Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a compliant, endovascular balloon designed to occlude the thoracic or lower abdominal aorta in hemorrhagic shock, for temporary control of bleeding in the abdomen or pelvis.

The REBOA catheter is placed through a sheath in the right or left common femoral artery, accessed using anatomic landmarks, ultrasound guidance, or with open surgical technique. The balloon is then inflated in the thoracic or abdominal aorta, effectively acting as a minimally invasive aortic cross-clamp.

The procedure for placing a REBOA takes only a few minutes.

REBOA is ideally suited for hypotensive patients with abdominal or pelvic bleeding and can be placed in the emergency room, intensive care unit, or the operating theater.

REBOA balloon placement can be guided and confirmed using external landmarks, X-ray, fluoroscopy, or ultrasound. Balloon inflation volumes are titrated based on invasive blood pressure monitoring, haptic feedback, and imaging.

REBOA is contraindicated in patients with intrathoracic, neck, or facial bleeding, in cases with high suspicion for blunt thoracic aortic injury, and in patients in cardiac arrest.

Aortic occlusion is a temporary, resuscitative measure and should be considered a transition to definitive care. After inflation, the patient should be immediately transported to the operating room or the interventional suite for definitive management of their traumatic injuries.

REBOA balloon inflation results in distal ischemia and as such, occlusion times should be minimized.

REBOA placement requires access to the common femoral artery. It is critical that the sheath access point is above the common femoral artery bifurcation in order to minimize the risk of distal limb ischemia.

For the purposes of REBOA placement, the thoracic and abdominal aorta is divided into three zones (Figure 24.1).

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  Zone 1: left subclavian artery to the diaphragm

  
  
  
  
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    The descending aorta passes through the diaphragm at T12–L1.

    
    
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    The external landmark for balloon inflation in Zone 1 is the mid sternum.

  
  
  
  
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  Zone 2: celiac artery to renal artery. Inflation in Zone 2 should be avoided due to risk of damage to the visceral and renal vessels, especially in patients with existing atherosclerotic disease.

  
  

  
  

  

  
  

  
  

  Figure 24.1 For the purposes of REBOA placement, the aorta is divided into three anatomic zones. Zone 1 spans distal to the left subclavian artery to the level of the diaphragm and is ideal for abdominal or pelvic bleeding. Zone 3 describes the zone of occlusion for pelvic and perineal bleeding and spans the area distal to the renal vessels and above the aortic bifurcation. Zone 2 is the region of the visceral and renal vessels, and REBOA inflation in this zone should be avoided.

  
  

  
  

  

  
  

  
  

  Figure 24.2 Access to the common femoral artery is obtained using a percutaneous or open technique. Depending on the catheter system available, a 7F or larger sheath in the common femoral artery is used for introduction of the REBOA catheter.

  
  
  
  
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  Zone 3: renal artery to aortic bifurcation

  
  
  
  
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    The renal arteries branch at the level of L2 and the aorta bifurcates into the right and left common iliac arteries at L4–L5.

  
  

There are several commercially available balloons that can be used for endovascular occlusion of the aorta. The currently available devices are used with a 7–12F introducer sheath (Fig. 24.2). Wire-based and wireless catheter kits are available and balloon inflation volumes vary based on manufacturers’ guidelines. It is imperative that the provider is familiar with and trained on the device available within the home institution, as there is wide variation in insertion technique and inflation volumes.

Additional materials for REBOA insertion are modified based on the catheter used and include additional wires, dilators, syringes, and arterial monitoring devices.

Current wireless catheter systems require a 10–30 cm³ syringe for balloon inflation, an additional 10 cm³ syringe to flush the arterial port, and ideally an arterial line set up for ongoing blood pressure monitoring once the catheter is in place.

A portable ultrasound machine with high-frequency probes (optional).

Basic open surgical tray should be available in case open cut-down is required to obtain femoral access.

Diluted injectable contrast media is instilled through the balloon port of the REBOA catheter.

An invasive arterial line and monitoring system is ideally in place to guide placement, occlusion, and postocclusion management (optional).