exchange over a guide wire from an existing femoral arterial line. Percutaneous access is now commonly accomplished under ultrasound guidance using the same probe used for the FAST examination. Ultrasound or direct surgical identification of the femoral artery lateral to the vein is especially important in the hypotensive patient without a palpable pulse. A quick reminder that recent studies have shown that the “femoral pulse” most commonly identified during closed chest cardiac compressions is in reality venous plusations in femoral veins.

25. Establishing Arterial Access
The skills and technology for REBOA are available. It provides a less invasive but expedient means to control life threatening hemorrhage.
The skills and technology for REBOA are readily available. REBOA provides a less invasive but still expedient means to control life threatening hemorrhage. The skill set for REBOA insertion is the seldenger technique we are all familiar with for placing lines. The technology for REBOA is the CODA catheter by Cook Medical.
Skill:
Technology:

26. Selection and Positioning of Initial Sheath
Common sheaths are 5 Fr to 8 Fr and come in lengths from 8 cm to 15 cm.
The sheath can also be placed after removing an existing arterial line over a wire (i.e., “rewiring”).
Selection and Positioning of Initial Sheath: Common sheaths are 5 Fr to 8 Fr and come in lengths from 8 cm to 15 cm. The sheath can also be placed after removing an existing arterial line over a wire (i.e., “rewiring”).

27. SELECTION OF THE BALLOON
Any balloon inflated inside the aorta to occlude flow must be soft or compliant and of large diameter.
SELECTION OF THE BALLOON: A balloon inflated inside the aorta to occlude flow must be soft or compliant and of large diameter. It is critical that stiff or noncompliant balloons be avoided as their inflation inside the aorta poses a higher risk of damage to the vessel including dissection and / or rupture.

28. SELECTION OF THE BALLOON
Examples of compliant balloons with their range of diameter and required sheath sizes are:
Coda balloon (Cook Medical): 32 mm to 40 mm, 14 Fr
Reliant balloon (Medtronic): 10 mm to 46 mm, 12 Fr
Berenstein balloon (Boston Scientific): 11.5 mm, 6 Fr.
MORE ON THE SELECTION OF THE BALLOON: Examples of compliant balloons with their range of diameter and required sheath sizes are: the Coda balloon (Cook Medical): 32 mm to 40 mm, 14 Fr. The Reliant balloon (Medtronic): 10 mm to 46 mm, 12 Fr and the Berenstein balloon (Boston Scientific): 11.5 mm, 6 Fr.

29. SELECTION OF THE BALLOON
The balloon which has greatest application to young trauma patients is the Coda.
The balloon which has greatest application to young trauma patients is the Coda balloon by Cook Medical as it is unlikely for young trauma patients to have ectactic aortas.

30. Inflation of the Balloon
A large-volume syringe is filled with a half-and-half solution of sterile saline and iodinated contrast.
The balloon is inflated until the outer edges of the balloon change from convex to parallel as the balloon takes on the contour of the aortic wall.
Inflation of the Balloon: A large-volume syringe (30–60 mL) is filled with a half-and-half solution of sterile saline and iodinated contrast. This mixture allows radiologic visualization of balloon inflation as well as a more rapid inflation and deflation by reducing the viscosity of the contrast solution. The balloon is inflated until the outer edges of the balloon change from convex to parallel as the balloon takes on the contour of the aortic wall, this should be confirmed radiologically. One may notice under fluoroscopy that during systole, the balloon will change shape and create a “mushroom cap” as it is pulsed inferiorly.

31. Securing the Inflated Balloon, Sheath, and Wire Apparatus
It is important to hold the balloon, sheath, and wire securely so they do not change position as the central aortic pressure increases.
Securing the Inflated Balloon, Sheath, and Wire Apparatus: It is important to hold the balloon, sheath, and wire securely so they do not change position as the central aortic pressure increases and pushes the balloon caudally. Although the balloon, sheath, and wire can be secured with sutures or an occlusive dressing that pin the apparatus to patient, the most reliable way to keep them in the desired location is to assign an assistant the task of holding the apparatus in place until balloon deflation is desired.

32. DEFLATION OF THE BALLOON
Care must be taken to deflate the balloon slowly as this step can be anticipated to result in a significant decrease in afterload and hypotension.
After prolonged balloon inflation, deflation of the balloon can be expected to result in a reperfusion washout of metabolic byproducts, and acidosis.
Intermittent balloon inflation and deflation may be necessary until hemodynamic stability is restored.
DEFLATION OF THE BALLOON: Once the decision to attempt deflation is made, care must be taken to deflate the balloon slowly as this step should be anticipated to result in a significant decrease in afterload and in hypotension. The main operator should be the person to deflate the balloon while the assistant continues to hold the balloon, sheath, and wire in the desired location. After prolonged balloon inflation, deflation of the balloon can be expected to result in a reperfusion washout of metabolic byproducts, and in acidosis. Intermittent balloon inflation and deflation may be necessary until hemodynamic stability is restored.

33. REMOVAL OF THE BALLOON AND SHEATH
After REBOA is no longer required, the deflated balloon and wire may be removed from the sheath which should then be flushed.
The large diameter sheaths are best removed with open surgical exposure of the femoral artery.
The resulting arteriotomy should be have a primary closure.
Restoration of flow through the arterial segment should be confirmed.
REMOVAL OF THE BALLOON AND SHEATH: After REBOA is no longer required, the deflated balloon and wire may be removed from the sheath which should then be flushed with heparinized saline. The large diameter sheaths required to deploy the currently available balloons are best removed with open surgical exposure of the femoral artery. The resulting arteriotomy should be closely examined and tailored if necessary to allow primary transverse closure. Restoration of flow through the arterial segment can be confirmed using manual palpation for pulses and use of continuous wave Doppler.

