Endovascular methods for aortic control in trauma
- Jonathan J Morrison, MD, PhD, FRCS
Jonathan J Morrison, MD, PhD, FRCS
- Assistant Professor of Surgery
- R Adams Cowley Shock Trauma Center
- University of Maryland Medical System
- Todd E Rasmussen, MD, FACS, COL, USAF, MC
Todd E Rasmussen, MD, FACS, COL, USAF, MC
- Harris B Shumacker, Jr. Professor of Surgery
- Associate Dean for Research
- F. Edward Hebért School of Medicine
- Uniformed Services University of the Health Sciences
- Bethesda, MD
- Attending Vascular Surgeon
- Walter Reed National Military Medical Center
- Bethesda, MD
- Jeremy W Cannon, MD, FACS
Jeremy W Cannon, MD, FACS
- Associate Professor of Surgery
- Perelman School of Medicine at the University of Pennsylvania
- Section Editors
- Eileen M Bulger, MD, FACS
Eileen M Bulger, MD, FACS
- Section Editor — Trauma Surgery
- Professor of Surgery
- University of Washington
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Science Center
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
Torso hemorrhage remains the leading cause of potentially preventable death following traumatic injury [1-5]. A significant proportion of patients with external bleeding can exsanguinate prior to definitive hemostasis due to the inability to apply direct pressure [6-9]. Internal hemorrhage requires rapid surgical intervention. Aortic occlusion as a part of trauma management can decrease the amount of bleeding and provide a window of opportunity for resuscitation and definitive hemorrhage control. Options for aortic occlusion include direct clamping through an open incisional technique (emergent thoracotomy) and resuscitative endovascular balloon occlusion (REBOA) .
Noncompressible torso hemorrhage remains the leading cause of preventable death following military injury  and, from registry studies, significantly contributes to mortality in civilian traumatic injury as well [3-5]. Torso hemorrhage may originate from arterial, venous, or combined sources within the chest, abdomen, or pelvis. Junctional hemorrhage from noncompressible sites in the axilla or groin is also included in this definition.
RESUSCITATIVE AORTIC OCCLUSION
Management of hemorrhage generally consists of direct pressure to limit external bleeding with resuscitation and, subsequently, definitive repair to stop bleeding. However, the inability to directly compress vessels in the torso leads to a significant proportion of patients exsanguinating prior to definitive management, often in the prehospital setting [6-9]. This risk is higher in rural or resource-limited environments where transport time to definitive surgical care may be prolonged. Management of torso hemorrhage as a result of trauma has traditionally included direct aortic clamping via a thoracotomy for patients in extremis or abdominal incision for those in the operating room. Several alternative management approaches to this vexing clinical problem have also been explored. Military antishock trousers (MAST) gained popularity many years ago as a noninvasive approach to prehospital torso hemorrhage control . However, further evaluation of this approach demonstrated no clear benefit, and they have since fallen out of use . A novel approach to torso hemorrhage that is undergoing preclinical testing is use of intraperitoneal expanding foams that create a tamponade effect to slow or stop bleeding [13,14]. This approach is not yet approved for use in the United States. Several compression devices for junctional hemorrhage are also in development. This review focuses exclusively on the emerging use of endovascular aortic occlusion, known as resuscitative endovascular balloon occlusion of the aorta (REBOA).
With developing expertise in minimally invasive endovascular methods, REBOA has been advocated as another approach supporting perfusion of vital organs until definitive hemostasis can be achieved [10,15]. REBOA has the advantage of being less invasive than open thoracotomy and, in one small observational study, was associated with fewer early deaths and improved overall survival compared with resuscitative thoracotomy . Consequently, preemptive placement in the emergency department (ED) or in the operating room (OR) prior to full cardiovascular collapse is possible. REBOA may also facilitate further imaging and access to angiography for embolization . (See 'Timing of placement' below.)
