Page 23 - Journal of Special Operations Medicine - Spring 2017

A Modern Case Series of Resuscitative Endovascular Balloon
Occlusion of the Aorta (REBOA) in an Out-of-Hospital,

Combat Casualty Care Setting

Justin D. Manley, MD; Benjamin J. Mitchell, MD;
Joseph J. DuBose, MD; Todd E. Rasmussen, MD

ABSTRACT

Background: Resuscitative endovascular balloon occlu- Introduction
sion of the aorta (REBOA) is used to mitigate bleeding
and sustain central aortic pressure in the setting of shock. Resuscitative endovascular balloon occlusion of the
The ER-REBOA catheter is a new REBOA technology, aorta (REBOA) has been demonstrated as a useful resus-
™
previously reported only in the setting of civilian trauma citative procedure in management of patients with severe
1–4
and injury care. The use of REBOA in an out-of-hospital injury and hemorrhagic shock. Occlusion of the aortic
setting has not been reported, to our knowledge. Meth- lumen using a compliant balloon proximal to the loca-
ods: We present a case series of wartime injured patients tion of hemorrhage supports life-sustaining perfusion
cared for by a US Air Force Special Operations Surgi- to the brain and heart, and mitigates or stops bleeding
5–7
cal Team at an austere location fewer than 3km (5–10 distal to the occlusion site. The hemodynamic benefits
minutes’ transport) from point of injury and 2 hours of resuscitative aortic occlusion to avert cardiovascular
from the next highest environment of care—a Role 2 collapse have long been recognized; analogous attempts
equivalent. Results: In a 2-month period, four patients to support preferential perfusion of the brain and heart
in the setting of severe hemorrhage have been proposed
Lifesaving. Combat Ready. presented with torso gunshot or fragmentation wounds, through the use of aortic cross-clamping. Not until the
hemoperitoneum, and class IV shock. Hand-held ultra-
sound was used to diagnose hemoperitoneum and fa- advent of less invasive endovascular technologies de-
™
T.A.L.O.N. IO Needle
Arrow EZ-IO T.A.L.O.N. IO Needle cilitate 7Fr femoral sheath access. ER-REBOA balloons ployed through a sheath in the femoral artery, however,
™
®

®
has aortic occlusion been able to be accomplished with-
NSN 6515-01-626-6395 were positioned and inflated in the aorta (zone 1 [n = out large open incisions in the abdomen or chest.
3] and zone 3 [n = 1]) without radiography. In all cases,
• VERSATILE: 7-site IO device REBOA resulted in immediate normalization of blood Endovascular aortic occlusion using a rudimentary bal-
(sternum, proximal humerus, proximal & distal tibia) pressure and allowed induction of anesthesia, initiation
of whole-blood transfusion, damage control laparotomy, loon device was first described during the Korean War,
• LIFE-SAVING: Delivers fluids and medications rapidly EZ-Connect ® and attainment of surgical hemostasis (range of inflation but not until the advent of endovascular aortic aneu-
Extension Set
and accurately for casualty resuscitation time, 18−65 minutes). There were no access- or REBOA- rysm repair in the 1990s was the technology used more
8–10
related complications and all patients survived to achieve commonly. Guided by data from wars in Afghanistan
• CONVENIENT: No need for additional gear, multiple needles transport to the next echelon of care in stable condition. and Iraq, the military introduced the concept of REBOA
or special removal tools Sternal as a potential solution to the scenario of noncompress-
Locator Conclusion: To our knowledge, this is the first series to ible torso hemorrhage (NCTH). 11–14 Despite significant
• SIMPLE: Designed for any level responder demonstrate the feasibility and effectiveness of REBOA innovation in the use of endovascular technologies for
in modern combat casualty care and the first to describe
use of the ER-REBOA catheter. Use of this device by the treatment of chronic vascular disease, it was not un-
nonsurgeons and surgeons not specially trained in vas- til the US Department of Defense (DoD) highlighted the
teleflex.com/military cular surgery in the out-of-hospital setting is useful as need to address the lethal implications of NCTH that
a stabilizing and damage control adjunct, allowing time research and development began to focus on trauma-
15–17
for resuscitation, laparotomy, and surgical hemostasis. specific endovascular applications such as REBOA.
Rx Only - Caution: Federal law (USA) restricts this device to sale by or on the order of a physician.See Instructions For Use for detailed information regarding the Instructions For Use, More research efforts have confirmed the hemodynamic
Contraindications, Potential Adverse Events, Warnings, and Cautions.The T.A.L.O.N Needle Set is manufactured in the USA. Potential complications may include local or systemic infection, Keywords: REBOA; endovascular balloon occlusion; shock, 1–5,7,15–17
hematoma, extravasations or other complications associated with percutaneous insertion of sterile devices. hemorrhagic; austere environment benefits of REBOA for trauma. To date, clini-
Teleflex, the Teleflex logo, Arrow, EZ-Connect, EZ-IO and T.A.L.O.N are trademarks or registered trademarks of Teleflex Incorporated or its affiliates, in the U.S. and/or other countries. cal reports describing REBOA have been limited to the
Information in this document is not a substitute for the product Instructions for Use. The products in this document may not be available in all countries. Please contact your local representative.
© 2016 Teleflex Incorporated. All rights reserved. MC-002362

1
Teleflex · 3015 Carrington Mill Boulevard, Morrisville, NC 27560
Toll Free: 866 246 6990|Phone: +1 919 544 8000
teleflex.com