A Balloon’s Journey Over The Red Falls

«Tempus fugit, sicut nubes, quasi naves, velut umbra» 

Vergilius Maro, Publius. Georgicon, III. c. 29 BC.

It is 4:30 PM on a pleasant Saturday shift, you are quietly enjoying a good cup of coffee when suddenly the phone buzzes…

“Quick! We have a trauma patient that will arrive in 5 minutes to the ED. It is a motorcycle collision with a suspected pelvic fracture, a penetrating injury to the right groin, and right lower limb amputation. Paramedics refer that the patient is deteriorating quickly, bleeding profusely despite the placement of two tourniquets. Cardiac arrest is possible before arrival”

Heart rate goes up, coffee goes down. Fortunately, an experienced trauma surgeon is your shift partner. Both rush to the trauma bay while your mind starts piecing together the scenario. But when you get to the ED everything is worse, in terrible chaos you can see a young man exsanguinating, HR 145 bpm, SBP <90mmHg, a lot of RBC passing, and getting lost in a puddle beneath the table. Time goes by…

Immediately your partner leads the situation, gets a left femoral arterial access, and inserts a REBOA. Shouts “blowing up the balloon”, and then, a miracle, the patient’s blood pressure climbs up and the bleeding halts. 

You excitedly comment “We have the situation under control, it’s time for another coffee!!!”. 

Your partner replies “Be aware, this has just begun, time is running out…”

Introduction

Uncontrolled hemorrhagic shock is a leading cause of potentially preventable death after traumatic injury. Mortality is most likely to occur within the first 6 h after injury, particularly in non-compressible torso areas, where hemorrhage cannot be controlled through local hemostatic maneuvers such as direct pressure. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emergent endovascular procedure designed to temporarily control non-compressible torso hemorrhage (NCTH), whereby a percutaneous inserted balloon is inflated into the aorta via the common femoral artery, thereby obstructing flow into the distal circulation (Figure 1). 

Originally introduced as a military technique (first described during the Korean War), REBOA has found its way into civilian trauma care. With advancements in catheter design and increased awareness among trauma and emergency surgeons, REBOA is gaining traction as a critical tool for resuscitative efforts in patients with traumatic injuries. 

Characteristics of the System 

Maneuver description can be summarized in five steps: 

Vascular access

The arterial access is the first and the most crucial step for its deployment. The common femoral artery can be cannulated using an open cut-down or percutaneous approach (blindly or under ultrasound guidance). There are several possible catheters and occlusion balloons, but, currently, the utilization of 4-7 Fr devices and compliant balloons tends to be the preferred option due to its feasibility and low complication rates: “The smaller the better”.  

Balloon placement

If the access sheath is placed correctly, a REBOA system can be inserted. The balloon landing place is planned before its insertion and is based on three anatomical zones (Figure 2): 

• Zone I (below left subclavian artery to celiac trunk): selected for any hemorrhages originating below the diaphragm and patients in cardiac arrest;
• Zone II (celiac trunk to renal arteries): considered as a no occlusion zone due to the high risk of complications; 
• Zone III (infrarenal, proximal to iliac bifurcation): pelvic injuries with no evidence of torso bleeding. 

Although the more sophisticated catheters are equipped with external landmarks, balloon placement can be confirmed with X-ray or fluoroscopy. Instructions for use indicate approximately 46 cm for Zone I and 28 cm for Zone III. 

Balloon inflation/deflation

The REBOA balloon is usually inflated slowly with a syringe containing a solution of saline and occasionally contrast media (8-10 mL for Zone I, and 3-5 mL for Zone III, or until resistance is felt). Correct inflation of the balloon leads to systolic blood pressure (SBP) increase and loss of femoral pulses. Don’t forget the stop-cock, hold the catheter, and fix the sheath. The international consensus statement does not recommend a total aortic occlusion time of >30 min in Zone I and >60 in Zone III. 

Once it has been successfully placed, the patient has stable hemodynamics and you are prepared for a definitive bleeding control procedure, the balloon can be deflated and removed. The main rule here is a very slow deflation and good communication with your Trauma Team. Be aware of possible complications: rebound cardiovascular collapse, recurrent bleeding, or severe reperfusion syndrome. Once the balloon is deflated, and inflation is not needed anymore, the balloon should be taken out as soon as possible.

Access withdrawal

If the patient’s status is satisfactory, sheath removal may be performed. Eventually, lower limb perfusion has to be confirmed by checking clinical pulses or using a Doppler ultrasound examination.

Indications and Contraindications

Indications 

The most important concept that must be underlined is that REBOA is an endovascular trauma tool for temporary bleeding control. Its placement is intended solely as a bridge to the definitive bleeding control procedure. 

Its essential indications are traumatic abdominopelvic or junctional hemorrhage, patients with severe postpartum hemorrhage, exsanguination secondary to iatrogenic injuries (for instance during pelvic surgery, cancer, or vascular surgery,) and in patients with severe gastrointestinal bleeding considered for emergency endoscopic treatment or angiographic embolization. It is also used in patients with traumatic arrest where massive hemorrhage is suspected and in selected cases of ruptured abdominal aortic aneurysms.

Contraindications 

Bleeding sites proximal to the left subclavian artery, thoracic hemorrhage, and bleeding sites originating in the neck are contraindications for its use. Furthermore, to date, the effects of REBOA on the progression of traumatic brain injury remain unclear and need to be carefully considered (i.e. worsening cerebral edema, increasing intracranial pressure, or exacerbating intracranial hemorrhage). 

Another essential concept is that any attempt at REBOA placement should not stop or significantly delay the resuscitation process and the definitive hemorrhage control.

