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REBOA: Resuscitative endovascular balloon occlusion of the aorta
Traumatic injury causes more than 5 million deaths annually, accounting for approximately 9% of all deaths worldwide. From 1999 to 2015 in the United States, injury was responsible for 21% of all years of potential life lost prior to age 70 years, followed by malignant neoplasms (19%) and heart disease (14%). Hemorrhage accounts for approximately 40% of all trauma deaths, more than 80% of all trauma deaths in the operating room, and is the most common cause of potentially preventable (treatable) death from trauma.
Severe subdiaphragmatic trauma is a frequent source of uncontrolled, noncompressible hemorrhage. For patients presenting in class III or class IV hemorrhagic shock and this injury profile, therapeutic options are limited in scope and mortality rates are very high. The use of aortic occlusion in this setting is believed to preserve cerebral and cardiac perfusion while simultaneously decreasing distal hemorrhage. The use of resuscitative thoracotomy with aortic cross-clamping in patients with blunt abdominal and pelvic hemorrhage has been associated with very poor outcomes and is considered futile care at many trauma centers. Angiographic identification of arterial injury with therapeutic embolization has proved useful for a variety of solid organ and boney pelvis injuries, but this approach requires time to assemble the interventional angiography team (approximately 1 hour). Patients that present in extremis may not survive until embolization can be performed. Clearly, additional therapeutic options are needed to improve the dismal outcomes observed for this patient population.
The use of an aortic occlusive balloon to provide temporary control of hemorrhage was first described by Hughes during the Korean Conflict. Unfortunately, neither of Hughes’ two critically injured patients survived and interest in this approach waned. With the rapid advancement of endovascular surgery and technology over the last two decades, interest in resuscitative endovascular balloon occlusion of the aorta (REBOA) in the trauma setting has increased substantially. Many trauma centers now have access to aortic occlusion balloon technology for the treatment of injured patients. Unfortunately, numerous questions remain regarding the optimal utilization and benefits of this technique for hemorrhage control.
Training
The basic endovascular techniques and instrumentation required for REBOA are well established in the realm of vascular surgery. With the introduction of a new technique or the new application of existing technology to address a clinical issue, training of surgeons and ancillary personnel is of paramount importance. There are several training paths for surgeons who plan to add this technique to their skill set. In some centers, trauma surgeons are required to attend a formal training course prior to performing REBOA in the clinical setting; other trauma centers have added REBOA to the armamentarium of trauma surgeons without additional training. Both approaches are problematic. Sending each trauma surgeon to an external training course is expensive and time-consuming. Allowing surgeons to perform REBOA without a clear understanding of the indications, technique, and required equipment is not a viable option. Since most practicing trauma surgeons have basic catheter- and wire-based skills obtained in general surgery residency or acute care surgery fellowship, a middle path involving the designation an institutional REBOA champion and an internal training program seems most appropriate. At the University of Florida, we developed an internal training program based on this concept. One trauma surgeon attended an external, 1-day (6-hour) course in basic endovascular skills for trauma. Subsequently, a brief educational program consisting of a 1.5-hour slide presentation and hands-on simulation training was performed for all trauma surgeons and senior (postgraduate year 4 and postgraduate year 5) residents. The REBOA champion was available for consultation. Brief, recurrent training sessions were conducted periodically until ongoing clinical experience obviated the requirement for this additional training. Additionally, several brief (30-minute) orientation sessions were offered to nurses and ancillary staff in the pertinent clinical areas. Support personnel participating in REBOA placement received orientation to the equipment and techniques.
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