Page 94 - Journal of Special Operations Medicine - Spring 2017

A Perspective on the Potential for Battlefield Resuscitative
Endovascular Balloon Occlusion of the Aorta

Ryan M. Knight, MD

ABSTRACT

Resuscitative endovascular balloon occlusion of the paradigms in medicine, REBOA dropped out of favor
aorta (REBOA) has a place in civilian trauma centers in and has recently returned as a cutting-edge medical
the United States, and British physicians performed the technique. Simply put, REBOA involves accessing the
first prehospital REBOA, proving the concept viable for common femoral artery (CFA), advancing a catheter, in-
civilian emergency medical service. Can this translate flating a balloon, and occluding blood flow in the aorta.
into battlefield REBOA to stop junctional hemorrhage REBOA is similar to tourniquet application except
and extend “golden hour” rings in combat? If yes, at there can be dramatic physiologic changes occurring
what level is this procedure best suited and what does it in a shorter time. Military physicians are beginning to
entail? This author’s perspective, after treating patients explore the utility of REBOA as a resuscitative adjunct
on the battlefield and during rotary wing evacuation, is both on the battlefield and in the resuscitation bay. A
that REBOA may have a place in prehospital resuscita- recent UK study focused on the utility of REBOA based
tion but patient and provider selection are paramount. on injury patterns from the war and demonstrated up to
The procedure, although simple in description, is quite 18% of patients in the UK Joint Theatre Trauma Regis-
complicated and can cause major physiologic changes try were potential candidates because of abdominal or
best dealt with by experienced providers. REBOA is in- pelvic hemorrhage. 7
capable of extending the golden hour limiting the pro-
cedure’s utility. The REBOA technique separates the body into three
zones (I, II, and III; Figure 1). Zone I is the descending
8
Keywords: REBOA; resuscitative endovascular balloon oc- thoracic aorta between the origin of the left subclavian
clusion of the aorta; battlefield resuscitation; junctional and celiac artery. Zone II encompasses territory below
hemorrhage the celiac but above the renal arteries. The celiac trunk
provides blood flow to the abdominal viscera; therefore,
zone II REBOA will not stop intra-abdominal hemor-
rhage and cutting blood flow to the renal arteries will
Introduction
only cause harm. Zone III places the balloon superior to
The Global War on Terror highlighted the first priority the bifurcation of the aorta but inferior to the renal ar-
for a medic on the battlefield is to prevent hemorrhage teries, allowing perfusion to the abdomen and kidneys
8
to decrease mortality. Refocusing medical training and but ceasing flow to the pelvis and lower extremities.
1–4
the addition of tourniquets led to a decreased mortal- REBOA is a temporizing measure that does not obviate
ity rate from compressible hemorrhage. Even with this the need for surgical or interventional management of
reduction, hemorrhage remains the number one cause hemorrhage.
of preventable death on today’s battlefield. Special Op-
5
erations Medics reliably evaluate and treat compressible The technique has been performed by interventional
hemorrhage. Recently, the focus shifted to acquiring the radiologists, cardiologists, and vascular surgeons for
tools to stop junctional (inguinal and axillary) bleeding years. It has also been used and studied in a trauma
and noncompressible hemorrhage. setting with successful outcomes. In a case series of 21
patients, surgeons successfully occluded the aorta in 20
One of the latest tools is resuscitative endovascular patients and gained surgical hemorrhage control in 11
balloon occlusion of the aorta (REBOA). REBOA is patients after occlusion. REBOA kits are in development
9
not a new technique, nor is it new in military applica- but are not approved by the Food and Drug Administra-
tion; it was first described by Lieutenant Colonel Carl tion at this time. Therefore, the procedure described in
Hughes in the Korean War. As with many management this article is used by the London Helicopter Emergency
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