Chapter 46: Resuscitative Endovascular Balloon Occlusion of the Aorta for Vascular Trauma

INTRODUCTION

Uncontrolled hemorrhage remains the leading cause of preventable death in most military and civilian trauma patients that present to the hospital.^1,2 ATLS (advanced trauma life support) dictates immediate control of hemorrhage as one of the most important aspect of management. Direct pressure and tourniquet-based proximal control can suffice to obtain extremity hemostasis, but a significant proportion of patients with torso injuries have noncompressible hemorrhage. Effective operative management for these patients includes aortic occlusion by either resuscitative endovascular balloon occlusion of the aorta (REBOA) and resuscitative thoracotomy with aortic cross clamping.

REBOA is currently a reliable means of obtaining torso hemorrhage control. This gives time for the trauma surgeon to achieve definitive operative hemostasis of torso injuries. REBOA represents a significant expansion of the trauma surgeon’s tool kit for hemorrhage control and potential salvage of these patients.

HISTORICAL PERSPECTIVE OF AORTIC CONTROL FOR TORSO HEAMMORAGE

Although the oldest reported successful case of resuscitative thoracotomy dates as far back as 1896 by Luwig Rehn, the first formal report of an immediate ED thoracotomy for a hemodynamically unstable trauma patient was by Beall et al., in 1967.^3,4 The applicability of the technique was further broadened in 1976 when Ledgerwood described pre-laparotomy thoracotomy with aortic clamping for abdominal exsanguination.⁵ The left lateral thoracotomy with aortic cross clamping avoided hemodynamic collapse caused by a laparotomy and associated release of tamponade of an abdominal bleed. It also gave access to repair cardiac injuries, release cardiac tamponade, and perform open cardiac massage.

In contrast to the open technique, the minimally invasive endovascular approach to proximal aortic control was first described in the military by CW Hughes in 1954, but was not widely utilized due to the cumbersome nature of early endovascular techniques and lack of appropriate training and equipment.⁶ There were civilian attempts made in the pre-endovascular era in the 1980s to expand on the concept, but had poor outcomes.⁷ With the advent of the endovascular era in the early 2000s, and increased experience of the vascular surgeons, REBOA became common to control hemorrhage in the setting of a ruptured abdominal aortic aneurysm.⁸ This led to a renewed interest in REBOA for trauma hemorrhage control. High-quality translational research with animal models was conducted with promising results including improved hemorrhage control, rapid improvement in systolic blood pressures, reduction in acidosis, and improved outcomes to a thoracotomy. These studies lead to a resurgence in REBOA use by the trauma surgeon in the late 2000s for abdominal injuries with promising results from the AAST (American Association for Surgery of Trauma) AORTA study group. In the review, 85 REBOA patients were compared to 202 resuscitative thoracotomy patients, and survival was higher in the REBOA group (10% vs 3%).^9,10

INDICATIONS

There is not enough data to describe absolute indications for REBOA; however, all patients ...