Thrailkill et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
(2021) 29:8
https://doi.org/10.1186/s13049-020-00807-9
REVIEW Open Access
Resuscitative Endovascular Balloon
Occlusion of the Aorta (REBOA): update
and insights into current practices and
future directions for research and
implementation
Marianne A. Thrailkill1,2†, Kevin H. Gladin3†, Catherine R. Thorpe2,4, Teryn R. Roberts2,5, Jae H. Choi2,5,
Kevin K. Chung6, Corina N. Necsoiu7, Todd E. Rasmussen6, Leopoldo C. Cancio8 and Andriy I. Batchinsky2,5*
Abstract
Background: In this review, we assess the state of Resuscitative Endovascular Occlusion of the Aorta (REBOA) today
with respect to out-of-hospital (OOH) vs. inhospital (H) use in blunt and penetrating trauma, as well as discuss areas
of promising research that may be key in further advancement of REBOA applications.
Methods: To analyze the trends in REBOA use, we conducted a review of the literature and identified articles with
human or animal data that fit the respective inclusion and exclusion criteria. In separate tables, we compiled data
extracted from selected articles in categories including injury type, zone and duration of REBOA, setting in which
REBOA was performed, sample size, age, sex and outcome. Based on these tables as well as more detailed review
of some key cases of REBOA usage, we assessed the current state of REBOA as well as coagulation and histological
disturbances associated with its usage. All statistical tests were 2-sided using an alpha=0.05 for significance. Analysis
was done using SAS 9.5 (Cary, NC). Tests for significance was done with a t-test for continuous data and a Chi
Square Test for categorical data.
(Continued on next page)
* Correspondence:
The views expressed in this article are those of the authors and do not
reflect the official policy or position of the U.S. Army Medical Department,
Department of the Army, DoD, or the U.S. Government.
†
Marianne Thrailkill and Kevin Gladin contributed equally to this work.
2
Extracorporeal Life Support Capability Area, United States Army Institute of
Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX 78234, USA
5
Autonomous Reanimation and Evacuation Research Program, The Geneva
Foundation, San Antonio, TX, USA
Full list of author information is available at the end of the article
© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
changes were made. The images or other third party material in this article are included in the article's Creative Commons
licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons
licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.
, Thrailkill et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2021) 29:8 Page 2 of 15
(Continued from previous page)
Results: In a total of 44 cases performed outside of a hospital in both military and civilian settings, the overall
survival was found to be 88.6%, significantly higher than the 50.4% survival calculated from 1,807 cases of REBOA
performed within a hospital (p<.0001). We observe from human data a propensity to use Zone I in penetrating
trauma and Zone III in blunt injuries. We observe lower final metabolic markers in animal studies with shorter
REBOA time and longer follow-up times.
Conclusions: Further research related to human use of REBOA must be focused on earlier initiation of REBOA after
injury which may depend on development of rapid vascular access devices and techniques more so than on any
new improvements in REBOA. Future animal studies should provide detailed multisystem organ assessment to
accurately define organ injury and metabolic burden associated with REBOA application. Overall, animal studies
must involve realistic models of injury with severe clinical scenarios approximating human trauma and
exsanguination, especially with long-term follow-up after injury.
Keywords: REBOA, Non-compressible torso hemorrhage
Introduction Together with pioneering activities within the U.S.
Intravascular occlusion to control hemorrhage was first military, the availability of compact REBOA-specific
described during the Korean War by Lieutenant Colonel technology ushered in a new era of translational and
Hughes, who used an intra-aortic balloon to manage clinical research well summarized in recent reviews [7–
hemorrhage in two patients. Hughes postulated that an 11]. The purpose of this manuscript is to assess the state
earlier intervention using this method could have been of REBOA today with respect to out-of-hospital (OOH)
beneficial, and potentially life-saving, paving the way for vs. in-hospital (H) use in blunt and penetrating trauma,
utilization of an intravascular hemorrhage-control cap- as well as to discuss areas of promising research that
ability as a form of internal tourniquet and life-saving may be key in further advancement of REBOA applica-
intervention during exsanguination [1]. Decades later, tions. We also report on common metabolic markers
this initial vision for the management of difficult-to- during REBOA use in animals and revisit certain
control bleeding is generally still valid today. ischemia-reperfusion, coagulation and histological dis-
Numerous studies were performed in the subsequent de- turbances associated with REBOA use.