34. Joint Theater Trauma System Clinical Practice Guideline
The material for this presentation was largely taken from the Joint Theater Trauma System Clinical Practice Guideline entitled “Resusciatative Endovascular Ballon Occlusion of the Aorta for Hemorrhagic Shock” dated 16 June 2014.

35. REBOA In The News
On 16 June 2014, incidentally the same date that the Joint Theater Trauma System Clinical Practice Guideline was published, the London Air Ambulance Service operating out of the Royal London Hospital performed the world’s first roadside REBOA insertion.

36. References
1.Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J. Trauma. 2011: 71(6):
2 Hughes CW. Use of an intra-aortic balloon catheter tamponade for controlling.intraabdominal hemorrhage in man. Surgery. 1954;36: 65–68.
3.Edens JW, Beekley AC, Chung KK, Cox ED, Eastridge BJ, Holcomb JB, et al. Longterm outcomes after combat casualty emergency department thoracotomy. Journal of the American College of Surgeons. American College of Surgeons; 2009 Aug;209(2):188–97.
4.Tien HC, Spencer F, Tremblay LN, Rizoli SB, Brenneman FD. Preventable deaths from hemorrhage at a level I Canadian trauma center. The Journal of Trauma: Injury,Infection, and Critical Care Jan;62(1):142–6.
5.Stannard A, Morrison JJ, Scott DJ, Ivatury RA, Ross JD, Rasmussen TE, et al. The epidemiology of noncompressible torso hemorrhage in the wars in Iraq and Afghanistan. J Trauma Acute Care Surg. 2012;00(00):1–5.
6. Mattox K, Feliciano D. Role of external cardiac compression in truncal trauma. The Journal of Trauma. 1982;64(1):1–7.
7. White JM, Cannon JW, Stannard A, Burkhardt GE, Spencer JR, Williams K, et al. Direct vascular control results in less physiologic derangement than proximal aortic clamping in a porcine model of noncompressible extrathoracic torso hemorrhage. The Journal of Trauma: Injury, Infection, and Critical Care Nov;71(5):1278–86; discussion
8.Seamon MJ, Fisher C a, Gaughan J, Lloyd M, Bradley KM, Santora T a, et al. Prehospital procedures before emergency department thoracotomy: “scoop and run” saves lives. The Journal of Trauma: Injury, Infection, and Critical Care Jul;63(1):113–20.
9.Kidher E, Krasopoulos G, Coats T, Charitou A, Magee P, Uppal R, et al. The effect of prehospital time related variables on mortality following severe thoracic trauma. Injury. Elsevier Ltd; 2011 May 10;
10. Burlew CC, Moore EE, Moore F a, Coimbra R, McIntyre RC, Davis JW, et al. Western Trauma Association critical decisions in trauma: resuscitative thoracotomy. J Trauma Acute Care Surg Dec;73(6):1359–63; discussion 1363–4.

37. More References
11. Seamon MJ, Fisher C a, Gaughan JP, Kulp H, Dempsey DT, Goldberg AJ. Emergency department thoracotomy: survival of the least expected. World Journal of Surgery Apr;32(4):604–12.
12. Seamon MJ, Pathak AS, Bradley KM, Fisher C a, Gaughan J a, Kulp H, et al. Emergency department thoracotomy: still useful after abdominal exsanguination? The Journal of Trauma: Injury, Infection, and Critical Care Jan;64(1):1–7; discussion 7–8.
13. Avaro J-P, Mardelle V, Roch A, Gil C, De Biasi C, Oliver M, et al. Forty-minute endovascular aortic occlusion increases survival in an experimental model of uncontrolled hemorrhagic shock caused by abdominal trauma. The Journal of Trauma: Injury, Infection, and Critical Care Sep;71(3):720–5; discussion 725–6.
14. Working Group, Ad Hoc Subcommittee on Outcomes AC of S-C on T. Practice management guidelines for emergency department thoracotomy. J Am Coll Surg. 2001;7515(01):303–9.
15. Ledgerwood AM, Kazmera M, Lucas CE. The role of thoracic aortic occlusion for massive hemoperitoneum. J Trauma. 1976;16:610–615.
16. Gupta BK, Khaneja SC, Flores L, Eastlick L, Longmore W, Shaftan GW. The role of intra-aortic balloon occlusion in penetrating abdominal trauma. J Trauma. 1989;29:861– 865.
17. White JM, Cannon JW, Stannard A, Markov NP, Spencer JR, Rasmussen TE. Endovascular balloon occlusion of the aorta is superior to resuscitative thoracotomy with aortic clamping in a porcine model of hemorrhagic shock. Surgery. 2011;150:400–409.
18. Avaro JP, Mardelle V, Roch A, et al. Forty-minute endovascular aortic occlusion increases survival in an experimental model of uncontrolled hemorrhagic shock caused by abdominal trauma. J Trauma. 2011;71: 720–725.
19. Martinelli T, Thony F, Declety P, et al. Intra-aortic balloon occlusion to salvage patients with life-threatening hemorrhagic shock from pelvic fractures. J Trauma. 2010;68:942– 948

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