There are several commercially available catheters for endovascular occlusion of the aorta. Pictured is the ER-REBOA catheter (Prytime Medical) with an arterial and balloon port, measurement markings, and an atraumatic tip for insertion
Algorithm for REBOA placement. Zone I is between the left subclavian and celiac arteries. Zone III is between the lowest renal artery and the aortic bifurcation
Indications
The indications for REBOA placement remain controversial. REBOA is indicated for truncal hemorrhage that cannot be controlled by a tourniquet, junction devices, or manual pressure. Due to distal ischemia, REBOA is considered a bridge to definitive treatment and should be only temporarily deployed and followed immediately with an intervention to treat the underlying hemorrhagic source.
Thoracic trauma is considered a relative contraindication to REBOA placement, and as such, a chest X-ray is recommended prior to deployment.
Zone I occlusion is considered in patients with severe hypotension or arrest due to hemorrhage in the abdomen or pelvis. Ideal occlusion times in Zone I are less than 20–30 minutes.
Zone III occlusion is considered in patients with severe hypotension due to hemorrhage in the pelvis or perineum and can support longer occlusion times (Fig. 13.3).
(a) REBOA placement at Zone I: the descending thoracic aorta below the level of the left subclavian. (b) REBOA placement at Zone III: just above the aortic bifurcation
Procedure
Preparation and Access
The bilateral groins should be prepped and draped in the standard sterile fashion. If ultrasound is available, the common femoral artery can be accessed using ultrasound guidance and a micropuncture kit (Fig. 13.4).
It is imperative to access the artery well above the bifurcation and below the inguinal ligament in order to avoid injury to the superficial femoral artery and resultant limb ischemia, as well as accumulation of retroperitoneal hematoma due to iatrogenic iliac injury. If ultrasound is not available, open groin exploration and direct visualization of the femoral artery are appropriate (Fig. 13.5).
In some cases, a hybrid approach with skin incision and ultrasound localization is effective, especially in the severely hypotensive patient with poorly palpable pulses.
Once the common femoral artery is accessed, an introducer sheath is placed. Sheath size is dependent upon the commercially available REBOA catheter available at the institution. For example, the low-profile ER-REBOA used for the procedure below is introduced via a 7F sheath, while several other catheters require a larger sheath for access.
(a–c) Ultrasound of the groin can be used to identify the common femoral artery and vein as well as the inguinal ligament and arterial bifurcation. Once the artery is accessed, ultrasound can be used to confirm placement in the artery
Open groin exposure is a common method of accessing the common femoral artery, especially in hypotensive patients
Catheter Deployment
The following steps are specific to the ER-REBOA catheter (Prytime Medical). For other commercially available catheters, modify the below procedure accordingly.
Dependent upon desired landing zone, the approximate catheter insertion length is estimated based on external landmarks. The arterial port is flushed with saline and emptied of any air bubbles. The orange peel-away sheath is advanced in a corkscrew fashion over the catheter balloon and P-tip (Fig. 13.6). The orange peel-away sheath is inserted less than 1 cm into the arterial sheath and the REBOA catheter is advanced into the arterial lumen. Once the balloon has passed the sheath valve, the orange peel-away is divided and removed while the REBOA catheter is advanced to the desired position. Once in place, X-ray or fluoroscopy is used to guide and confirm precise positioning (Fig. 13.7). The catheter can be attached to a standard arterial line setup to allow blood pressure monitoring above the level of the balloon. The balloon is then inflated to the desired volume to achieve aortic occlusion. Inflation volume is guided by tactile feedback, imaging (Fig. 13.7), and blood pressure monitoring above the level of the balloon. Make sure to secure the catheter at the desired level (Fig. 13.8) before, during, and after inflation, as it has a tendency to migrate out. The time of balloon inflation and deflation should be meticulously recorded.
