Chapter 21 – Resuscitative Endovascular Occlusion of the Aorta (REBOA)


REBOA is an endovascular occlusion balloon, inserted through the femoral artery, designed to occlude the aorta in the setting of severe abdominal or pelvic hemorrhage (Figure 21.1).

Chapter 21 Resuscitative Endovascular Occlusion of the Aorta (REBOA)

Elizabeth R. Benjamin and Kazuhide Matsushima

General Principles

  • REBOA is an endovascular occlusion balloon, inserted through the femoral artery, designed to occlude the aorta in the setting of severe abdominal or pelvic hemorrhage (Figure 21.1).

  • REBOA is a resuscitative adjunct that, in the appropriate setting, can delay exsanguination and provide support during transition to definitive operative care.

  • Although most commonly described for hemorrhage due to trauma, REBOA may also play a role in resuscitation during obstetric catastrophes or bleeding from nontraumatic sources such as gastrointestinal or hepatic parenchymal hemorrhage.

  • For the purposes of REBOA insertion, the aorta is divided into three anatomical zones (Figure 21.2):

    1. o Zone I: Distal to the left subclavian artery, above the diaphragm

    2. o Zone II: From the celiac artery to renal arteries

    3. o Zone III: Distal to the renal arteries to above the abdominal aorta bifurcation

  • For bleeding control from the upper abdomen, the catheter balloon is inflated in zone I (external landmark is the mid-sternum). For bleeding control in the pelvis, the balloon is inflated in zone III. Inflation of the balloon is not recommended in zone II.

  • The rate-limiting step in REBOA placement is arterial access and, for this reason, if potential need for aortic occlusion is anticipated, access can be secured early using a femoral arterial line or a 5-F sheath. For example, in cases of placenta accreta, preoperative placement of a minimally invasive small-gauge femoral arterial line, can potentially save time, allowing for rapid upsize rather than de novo placement of access for REBOA insertion in the event of acute hemorrhage.

  • REBOA can be placed in the Emergency Department, ICU, or operating room by a trained provider.

  • REBOA is a temporary occlusion device and prolonged inflation can lead to visceral and/or limb ischemia and should be avoided at all cost. REBOA should be considered and inflated only in the setting of available surgical providers to address the immediate hemorrhage control needs of the patient. Access to providers to address potential complications of catheter placement, including peripheral and central arterial injury, is also a necessity.

  • REBOA is contraindicated for thoracic or neck bleeding. Whenever possible, thoracic imaging such as a chest X-ray should be obtained prior to REBOA placement to rule out a thoracic source of hemorrhage that may be exacerbated by aortic balloon occlusion.

Figure 21.1 The REBOA catheter. Pictured is a common commercially available catheter (ER-REBOA™) with an atraumatic p-tip, radio-opaque markers above and below the compliant balloon, cm markings for precise placement, and an arterial port for proximal pressure monitoring.

Figure 21.2 The zones of occlusion include zone I, above the level of the diaphragm, distal to the left subclavian artery, ideal for abdominal hemorrhage, and zone III, below the renal arteries and above the bifurcation, ideal for pelvic and perineal hemorrhage. Zone II is perivisceral and inflation in this zone is not recommended.


  • The common femoral artery can be accessed at about 2 cm below the inguinal ligament, halfway between the pubic symphysis and the anterior superior iliac spine. The artery is accessed either percutaneously with ultrasound guidance (Figure 21.3 A,B) or via an open groin dissection (Figure 21.4 A,B).

  • Initial access options include an 18-gauge femoral arterial catheter, which may later be upsized to a 7-F sheath, a 5-F sheath that can be used for arterial monitoring and also upsized, or immediate placement of a 7-F sheath. Prior to initiating a REBOA program, the sequence options should be protocolized and materials bundled in an easily accessible kit, as not all wires and catheters are complimentary (Figure 21.5 A,B, Figure 21.6).

  • Once the 7-F sheath is in place, this should be adequately secured.

  • The REBOA catheter is prepared using the following steps:

    1. o Residual air is removed from the balloon and the peel-away sheath is spiraled carefully over the balloon and p-tip (Figure 21.7 A,B).

    2. o The arterial port is flushed with saline.

    3. o Using external landmarks, distance to zone I occlusion is approximated by measuring the distance from the sheath to the balloon at the mid sternum. The external landmark for zone III occlusion is less well defined, but balloon placement above the level of the umbilicus most reliably approximates inflation above the iliac bifurcation. X-ray confirmation of balloon placement is recommended prior to zone III inflation, given the short landing zone and variability of umbilical measurements with body habitus (Figure 21.8).

  • The peel-away sheath is inserted less than 1 cm into the 7-F sheath, and the catheter is advanced until the balloon is distal to the sheath valve, after which point the peel away is removed. The arterial port is flushed and connected to an arterial monitoring device (Figure 21.9 AC).

  • Once the catheter is at the desired position, time and resource permitting, an X-ray is obtained to confirm placement (Figure 21.10).

  • The balloon is then inflated with a 50% strength contrast. The volume needed for inflation differs based on catheter type and aortic diameter. Occlusion volume can be determined using fluoroscopy, by haptic feedback, loss of contralateral pulse, or loss of arterial waveform if an arterial pressure monitor is present on the contralateral side below the level of occlusion.

  • Balloon morphology is confirmed by X-ray, taking care to evaluate for over- or under-inflation (Figure 21.11 A,B).

  • Once placement is confirmed, the catheter is secured in place.

  • Proceed immediately to definitive hemorrhage control.

Apr 22, 2021 | Posted by in EMERGENCY MEDICINE | Comments Off on Chapter 21 – Resuscitative Endovascular Occlusion of the Aorta (REBOA)
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