Variations of REBOA Use

Complete Occlusion (cREBOA)

The traditional use of the device. The balloon is fully inflated, resulting in a complete aortic occlusion. This strategy better controls the exsanguinating situation, but it´s time-limited and has a higher risk of complications. 

Partial Occlusion (pREBOA)

The balloon volume is titrated against the patient’s blood pressure. In essence, the balloon is partially deflated to permit some blood to pass the balloon, permitting a certain degree of distal perfusion, accepting that some blood will be lost at the injury site (goal = SBP around 90mmHg). 

Intermittent Occlusion (iREBOA)

The balloon is deliberately deflated in order to provide a degree of reperfusion, and to help the surgeon or radiologist locate the focus of bleeding in a controlled manner. The refinement of the technique could probably increase the duration of aortic occlusion without ischemic complications. 

Benefits and Limitations

Benefits 

The main benefit is the capacity to temporarily control the hemorrhage, reducing the volume of blood lost and consistently the trauma-induced coagulopathy and its associated morbidity and mortality. It is therefore considered a revolutionary tool in damage control resuscitation, as a bridge to definitive bleeding control. REBOA is recognized as a minimally invasive and lower-risk procedure in comparison to emergency room thoracotomy.

By occluding the aorta, REBOA redistributes blood flow toward the heart and vital organs, effectively increasing the central blood volume. This can lead to hemodynamic stability (i.e. improved cardiac output, systemic blood pressure, mean arterial pressure, and decreased heart rate). Consequently to this redistribution of arterial flow, perfusion pressure and oxygen delivery are maintained, potentially preventing organ failure. 

The currently new atraumatic endovascular low profiles and the advanced training programs make possible its use in several situations and environments, including prehospital settings, in a safe, quick, and relatively easy way. 

Limitations

Complications may be related to vascular access, the mechanism itself, or failure of the technique. The most common are as follows: 

• Procedure-related complications: the most common overall limitation is vascular access. Catheter insertion may lead to vascular dissection, rupture, perforation or embolization, and loss of time in inexperienced hands. Other complications may be balloon migration and sheath removal issues. 
• Balloon occlusion complications: extended occlusion times in trauma patients are associated with more adverse outcomes, including ischemic problems and organ failure. 
• Systemic-related complications: prolonged occlusion carries the risk of ischemia-reperfusion injuries to distal organs, including spinal cord ischemia, acute kidney injury, and lower limb ischemia. 
• Mortality: the impact on mortality remains inconsistent, but its off-label use and training may improve it considerably.

Specific Algorithms

The use of REBOA should be guided by established protocols and algorithms to ensure patient safety, guarantee its effectiveness, and optimize outcomes (Figure 3). 

Future Directions

This relatively novel technique has revolutionized endovascular trauma management and its implementation is expanding beyond its traditional role. Emerging research and clinical innovations are paving the way for broader applications in prehospital care, cardiac arrest management, and the enhancement of training and simulation programs. 

Prehospital environment 

One of the most exciting advancements in REBOA research is its potential application in the prehospital setting. The primary goal of prehospital REBOA is to provide early hemorrhage control and hemodynamic stabilization, reducing the risk of hypovolemic cardiac arrest and early death due to exsanguination. Thus, it aims to increase the number of patients arriving alive at the hospital for definitive hemorrhage control.

Even though REBOA’s out-hospital application is not exempt from challenges and possible complications, its prehospital implementation requires a well-coordinated, adequately trained, and properly equipped healthcare system. Never stop the evacuation for any heroic REBOA maneuver.

The international expert panel agreed that REBOA can be used in civilian prehospital settings for temporary control of NCTH, provided that personnel are properly trained and protocols are established. 

Cardiac arrest 

There is emerging evidence that REBOA might have a role in non-traumatic cardiac arrest by increasing coronary and cerebral perfusion pressure during cardiopulmonary resuscitation, improving the likelihood of successful return of spontaneous circulation (ROSC). The incorporation of REBOA into cardiac arrest algorithms remains an area of debate, and there are significant logistical considerations, such as the ability to perform the procedure rapidly in an already complex resuscitation scenario. 

Training and simulation programs 

Advancements in training and simulation, such as virtual reality, are enhancing clinician proficiency, making REBOA safer and more accessible. The development of high-fidelity simulation-based training allows clinicians to practice REBOA in a controlled environment, improving technical skills, team coordination, and decision-making (Figure 4). Future training programs may include standardized certifications, competency-based assessments, and integration into existing trauma life support courses.

Conclusions 

REBOA has emerged as a powerful endovascular tool in the armamentarium of trauma and emergency care, offering a potentially life-saving procedure, especially for temporary bleeding control of NCTH. Its applications have expanded from the military to civilian trauma settings, demonstrating improved outcomes when used appropriately. While the technique is associated with risks and complications, its benefits in stabilizing hemodynamics and preventing early death are notable. Meanwhile, advancements in technology and training programs are progressing. 

The future of REBOA is promising, with potential applications extending into prehospital care and cardiac arrest management, improving the survival and chances of ROSC. The success of REBOA depends on meticulous patient selection, adherence to established protocols, and proper training of healthcare providers. As the technique evolves, it will likely become a cornerstone of damage control resuscitation, further refining its role in the management of critically injured patients.

 “Remember, REBOA is a living entity and never a definitive solution. Respect it and think before using it!” The EVTM Society. 

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How to Cite This Post

Martínez Hernández A, Marrano E, Cioffi SPB, Bellio G. A Baloon’s Journey Over the Red Falls. Surgical Pizza. Published on December 12, 2024. Accessed on May 15, 2025. Available at [https://surgicalpizza.org/trauma/balloon-journey-over-the-red-falls/].