Evolution of endovascular aortic control — The earliest reported use of aortic balloon occlusion in trauma was during the Korean War, where a balloon catheter was inserted via the femoral artery into the thoracic aorta in two patients with abdominal bleeding . Although neither patient survived deflation of the balloon, the maneuver effectively demonstrated the feasibility of balloon occlusion to aid resuscitation. Open aortic clamping in the operating room subsequently gained favor as a means to resuscitate patients in extremis. Some surgeons even advocated thoracotomy and aortic clamping for patients with extrathoracic trauma who presented with tense hemoperitoneum and preserved pulses . In subsequent years, resuscitative thoracotomy with aortic clamping, now typically performed in the emergency department, has gained acceptance for the management of patients with traumatic arrest from torso injuries within a limited time window , and for some nontorso injuries . (See "Resuscitative thoracotomy: Technique", section on 'Morbidity and mortality'.)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Morrison JJ, Rasmussen TE. Noncompressible torso hemorrhage: a review with contemporary definitions and management strategies. Surg Clin North Am 2012; 92:843.
- Kisat M, Morrison JJ, Hashmi ZG, et al. Epidemiology and outcomes of non-compressible torso hemorrhage. J Surg Res 2013; 184:414.
- Teixeira PG, Inaba K, Hadjizacharia P, et al. Preventable or potentially preventable mortality at a mature trauma center. J Trauma 2007; 63:1338.
- Tien HC, Spencer F, Tremblay LN, et al. Preventable deaths from hemorrhage at a level I Canadian trauma center. J Trauma 2007; 62:142.
- Dutton RP, Stansbury LG, Leone S, et al. Trauma mortality in mature trauma systems: are we doing better? An analysis of trauma mortality patterns, 1997-2008. J Trauma 2010; 69:620.
- Davis JS, Satahoo SS, Butler FK, et al. An analysis of prehospital deaths: Who can we save? J Trauma Acute Care Surg 2014; 77:213.
- Kleber C, Giesecke MT, Tsokos M, et al. Trauma-related preventable deaths in Berlin 2010: need to change prehospital management strategies and trauma management education. World J Surg 2013; 37:1154.
- Gomez D, Berube M, Xiong W, et al. Identifying targets for potential interventions to reduce rural trauma deaths: a population-based analysis. J Trauma 2010; 69:633.
- Chiara O, Scott JD, Cimbanassi S, et al. Trauma deaths in an Italian urban area: an audit of pre-hospital and in-hospital trauma care. Injury 2002; 33:553.
- Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma 2011; 71:1869.
- Kaback KR, Sanders AB, Meislin HW. MAST suit update. JAMA 1984; 252:2598.
- Mattox KL, Bickell W, Pepe PE, et al. Prospective MAST study in 911 patients. J Trauma 1989; 29:1104.
- Rago AP, Marini J, Duggan MJ, et al. Diagnosis and deployment of a self-expanding foam for abdominal exsanguination: Translational questions for human use. J Trauma Acute Care Surg 2015; 78:607.
- Mesar T, Martin D, Lawless R, et al. Human dose confirmation for self-expanding intra-abdominal foam: A translational, adaptive, multicenter trial in recently deceased human subjects. J Trauma Acute Care Surg 2015; 79:39.
- Morrison JJ, Ross JD, Rasmussen TE, et al. Resuscitative endovascular balloon occlusion of the aorta: a gap analysis of severely injured UK combat casualties. Shock 2014; 41:388.
- Moore LJ, Brenner M, Kozar RA, et al. Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage. J Trauma Acute Care Surg 2015; 79:523.
- Ogura T, Lefor AT, Nakano M, et al. Nonoperative management of hemodynamically unstable abdominal trauma patients with angioembolization and resuscitative endovascular balloon occlusion of the aorta. J Trauma Acute Care Surg 2015; 78:132.
- HUGHES CW. Use of an intra-aortic balloon catheter tamponade for controlling intra-abdominal hemorrhage in man. Surgery 1954; 36:65.
- Ledgerwood AM, Kazmers M, Lucas CE. The role of thoracic aortic occlusion for massive hemoperitoneum. J Trauma 1976; 16:610.
- Burlew CC, Moore EE, Moore FA, et al. Western Trauma Association critical decisions in trauma: resuscitative thoracotomy. J Trauma Acute Care Surg 2012; 73:1359.
- Sheppard FR, Cothren CC, Moore EE, et al. Emergency department resuscitative thoracotomy for nontorso injuries. Surgery 2006; 139:574.
- Gupta BK, Khaneja SC, Flores L, et al. The role of intra-aortic balloon occlusion in penetrating abdominal trauma. J Trauma 1989; 29:861.
- Low RB, Longmore W, Rubinstein R, et al. Preliminary report on the use of the Percluder occluding aortic balloon in human beings. Ann Emerg Med 1986; 15:1466.
