Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) was developed to help fulfill one of the major tenets of trauma patient management — stop massive exsanguination.
While REBOA has many supporters, controversies surrounding both its placement and efficacy abound. Even physicians who are enthusiastic about REBOA (including this author) acknowledge the accompanying risks, which include both iatrogenic and ischemic complications.
Based on my personal experience, here are three easy changes that trauma professionals can implement to address the three most commonly encountered problems with REBOA.
1. Reduce dissection risk by lengthening the introducer sheath
The most common iatrogenic complication with the current REBOA device is dissection of the vessel upon its introduction. Physicians can guard against this complication by using an introducer sheath that is long enough to terminate in the distal aorta, just above its bifurcation.
The key fact here is that the sheath is advanced over a guidewire. When the existing REBOA device is then advanced through this sheath, it exits the sheath in the large-caliber aorta.
This simple modification allows the REBOA to be advanced in an atraumatic fashion through the iliac arteries, which are often small and in spasm in the hypovolemic trauma patient. The pigtail catheter of the REBOA can easily form in the significantly larger aorta.
2. Guard against ischemic complications by establishing an inflation/deflation protocol
Animal studies show that ischemic complications result when REBOA inflation times exceed 30 minutes. This is a reasonable safety threshold until data is gathered from formal prospective studies. But no matter what threshold your center chooses, the key to ensuring patient safety is to establish an inflation/deflation protocol.
If a center deems an occlusion time of up to 30 minutes to be safe, then start with a protocol of 15 minutes up / 1 minute down. Controlling the balloon is a simple matter, and the inflation/deflation maneuver can be assigned to any ancillary staff.
One note: Other than on the battlefield or in a remote location, there is no indication for continuous inflation times to ever reach 60 minutes.
3. Improve individual and team skills by mandating IR-led training
When aortic stent grafts were originally introduced, the manufacturers mandated that training must include an interventional radiologist (IR). This requirement acknowledged the fact that IRs pioneered literally all percutaneous endovascular procedures and had incomparable experience in the use of guidewires, catheters, balloons and stents.
This training approach for aortic stent grafts was very successful, and it has allowed vascular surgeons to achieve the level of expertise in the deployment of endografts that they demonstrate today. Unfortunately, IR involvement has largely been left out of both the REBOA design process and training in the use of the REBOA device.
In my opinion, companies that manufacture REBOA systems should require users to complete a course supervised by Interventional Radiology. Until then, centers can and should establish REBOA training programs that incorporate IR specialists.
Learn more at “How to Save a Life”
To learn more about current endovascular and interventional techniques in the care of trauma patients, I invite you to attend How to Save a Life: IR and Surgical Management of the Trauma Patient.
This multidisciplinary meeting sponsored by the University of Chicago will promote the efficient management of the trauma patient using state-of-the-art IR equipment and procedures. The focus will include embolization, balloon occlusion, stent, and stent-graft placement, as well as other downstream interventions. Distinguished presenters will include Peter Rhee, Deb Allen and Kenneth Mattox.
This conference will take place October 9-11, 2022, at Disney’s Yacht and Beach Club in Lake Buena Vista, Florida. To find out more and register to attend, visit How to Save a Life: IR and Surgical Management of the Trauma Patient.
Jeffrey A. Leef, MD is a professor of radiology and the Director of Interventional Radiology Trauma at the University of Chicago.