REBOA- Past, Present, Future… in light of the new DCR CPG by JTS.

September 17, 2018

REBOA

 

Background: 

The concept of aortic balloon occlusion for hemorrhage control is not new. One case series published in 1954 described the use of REBOA in combat. Vascular surgeons have been using this technique for years to sustain patients with ruptured abdominal aortic aneurysms until they can reach the OR. Interest in REBOA for traumatic hemorrhage was re-invigorated after truncal hemorrhage was found to be responsible for over half of preventable deaths in the Eastridge study “Death on the battlefield (2001-2011): Implications for the future of combat casualty care”. With few options aside from TXA to assist with non-compressible torso hemorrhage, combat medical practitioners need additional resources to assist in prehospital hemorrhage control. In the austere setting, the goal of REBOA is to control abdominal and pelvic hemorrhage until the casualty can reach a forward surgical team.  

 

Most of the experience with REBOA originates from U.S. civilian trauma centers. Because our experience is still limited and data is still being collected, REBOA has been adopted at relatively few civilian trauma centers. Intense debate persists about appropriate timing, indications, location of balloon placement, duration of occlusion, and partial vs complete occlusion. Until we have more data, it is unlikely that REBOA will be widely implemented at civilian trauma centers. However, combat and austere medicine involves a different set of logistical constraints and a higher incidence of non-compressible truncal hemorrhage. There are no other field-expedient techniques to control this type of hemorrhage and few surgeons available in this setting for resuscitative thoracotomy. If we are going to minimize preventable death on the battlefield, one goal needs to be pushing advanced hemorrhage control techniques far-forward. With that in mind, advanced combat medics, PA’s, and physicians are being trained in REBOA. Special operation surgical teams have been deploying REBOA for some time. The training and supplies are now being distributed to all forward surgical elements in Iraq and Afghanistan. While the available REBOA data is currently in evolution, the safest use of REBOA seems to be short term occlusion of the aorta in Zone 3 for severe pelvic hemorrhage. The concept of ‘partial occlusion’ in Zones 1 and 3 is still under investigation and may confer survival benefit with fewer complications. 

 

 

 

 

Who/when/what/where?

Candidates- 

 -Hemodynamically unstable

 -In traumatic cardiac arrest patients with signs of life 

 -Suspected abdominal and/or pelvic hemorrhage, high amputations or junctional injuries

 -No evidence of thoracic hemorrhage or severe TBI

 -Needs to be considered during MARCH algorithm as soon as tactically feasible (ie during Tactical Field Care)

What-

-ER-REBOA Catheter from PryTime Medical 

-FDA approved

-Requires percutaneous or open cutdown access to common femoral artery in groin, placement of 7 French sheath

Where-

-Balloon occlusion of thoracic aorta above diaphragm (Zone 1) or just below renal arteries in the abdomen (Zone 3)

-Can be deployed in austere circumstances with sterile technique

-Casualty can be transported to definitive forward surgical care in no more than 2-4 hours

 

Data:

The data on REBOA remains controversial and is a work in progress. We have limited published data from REBOA used in combat. Dr. Rasmussen’s team published a case series of 4 REBOA deployments in austere environment in 2016. Their study showed all patients survived to Role 2 hospital and there was no evidence of any complications related to the procedure. 

 

Logistical challenges:

Time intensive (access to femoral artery typically takes longest)

Femoral artery access in hypovolemic patient challenging- commonly requires ultrasound or cutdown

Confirmation of appropriate balloon location is challenging in austere setting- options are blind, fluoro/XRay guided, ultrasound, and infrared

REBOA is an adjunct to aggressive hemorrhage control and resuscitation, should be considered a bridge to definitive management only

Complete Zone 1 occlusion tolerated for no more than 30-60 minutes

Complete Zone 3 occlusion tolerated for 2-4 hours

Deployment of REBOA requires extensive training but currently the idea training and certification processes are unknown

 

Complications:

Femoral vessel injuries ranging in severity from those requiring surgical repair to those resulting in loss of limb perfusion and ultimately limb loss

Balloon malposition or overinflation resulting in aortic dissection, rupture, perforation

Zone 2 placement with ischemic injury to kidneys resulting in kidney failure

Ischemia reperfusion injury to lower half of body including intestines if placed in Zone 1

Death (only 20% of casualties survive open or endovascular aortic occlusion in civilian studies)

 

Tips:

All REBOA supplies and equipment should be stored in pre-packaged kits

Anticipate need for REBOA and place femoral access sheath early, before patient crashes but after initial MARCH interventions are complete (ie REBOA, which should be considered as part of Massive Hemorrhage, should not come before appropriate access and resuscitation have been initiated)

REBOA course is a must (ie BEST course by American College of Surgeons) 

Have a protocol in place for REBOA indications, placement, and position confirmation

Utilize in conjunction with aggressive whole blood or MTP resuscitation strategy

Access common femoral artery at the inguinal ligament, visualize the SFA/profunda bifurcation on ultrasound and stay above it

Do not overinflate balloon (use “three to eight don’e overinflate” rule)

Catheter will migrate if not aggressively secured in place

Do not remove sheath until patient is resuscitated, hemorrhage controlled, and stabilized at Role 3 hospital.