- Masamoto H, Uehara H, Gibo M, et al. Elective use of aortic balloon occlusion in cesarean hysterectomy for placenta previa percreta. Gynecol Obstet Invest 2009; 67:92.
- Harma M, Harma M, Kunt AS, et al. Balloon occlusion of the descending aorta in the treatment of severe post-partum haemorrhage. Aust N Z J Obstet Gynaecol 2004; 44:170.
- Bell-Thomas SM, Penketh RJ, Lord RH, et al. Emergency use of a transfemoral aortic occlusion catheter to control massive haemorrhage at caesarean hysterectomy. BJOG 2003; 110:1120.
- Xue-Song L, Chao Y, Kai-Yong Y, et al. Surgical excision of extensive sacrococcygeal chordomas assisted by occlusion of the abdominal aorta. J Neurosurg Spine 2010; 12:490.
- Tang X, Guo W, Yang R, et al. Use of aortic balloon occlusion to decrease blood loss during sacral tumor resection. J Bone Joint Surg Am 2010; 92:1747.
- Zhang L, Gong Q, Xiao H, et al. Control of blood loss during sacral surgery by aortic balloon occlusion. Anesth Analg 2007; 105:700.
- Arthurs ZM, Sohn VY, Starnes BW. Ruptured abdominal aortic aneurysms: remote aortic occlusion for the general surgeon. Surg Clin North Am 2007; 87:1035.
- Assar AN, Zarins CK. Endovascular proximal control of ruptured abdominal aortic aneurysms: the internal aortic clamp. J Cardiovasc Surg (Torino) 2009; 50:381.
- Mayer D, Pfammatter T, Rancic Z, et al. 10 years of emergency endovascular aneurysm repair for ruptured abdominal aortoiliac aneurysms: lessons learned. Ann Surg 2009; 249:510.
- Philipsen TE, Hendriks JM, Lauwers P, et al. The use of rapid endovascular balloon occlusion in unstable patients with ruptured abdominal aortic aneurysm. Innovations (Phila) 2009; 4:74.
- Arthurs Z, Starnes B, See C, Andersen C. Clamp before you cut: Proximal control of ruptured abdominal aortic aneurysms using endovascular balloon occlusion--Case reports. Vasc Endovascular Surg 2006; 40:149.
- Malina M, Veith F, Ivancev K, Sonesson B. Balloon occlusion of the aorta during endovascular repair of ruptured abdominal aortic aneurysm. J Endovasc Ther 2005; 12:556.
- Morrison JJ, Stannard A, Rasmussen TE, et al. Injury pattern and mortality of noncompressible torso hemorrhage in UK combat casualties. J Trauma Acute Care Surg 2013; 75:S263.
- Stannard A, Morrison JJ, Scott DJ, et al. The epidemiology of noncompressible torso hemorrhage in the wars in Iraq and Afghanistan. J Trauma Acute Care Surg 2013; 74:830.
- Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care Surg 2012; 73:S431.
- White JM, Cannon JW, Stannard A, et al. Endovascular balloon occlusion of the aorta is superior to resuscitative thoracotomy with aortic clamping in a porcine model of hemorrhagic shock. Surgery 2011; 150:400.
- Markov NP, Percival TJ, Morrison JJ, et al. Physiologic tolerance of descending thoracic aortic balloon occlusion in a swine model of hemorrhagic shock. Surgery 2013; 153:848.
- Morrison JJ, Ross JD, Markov NP, et al. The inflammatory sequelae of aortic balloon occlusion in hemorrhagic shock. J Surg Res 2014; 191:423.
- Morrison JJ, Galgon RE, Jansen JO, et al. A systematic review of the use of resuscitative endovascular balloon occlusion of the aorta in the management of hemorrhagic shock. J Trauma Acute Care Surg 2016; 80:324.
- Scott DJ, Eliason JL, Villamaria C, et al. A novel fluoroscopy-free, resuscitative endovascular aortic balloon occlusion system in a model of hemorrhagic shock. J Trauma Acute Care Surg 2013; 75:122.
- White JM, Cannon JW, Stannard A, et al. A porcine model for evaluating the management of noncompressible torso hemorrhage. J Trauma 2011; 71:S131.
