Page 35 - JSOM Fall 2025

In-Theater Assessment of Resuscitative Balloon Occlusion
of the Aorta (REBOA) Capabilities and Training

Alex Y. Koo, MD *; Jerry Hu, DO, PharmD ; Kyle Couperus, MD, MBA, BSN ;
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Jamie Eastman, BSN ; Thomas Kwolek, BSN ; Kyle Remick, MD 6
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ABSTRACT
Background: Resuscitative endovascular balloon occlusion civilian trauma centers. The “ER” is named after the sur-
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of the aorta (REBOA) is an endovascular technology indi- geons who helped develop the product. This unique endovas-
cated for temporarily controlling traumatic life-threatening, cular technology is used for temporarily controlling traumatic
noncompressible abdominal, truncal, or pelvic hemorrhage. life-threatening, noncompressible abdominal, truncal, or pel-
Through percutaneous access or cut-down to the femoral ar- vic hemorrhage. REBOA is performed through percutaneous
tery, an intra-aortic balloon catheter is fed into the aorta and access or cut-down to the femoral artery. Then an intra-aortic
inflated, occluding distal blood flow and, thus, bleeding. To de- balloon catheter is fed into the aorta and inflated, occluding
termine specific barriers to REBOA in deployed environments, distal blood flow and thus bleeding. In situations where there
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we conducted a quality improvement project and survey of are multiple surgical trauma casualties and limited damage
ER-REBOA placement and monitoring capabilities at four control surgery resources or delayed transportation, REBOA
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medical treatment locations in Iraq and Kuwait during the can be deployed for temporary hemorrhage control for up to
spring of 2019. Methods: The primary objective was to eval- 30 or 60 minutes, when placed in zone 1 or 3, respectively.
uate each in-theater medical site’s ability to deploy REBOA,
which was defined as having a provider capable of placing While there have been considerable strides in battlefield hemor-
REBOA and the minimum equipment necessary. The investi- rhage control, noncompressible torso injuries still account for
gators interviewed providers and through self-reported sur- 13% of injuries sustained in Afghanistan and Iraq, with 17%
veys, determined the personnel capable of placing a REBOA. of these injuries confirmed to have ongoing noncompressible
REBOA equipment and monitoring equipment were identified hemorrhage. Also, in a review of potentially survivable injuries,
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through direct inspection of sites and interviews with logisti- 50% were truncal hemorrhages. In resource-limited settings
cal and equipment staff. Results: A total of 113 individuals and/or prolonged transport times, REBOA can be implemented
participated in the evaluation and training. Three of the four if there is delay in damage control resuscitation and/or surgery. 8
sites had the minimum training and equipment requirements
to complete the procedure: one REBOA-capable provider, an Considerable challenges to the procedural success of REBOA
unexpired ER-REBOA device, and an unexpired introducer include significant training and experience gaps in obtaining
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catheter kit. Overall, 6 out of 32 physicians (18.7%) were ca- emergent arterial and venous access, placement depth, and
pable of placing an ER-REBOA. Conclusion: This deployed management of endovascular occlusion in critically wounded
site survey demonstrates that the minimal requirements and patients. 9–11 Existing training programs of intra-aortic occlu-
personnel for ER-REBOA placement were met at most studied sion device placement, such as the American College of Sur-
locations in 2019. However, improvements in pre-deployment geons’ (ACS) Basic Endovascular Skills for Trauma (BEST), are
training of select medical personnel in REBOA and arterial often inaccessible to the wide range of military medical pro-
blood pressure monitoring are recommended to ensure ade- viders who may be required to perform the procedure or care
quate resourcing and redundancy in training. for patients after placement. REBOA training is not formalized
in any predeployment training platforms for military medical
Keywords: REBOA; resuscitative endovascular balloon occlusion personnel. In addition, deployed environments create unique
of the aorta; intra-aortic balloon; ER-REBOA; deployment; challenges for military medical personnel. Deployments in-
noncompressible hemorrhage volve frequent turnover of medical personnel of varying train-
ing and experience, constant battlefield movements, coalition
partners, and nonstandardized predeployment training cycles
across different deploying units.
Introduction
A current model for REBOA, cleared by the U.S. Food and We seek to determine the readiness of medical units to em-
Drug Administration (FDA) in 2016 is the ER-REBOA ploy REBOA in deployed environments while also creating an
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( Prytime Medical Inc., Boerne, TX), specifically created for educational opportunity for review and training in REBOA
advanced trauma management both on the battlefield and at placement by subject matter experts.
*Correspondence to alex.koo@georgetown.edu
1 Dr. Alex Koo is affiliated with the Department of Emergency Medicine, MedStar Georgetown University Hospital, Washington, DC and the
Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC. Dr. Jerry Hu is affiliated with the Madigan Army
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Medical Center, Tacoma, WA. Dr. Kyle Couperus is affiliated with the Department of Emergency Medicine, Madigan Army Medical Center,
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Tacoma, WA. Jamie Eastman is affiliated with the United States Army. Thomas Kwolek and COL (Ret) Kyle Remick are affiliated with the
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Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD.
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