Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a medical procedure used in emergency situations for severe internal bleeding. It temporarily controls massive hemorrhage within the torso, providing a crucial window for medical teams to stabilize patients before definitive surgical repair. This intervention is reserved for critical care scenarios where rapid blood loss threatens life.
Understanding the Mechanism
The REBOA procedure involves inserting a thin, flexible catheter into the femoral artery in the groin. This catheter is guided through the arterial system to the aorta, the body’s largest artery. Once positioned, a small balloon at the tip is inflated, temporarily blocking blood flow and reducing bleeding downstream.
The aorta is divided into “zones” for REBOA placement.
Zone 1
Zone 1 is the upper descending aorta, from below the left subclavian artery to the celiac artery. Occlusion here controls bleeding in the abdomen, pelvis, and lower extremities.
Zone 3
Zone 3 is the infrarenal aorta, from the lowest renal artery to where the aorta splits into leg arteries. Occlusion here controls bleeding specifically in the pelvis and lower extremities, preserving blood supply to abdominal organs.
Zone 2
Zone 2, between Zone 1 and Zone 3, is generally avoided for balloon inflation. This is due to the risk of depriving vital organs like the kidneys and intestines of blood flow.
Clinical Applications
REBOA is indicated for patients with severe hemorrhagic shock due to non-compressible torso hemorrhage. This bleeding, often from major pelvic fractures, abdominal trauma, or certain chest injuries, cannot be stopped by direct pressure. Temporarily occluding the aorta helps maintain blood pressure to the brain and heart while reducing blood loss in the injured area.
This procedure serves as a temporizing measure, buying critical time for rapidly deteriorating patients to reach an operating room for definitive surgical repair. It is performed in specialized medical settings like trauma centers and emergency departments. While primarily used in trauma, REBOA has also been explored in non-traumatic scenarios, including obstetric emergencies like postpartum hemorrhage and massive gastrointestinal bleeding.
Important Considerations
REBOA use is time-sensitive. The procedure must be deployed rapidly, and balloon inflation time limited. Prolonged occlusion in Zone 1 is advised for no more than 30 minutes, as longer durations can lead to metabolic derangement and organ damage. For Zone 3, occlusion times might extend to around 90 minutes, though shorter times are preferred.
REBOA requires specialized medical teams with specific training due to its technical nature and the critical condition of patients. Potential complications include ischemia, a lack of blood flow to tissues below the balloon, and reperfusion injury, which is damage that occurs when blood flow is restored after a period of ischemia. Other risks involve injury at the access site, such as hematoma or damage to the artery.
These risks underscore that REBOA is a temporary, last-resort intervention used in life-threatening circumstances, not a definitive treatment for bleeding. Ongoing research continues to evaluate its effectiveness and potential risks, with some studies suggesting REBOA may increase mortality in certain patient groups. This emphasizes the need for careful patient selection.