- Long KN, Houston R 4th, Watson JD, et al. Functional outcome after resuscitative endovascular balloon occlusion of the aorta of the proximal and distal thoracic aorta in a swine model of controlled hemorrhage. Ann Vasc Surg 2015; 29:114.
- Morrison JJ, Ross JD, Houston R 4th, et al. Use of resuscitative endovascular balloon occlusion of the aorta in a highly lethal model of noncompressible torso hemorrhage. Shock 2014; 41:130.
- Avaro JP, Mardelle V, Roch A, et al. Forty-minute endovascular aortic occlusion increases survival in an experimental model of uncontrolled hemorrhagic shock caused by abdominal trauma. J Trauma 2011; 71:720.
- Morrison JJ, Percival TJ, Markov NP, et al. Aortic balloon occlusion is effective in controlling pelvic hemorrhage. J Surg Res 2012; 177:341.
- Nozari A, Rubertsson S, Wiklund L. Improved cerebral blood supply and oxygenation by aortic balloon occlusion combined with intra-aortic vasopressin administration during experimental cardiopulmonary resuscitation. Acta Anaesthesiol Scand 2000; 44:1209.
- Biffl WL, Fox CJ, Moore EE. The role of REBOA in the control of exsanguinating torso hemorrhage. J Trauma Acute Care Surg 2015; 78:1054.
- Biffl WL, Smith WR, Moore EE, et al. Evolution of a multidisciplinary clinical pathway for the management of unstable patients with pelvic fractures. Ann Surg 2001; 233:843.
- Burlew CC, Moore EE, Smith WR, et al. Preperitoneal pelvic packing/external fixation with secondary angioembolization: optimal care for life-threatening hemorrhage from unstable pelvic fractures. J Am Coll Surg 2011; 212:628.
- Martinelli T, Thony F, Decléty P, et al. Intra-aortic balloon occlusion to salvage patients with life-threatening hemorrhagic shocks from pelvic fractures. J Trauma 2010; 68:942.
- Stahel PF, Mauffrey C, Smith WR, et al. External fixation for acute pelvic ring injuries: decision making and technical options. J Trauma Acute Care Surg 2013; 75:882.
- Abu-Zidan FM. Should intra-aortic balloon occlusion be used to stop bleeding from severe pelvic fractures? J Trauma 2010; 69:1005.
- True NA, Siler S, Manning JE. Endovascular resuscitation techniques for severe hemorrhagic shock and traumatic arrest in the presurgical setting. J Spec Oper Med 2013; 13:33.
- Chaudery M, Clark J, Wilson MH, et al. Traumatic intra-abdominal hemorrhage control: has current technology tipped the balance toward a role for prehospital intervention? J Trauma Acute Care Surg 2015; 78:153.
- Stannard A, Morrison JJ, Sharon DJ, et al. Morphometric analysis of torso arterial anatomy with implications for resuscitative aortic occlusion. J Trauma Acute Care Surg 2013; 75:S169.
- Teeter WA, Matsumoto J, Idoguchi K, et al. Smaller introducer sheaths for REBOA may be associated with fewer complications. J Trauma Acute Care Surg 2016; 81:1039.
- Morrison JJ, Stannard A, Midwinter MJ, et al. Prospective evaluation of the correlation between torso height and aortic anatomy in respect of a fluoroscopy free aortic balloon occlusion system. Surgery 2014; 155:1044.
- Villamaria CY, Eliason JL, Napolitano LM, et al. Endovascular Skills for Trauma and Resuscitative Surgery (ESTARS) course: curriculum development, content validation, and program assessment. J Trauma Acute Care Surg 2014; 76:929.
- Berland TL, Veith FJ, Cayne NS, et al. Technique of supraceliac balloon control of the aorta during endovascular repair of ruptured abdominal aortic aneurysms. J Vasc Surg 2013; 57:272.
- http://www.usaisr.amedd.army.mil/cpgs/REBOA_for_Hemorrhagic_Shock_16Jun2014.pdf (Accessed on June 09, 2015).
- Wolf RK, Berry RE. Transaxillary intra-aortic balloon tamponade in trauma. J Vasc Surg 1986; 4:95.
- Ogura T, Lefor AK, Nakamura M, et al. Ultrasound-Guided Resuscitative Endovascular Balloon Occlusion of the Aorta in the Resuscitation Area. J Emerg Med 2017; 52:715.
