Complete and Partial Resuscitative Endovascular Balloon Occlusion of the Aorta for Hemorrhagic Shock

Hemorrhage is the leading cause of preventable death in trauma patients. And this new partial REBOA device not only provides hemorrhage control but also decreases reperfusion injury and distal ischemia. The main advantage of true partial REBOA is that it extends the safe occlusion time, breaking the traditional 30-minute time barrier in zone 1 complete occlusion cases.

The implications of dealing with patients who are hypertensive from non-compressible truncal hemorrhage are profound. With true partial REBOA, it allows us to decrease reperfusion injury, reduce intraoperative bleeding, which thus reduces blood product usage. It also allows us for surgical planning.

First, use percutaneous landmarks and ultrasound guidance to locate the common femoral artery of the patient. For safe arterial access, use the modified Seldinger technique in which a needle is used to puncture the ventral arterial wall of the common femoral artery at an angle of 45 degrees. Insert a compatible guidewire into the artery through the needle, and then remove the needle.

Place a 4-French sheath with a dilator firmly over the wire into the artery. Keep the sheath in place and remove the wire and the dilator. Transduce the common femoral arterial line.

To confirm arterial placement, verify the waveform and transduce the pressure. Use the Seldinger technique with a 0.035 inch wire to upsize to a compatible 7-French sheath. Remove the wire and dilator.

Pass the 7-French sheath over the guidewire. Then connect the distal arterial line to the side arm of the sheath. To prepare the catheter, according to the manufacturer's instructions, attach a 30 milliliter syringe with normal saline to the BAL port to prime the safety valve of the catheter while leaving the orange peel away in place.

Then use the syringe to pull a vacuum to evacuate the air and close the stopcock. Advance the orange peel away to straighten and cover the atraumatic Ptip for insertion. Connect the proximal arterial line to the ART port on the device and flush.

For performing REBOA, insert the orange peel-away approximately five millimeters into the hemostasis valve on the sheath until the peel-away stops. Then advance the dedicated partial occlusion catheter to the desired aortic zone using zone markers and measurements on the catheter. Then remove the orange peel away from the hemostasis valve.

Flush the proximal and distal arterial lines after placing the catheter. Use imaging techniques, such as x-ray or fluoroscopy, to confirm the placement of the balloon before inflation using radiopaque markers on both ends of the balloon as references for placement. Using the patient's physiologic response as a guide, use a 30 milliliter syringe to inflate the balloon with saline to support a proximal systolic blood pressure target of 100 to 130 millimeters of mercury.

For partial REBOA, verify the presence of pulsatile flow on the distal arterial wave form measured from the sheath to ensure partial occlusion. For complete a occlusion, continue inflating until non-pulsatile blood flow is observed on the distal arterial line. Secure the device near the sheath with the securement clip and provide definitive hemorrhage control.

For removing REBOA, first, slowly deflate the balloon using a 30 milliliter syringe. Pull a strong vacuum to ensure complete evacuation of balloon volume and close the stopcock. Then remove the catheter and begin twisting the catheter during removal at the 20 centimeter mark.

This wraps the balloon around the catheter shaft so it fits through the sheath more easily. After removing the catheter, remove the sheath as soon as possible and manage the access site according to institutional protocols. When compared to complete occlusion, physicians report that partial occlusion significantly improves the transition to reperfusion, the extension of safe occlusion time, and reduces distal ischemia.

Moreover, with partial occlusion, there is a trend toward the reduction of proximal hypertension. Furthermore, in cases with occlusion times of 30 minutes or more, the reduction of distal ischemia and the extension of safe occlusion time were reported significantly more frequently than in cases of occlusion times less than 30 minutes. The most important thing to remember in the REBOA procedure is to monitor the patient's response to air occlusion to better assist you in your differential diagnosis of hemorrhage.

When we use partial REBOA, it allows us to go beyond our simple imaging techniques like x-rays and ultrasound in the trauma bay. It allows us time to obtain CT scans for surgical planning.