Page 43 - JSOM Winter 2018

metabolic acidosis. A subsequent study by Kuckelman and FIGURE 2 ER-REBOA device.
78
colleagues reported 100% mortality shortly after balloon de-
flation following 60 minutes of Zone 1 REBOA in an animal
model that did not include post-deflation critical care support. 80

A second option currently being developed is ResQFoam,
a novel device that uses two polymer precursors that mix as Courtesy of Prytime Medical Devices, Inc. The REBOA Company ™ .
they are injected into the peritoneal cavity and expand, apply-
ing pressure to intra-abdominal bleeding sites. ResQFoam has
been shown to control bleeding from both hepatoportal inju-
ries model and external iliac artery injuries in animal mod-
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els. There have been preclinical safety studies of ResQFoam
82
with 90-day survival periods to determine the optimal dosing of
the foam precursors. These studies found that that there were
bowel lesions in all of the surviving animals. There is an FDA- center. The authors note that “REBOA allows for the same
83
97
cleared clinical study (not yet underway) to determine if the he- physiologic result as open aortic cross-clamping through a less
mostatic benefit provided by ResQFoam outweighs the risk of invasive, endovascular approach. Because of its minimally in-
enteric complications that may ensue from its use. ResQFoam vasive nature, REBOA can be performed as a proactive (rather
is not yet FDA-approved, however, so this device may not be than reactive) measure in patients with refractory hemorrhagic
fielded with combat forces at the time of this writing. 76 shock from intra-abdominal/pelvic bleeding.”
The third option for controlling abdominopelvic NCTH is The patients in that study were severely injured, with a median
REBOA, which will be discussed further below. A recent pub- Injury Severity Score (ISS) of 34. Eighty-seven percent of them
lication examined the location of the primary bleeding site in had suffered blunt trauma. Trauma patients with hemodynamic
402 trauma patients who required an emergent laparotomy instability that was attributed to an obvious catastrophic head
at a single trauma center. The study determined that Zone 1 injury (defined as visible brain matter or transcranial gunshot
REBOA could have been useful to stop the bleeding in 96% wound) were not considered candidates for REBOA. Of the
of patients; ResQFoam could have been effective in 87%; and 10 patients who had suffered a traumatic cardiac arrest before
AAJT could have been effective in 9%. The study also noted REBOA was performed, 60% had a return of spontaneous cir-
that the external location of the injury did not correlate well culation. Overall survival was 32%, but the incidence of early
with the internal bleeding site. 76 death from hemorrhage was 28% with only 2 of those deaths
occurring prior to arrival in the operating room. 97
The bottom line is that in 2018, neither the AAJT nor
ResQFoam are viable options for controlling NCTH, so they REBOA Zones
will not be discussed further in this paper.
Aortic Zone I refers to the descending thoracic aorta between
the left subclavian artery and the origin of the celiac trunk. In-
REBOA
flating the balloon in this zone will control hemorrhage in the
REBOA is a relatively new tool that may enable casualties abdomen and pelvis. Zone 2 is the aortic segment between the
with abdominopelvic NCTH to survive until their bleeding celiac trunk and the lower of the two renal arteries. This area is
can be definitively controlled at surgery. 80,84-92 not used for REBOA. Zone 3 extends from the lower of the two
renal arteries to the bifurcation of the aorta. Occlusion in Zone
The development of the REBOA technique evolved from the re- 3 can be used if there is assurance that there is no intra-thoracic
alization that NCTH is a leading cause for preventable trauma bleeding and no intra-abdominal bleeding originating from ves-
mortality for which survival has not been significantly improved sels or solid organs above the level of the aortic bifurcation.
in decades. The potential of the REBOA approach for saving Figure 3 illustrates the three aortic zones described above.
86
the lives of trauma patients with abdominopelvic NCTH has
caused it to be used over 4000 times in 264 hospitals (including A significant limitation of REBOA in the prehospital environ-
150 trauma centers) in the US and abroad within 30 months ment is the relatively short time that aortic occlusion in Zone
of the sale of the first ER-REBOA catheter (Prytime Medical, 1 is tolerated. The current JTS CPG recommends that Zone
Boerne, Texas). 86,93 Figure 2 shows the ER-REBOA device. 1 balloon inflation time not exceed 30-60 minutes. There is
25
potential for extending the time that Zone 1 REBOA can be
Although the presence of distal ischemia limits the time that used by employing partial or intermittent balloon inflation
full occlusion of the aorta can be tolerated, partial and inter- techniques. 80,87 These will be discussed later in this paper.
mittent REBOA techniques have the potential to allow for lon-
ger periods of effective control of abdominopelvic NCTH. 80,87 REBOA Complications
Further, use of REBOA is not necessarily limited to surgeons; REBOA is increasing in use in the hospital setting at this point
individuals who are not surgeons or interventional radiolo- in time. This procedure does entail the risk of a number of
gists have demonstrated the ability to perform REBOA after potential complications, including:
the appropriate training. 84,94-96
1. Distal ischemia
A 2016 report by Moore and colleagues reviewed all 31 2. Loss of a lower extremity
patients for whom REBOA was performed between Octo- 3. Access site bleeding
ber 2011 and September 2015 at a Level 1 civilian trauma 4. Arterial access site thrombosis

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