To REBOA or not to REBOA?

Korbin Haycock, MD, FACEP, RDMS, RDCS To REBOA or not to REBOA?

Conflict of interest? • Prytime Medical loaned me the simulation model for this course • Otherwise, I have no other conflict of interest

Overview and Key Points • What is REBOA and what is the idea(s) behind it? • How do you place a REBOA catheter? • What are the indications for REBOA and what is the evidence that it works? • Possible non-trauma applications

What is Resuscitative Endovascular Balloon Occlusion of the Aorta? • A minimally invasive procedure used in place of an emergency thoracotomy for traumatic arrest • There are some contraindications and possible additional indications with the procedure • Or a means to buy a bit of time to get definitive control of bleeding not responsive to resuscitative efforts

ER REBOA

Insertion • Cannulate a femoral artery and drop a guidewire • Insert a 7Fr introducer catheter • Measure • Evacuate • Flush • Insert • Inflate • Secure

Anatomy • The aorta (when talking REBOA) is divided into 3 zones • Zone 1 • Left subclavian artery to the celiac artery • Segment about 20 cm long • Zone 2 • Celiac artery to the most distal renal artery • Segment about 3 cm long • Zone 3 • Most distal renal artery to the aortic bifurcation • Segment about 10 cm long

Anatomy Zone 1 Zone 2 Zone 3

Anatomy • External landmarks for the zones are as follows: • Zone 1: The Sternal Notch (45 cm) • Zone 3: The Xiphoid (28 cm) • We don’t put the balloon in Zone 2

Test 1 Test 2 or pelvic instability Test 3 (Brenner, 2015)

Contraindications • Severe TBI • Suspected traumatic proximal aortic transection • Traumatic arrest due to tension PTX or pericardial tamponade

Traumatic Indications • Trauma to the torso with uncontrolled hemorrhage and shock • This includes solid organ injury • Pelvic injuries

Complications • Venous placement • Placement in smaller arteries • Vascular dissection • Retroperitoneal hemorrhage • Embolic clots • Ischemia

Data from the AAST/AORTA registry (DeBuse, 2016) • Data from 8 level 1 trauma centers • 46 REBOA, 68 Open AO • REBOA with higher SBP • 90 mmHg vs 65 mmHg • Similar Mortality • 72% vs 84% (p=0.12) • Adjusted Mortality REBOA vs Open AO • (OR, 0.263; 95% CI 0.043-1.61)

Data from the AAST/AORTA registry (Brenner, 2018) • 285 patients without penetrating thoracic injury • In patients without pre-hospital CPR, REBOA had better survival to discharge • RT 3.4% vs REBOA 22.2% • And, if arrival with hypotension: • RT 0% vs REBOA 44%

Norii et al. Survival of severe blunt trauma patients treated with resuscitative endovascular balloon occlusion of the aorta compared with propensity score-adjusted untreated patients. J Trauma Acute Care Surg 2015 Apr;78(4):721-8. Inoue et al. Resuscitative endovascular balloon occlusion of the aorta might be dangerous in patients with severe trauma: a propensity score analysis. The Journal of trauma and acute care surgery. 2016 Apr;80(4):559-66

Nationwide Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta in Civilian TraumaBellal Joseph, MD et al JAMA Surg. Published online March 20, 2019. doi:10.1001/jamasurg.2019.0096 • Propensity matched retrospective analysis of REBOA vs no REBOA • REBOA with higher rates of mortality at 24 hours, AKI, leg amputations • However: • SBP in REBOA 108 mmHg, Unknown inflation times, increased time to definitive management

What about non-trauma indications? • No real evidence beyond some case reports and case studies • In principle, REBOA does make sense in multiple scenarios

Non-Traumatic Indications • Exsanguinating Ectopic Pregnancy • Upper GI bleeding (non variceal) • Gastroduodenal artery • Ruptured AAA • Cardiac Arrest

Summary • REBOA is a new technology with potential harms, but also very promising benefits • The technology is evolving and improving making REBOA safer and probably more effective • Optimal indications for REBOA still need to be explored and worked out • Ongoing research for both traumatic and non-traumatic uses of REBOA will help guide future use

References • Bellal Joseph, MD et al,. Nationwide Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta in Civilian Trauma JAMA Surg. Published online March 20, 2019. doi:10.1001/jamasurg.2019.0096 • Brenner et al., Resuscitative Endovascular Balloon Occlusion of the Aorta and Resuscitative Thoracotomy in Select Patients with Hemorrhagic Shock: Early Results from the American Association for the Surgery of Trauma's Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery Registry.J Am Coll Surg 2018 May;226(5):730-740. • DeBose et al., The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: Data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA). J Trauma Acute Care Surg. 2016 Sep;81(3):409-19 • Inoue et al. Resuscitative endovascular balloon occlusion of the aorta might be dangerous in patients with severe trauma: a propensity score analysis. The Journal of trauma and acute care surgery. 2016 Apr;80(4):559-66 • Norii et al. Survival of severe blunt trauma patients treated with resuscitative endovascular balloon occlusion of the aorta compared with propensity score-adjusted untreated patients.J Trauma Acute Care Surg 2015 Apr;78(4):721-8

To REBOA or not to REBOA?