- Guliani S, Amendola M, Strife B, et al. Central aortic wire confirmation for emergent endovascular procedures: As fast as surgeon-performed ultrasound. J Trauma Acute Care Surg 2015; 79:549.
- Chaudery M, Clark J, Morrison JJ, et al. Can contrast-enhanced ultrasonography improve Zone III REBOA placement for prehospital care? J Trauma Acute Care Surg 2016; 80:89.
- Bogert JN, Patel BM, Johnson DJ. Ultrasound optimization for resuscitative endovascular balloon occlusion of the aorta. J Trauma Acute Care Surg 2017; 82:204.
- Pezy P, Flaris AN, Prat NJ, et al. Fixed-Distance Model for Balloon Placement During Fluoroscopy-Free Resuscitative Endovascular Balloon Occlusion of the Aorta in a Civilian Population. JAMA Surg 2017; 152:351.
- MacTaggart JN, Poulson WE, Akhter M, et al. Morphometric roadmaps to improve accurate device delivery for fluoroscopy-free resuscitative endovascular balloon occlusion of the aorta. J Trauma Acute Care Surg 2016; 80:941.
- Linnebur M, Inaba K, Haltmeier T, et al. Emergent non-image-guided resuscitative endovascular balloon occlusion of the aorta (REBOA) catheter placement: A cadaver-based study. J Trauma Acute Care Surg 2016; 81:453.
- Brenner ML, Moore LJ, DuBose JJ, et al. A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation. J Trauma Acute Care Surg 2013; 75:506.
- Aso S, Matsui H, Fushimi K, Yasunaga H. Resuscitative endovascular balloon occlusion of the aorta or resuscitative thoracotomy with aortic clamping for noncompressible torso hemorrhage: A retrospective nationwide study. J Trauma Acute Care Surg 2017; 82:910.
- Delamare L, Crognier L, Conil JM, et al. Treatment of intra-abdominal haemorrhagic shock by Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). Anaesth Crit Care Pain Med 2015; 34:53.
- Irahara T, Sato N, Moroe Y, et al. Retrospective study of the effectiveness of Intra-Aortic Balloon Occlusion (IABO) for traumatic haemorrhagic shock. World J Emerg Surg 2015; 10:1.
- Saito N, Matsumoto H, Yagi T, et al. Evaluation of the safety and feasibility of resuscitative endovascular balloon occlusion of the aorta. J Trauma Acute Care Surg 2015; 78:897.
- Norii T, Crandall C, Terasaka Y. Survival of severe blunt trauma patients treated with resuscitative endovascular balloon occlusion of the aorta compared with propensity score-adjusted untreated patients. J Trauma Acute Care Surg 2015; 78:721.
- DuBose JJ, Scalea TM, Brenner M, et al. The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: Data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA). J Trauma Acute Care Surg 2016; 81:409.
- Kirkpatrick AW, Vis C, Dubé M, et al. The evolution of a purpose designed hybrid trauma operating room from the trauma service perspective: the RAPTOR (Resuscitation with Angiography Percutaneous Treatments and Operative Resuscitations). Injury 2014; 45:1413.
- Brenner M, Hoehn M, Stein DM, et al. Central pressurized cadaver model (CPCM) for resuscitative endovascular balloon occlusion of the aorta (REBOA) training and device testing. J Trauma Acute Care Surg 2015; 78:197.
- Brenner M, Hoehn M, Pasley J, et al. Basic endovascular skills for trauma course: bridging the gap between endovascular techniques and the acute care surgeon. J Trauma Acute Care Surg 2014; 77:286.
- TORSO HEMORRHAGE
- RESUSCITATIVE AORTIC OCCLUSION
- Evolution of endovascular aortic control
- POTENTIAL INDICATIONS
- Abdominal trauma with shock
- Pelvic trauma with shock
- Torso trauma at risk of hemorrhagic shock
- AORTIC ANATOMY AND ZONES OF DEPLOYMENT
- Devices and equipment
- Timing of placement
- REBOA TECHNIQUE
- Obtain arterial access and place the sheath
- Insert the balloon catheter
- Inflate the balloon catheter
- Identify and control bleeding
- Deflate the balloon
- Remove the balloon catheter and sheath
- ONGOING CHALLENGES
- SUMMARY AND RECOMMENDATIONS