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delayed by infusion capabilities. REBOA placement allowed that REBOA is best used by teams of medical providers who
a more rapid increase coronary artery perfusion and cerebral can perform REBOA and other resuscitation/treatment tasks
perfusion pressure than blood product administration alone. simultaneously.
Although the balloon occlusion was not used during RW flight,
on the FW platform we noted a significant decrease in SBP on References
both take-off and landing, which were rapidly corrected with 1. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield
partial aortic occlusion (3mL) and resulted in stabilization of (2001–2011): implications for the future of combat casualty care.
the patient’s hemodynamic status. J Trauma Acute Care Surg. 2012;73:S431–S437.
2. Moore LJ, Brenner M, Kozar RA, et al. Implementation of re-
suscitative endovascular balloon occlusion of the aorta as an
Some authors have hypothesized that REBOA may be detri- alternative to resuscitative thoracotomy for noncompressible
mental in patients with noncompressible torso hemorrhage truncal hemorrhage. J Trauma Acute Care Surg. 2015;79:523–
and a concomitant head injury. The proposed mechanism is 530; discussion.
that AO will result in supraphysiologic MAP and increased 3. Zakaluzny SA, Beldowicz BC, Salcedo ES, et al. Guidelines for a
carotid blood flow, further contributing to cerebral edema, system-wide multi-disciplinary approach to institutional REBOA
implementation. J Trauma Acute Care Surg. 2018.
exacerbating intracerebral hemorrhage, and ICP. 7,14 However, 4. Manley JD, Mitchell BJ, DuBose JJ, et al. A modern case se-
the data are lacking to make any formal recommendations. ries of resuscitative endovascular balloon occlusion of the aorta
Johnson et al studied the effect of REBOA, PAO, and aggres- ( REBOA) in an out-of-hospital, combat casualty care setting. J
sive blood transfusion (control) on traumatic brain injury in Spec Oper Med. 2017;17:1–8.
a swine multiple injury model. Their results demonstrated 5. Northern, D. M, Manley, J. D, Lyon,= R. et al. Recent advances
15
that both complete and partial occlusion increased the MAP, in austere combat surgery: use of aortic balloon occlusion as
carotid blood flow, and cerebral perfusion pressure with no well as blood challenges by Special Operations medical forces
difference in maximal change in ICP or average change in ICP in recent combat operations. J Trauma Acute Care Surg. 2018;
85:S98–S103.
between any of the groups. A potential advantage of PAO vs 6. de Schoutheete JC, Fourneau I, Waroquier F, et al. Three cases
complete occlusion is that a partial occlusion may result in less of resuscitative endovascular balloon occlusion of the aorta (RE-
of the negative systemic effects by maintain partial distal per- BOA) in austere pre-hospital environment-technical and method-
fusion while still increasing cerebral perfusion pressure. ological aspects. World J Emerg Surg. 2018;13:54.
7. Russo RM, Neff LP, Johnson MA, et al. Emerging endovascular
therapies for non-compressible torso hemorrhage. Shock. 2016;
In summary, we see the two separate physiologic benefits from 46:12–19.
REBOA: decreased perfusion pressure distal to the balloon 8. Hughes CW. Use of an intra-aortic balloon catheter tamponade
and increased perfusion proximal to the balloon as driving for controlling intra-abdominal hemorrhage in man. Surgery.
two possible indications for REBOA. The first benefit corre- 1954;36:65–68.
sponds with the CPG indication for REBOA in patient with 9. DuBose JJ, Scalea TM, Brenner M. et al. The AAST prospective
hemorrhagic shock due to abdominal, pelvic, or lower extrem- Aortic Occlusion for Resuscitation in Trauma and Acute Care
ity junctional hemorrhage. In this case, however, we used the Surgery (AORTA) registry: data on contemporary utilization
and outcomes of aortic occlusion and resuscitative balloon oc-
second benefit, increasing central perfusion rapidly in a dy- clusion of the aorta (REBOA). J Trauma Acute Care Surg. 2016;
namic austere environment with resource constraints. 81:409–419.
10. Taylor JR, Harvin JA, Martin C, et al. Vascular complications
from resuscitative endovascular balloon occlusion of the aorta:
Conclusion life over limb. J Trauma Acute Care Surg. 2017;83:S120–S123.
The application of REBOA in the austere environment con- 11. Khan M. REBOA in the Role 2 Afloat environment. J R Army
Med Corps. 2018.
tinues to evolve. This case demonstrates that properly trained 12. Redman TT, Ross EM. A novel expeditionary perfused cadaver
physicians can safely place an ER-REBOA for treatment of a model for trauma training in the out-of-hospital setting. J Emerg
patient within a prehospital RW platform. In addition, there Med. 2018;55:383–389.
are additional indications for REBOA not outlined in the cur- 13. Cannon, J, Morrison, J, Lauer, C. et al. Resuscitative endovas-
rent CPG. REBOA can be used to treat hemorrhagic shock not cular balloon occlusion of the aorta (REBOA) for hemorrhagic
due to NCTH and facilitate blood product resuscitation when shock. Mil Med. 2018;183:55–59.
volume infusion is limited due to the austere setting. How- 14. Biffl WL, Fox CJ, et al. The role of REBOA in the control of
exsanguinating torso hemorrhage. J Trauma Acute Care Surg.
ever, clinicians must have an astute understanding of the phys- 2015;78:1054–1058.
iologic consequences prior to the application of REBOA for 15. Johnson MA, Williams TK, Ferencz SE, et al. The effect of re-
these conditions. Further research is needed to both refine the suscitative endovascular balloon occlusion of the aorta, partial
role of REBOA in the austere environment and delineate the aortic occlusion and aggressive blood transfusion on traumatic
appropriate skill level that is required for safe application in brain injury in a swine multiple injuries model. J Trauma Acute
the small surgical team environment. Our experience suggests Care Surg. 2017;83:61–70.

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