cades and raised concerns of complications from aortic blood
flow occlusion, such as mesenteric and lower body ischemia
and renal injury to name a few. Instead of balloon occlusion, Current use of REBOA
resuscitative thoracotomy (RT) with a descending aortic Originally conceived to manage non-compressible torso
clamp was adopted as a standard method of controlling ex- hemorrhage, the indications for the use of REBOA have
sanguinating hemorrhage in patients in extremis, and was come to address a broad array of morbidities, due to its
shown to improve survival, despite caution regarding inva- ability to induce occlusion of the aorta in multiple loca-
siveness not dissimilar to that of balloon occlusion [2–4]. tions or “Zones”. Deployment of REBOA in the supra-
Thus, despite the fact that RT involved invasive surgical ac- diaphragmatic location (Zone I) allows for control of
cess and was accompanied by the same complications that lower-torso/abdominal or lower extremity bleeding.
slowed the adoption of aortic balloon occlusion, RT was the Zone II deployment is problematic as it is highly
preferred method due to greater provider familiarity. These dependent on accurate placement between the celiac
and other aspects of balloon occlusion development were de- trunk and the renal arteries (Zone II), which is difficult
tailed in numerous reviews [5–7]. to achieve without contrast/visualization. Zone III in-
Beginning in 2010, improvements in balloon technol- volves placement below the renal arteries but proximal
ogy and a series of encouraging pre-clinical studies led to the iliac bifurcation. This is arguably the least compli-
to wider implementation of “Resuscitative Endovascular cated of the three zones, and is intended for control of
Balloon Occlusion of the Aorta” (REBOA). Importantly, bleeding in the pelvis and extremities [12]. Consensus
the appearance of purpose-designed prototypes circa opinions indicate that shorter periods of occlusion which
2011–2012, followed by U.S. Food and Drug Administra- minimize ischemic injury are best for patient survival,
tion (FDA) clearance of the REBOA-ER® (Prytime Med- with Zone III generally allowing for longer periods of oc-
ical Inc., Boerne, TX) in 2016, all led to a significant clusion than Zone I (60–90 min for Zone III vs. 30–60
inflection point (Fig. 1) in utilization of endovascular for Zone I) [13].
balloon technology specifically with the purpose of Over the last decade REBOA progressed to intense in-
hemorrhage control. vestigation in multiple clinical trials (Table 1).
(2021) 29:8
https://doi.org/10.1186/s13049-020-00807-9
REVIEW Open Access
Resuscitative Endovascular Balloon
Occlusion of the Aorta (REBOA): update
and insights into current practices and
future directions for research and
implementation
Marianne A. Thrailkill1,2†, Kevin H. Gladin3†, Catherine R. Thorpe2,4, Teryn R. Roberts2,5, Jae H. Choi2,5,
Kevin K. Chung6, Corina N. Necsoiu7, Todd E. Rasmussen6, Leopoldo C. Cancio8 and Andriy I. Batchinsky2,5*
Abstract
Background: In this review, we assess the state of Resuscitative Endovascular Occlusion of the Aorta (REBOA) today
with respect to out-of-hospital (OOH) vs. inhospital (H) use in blunt and penetrating trauma, as well as discuss areas
of promising research that may be key in further advancement of REBOA applications.
Methods: To analyze the trends in REBOA use, we conducted a review of the literature and identified articles with
human or animal data that fit the respective inclusion and exclusion criteria. In separate tables, we compiled data
extracted from selected articles in categories including injury type, zone and duration of REBOA, setting in which
REBOA was performed, sample size, age, sex and outcome. Based on these tables as well as more detailed review
of some key cases of REBOA usage, we assessed the current state of REBOA as well as coagulation and histological
disturbances associated with its usage. All statistical tests were 2-sided using an alpha=0.05 for significance. Analysis
was done using SAS 9.5 (Cary, NC). Tests for significance was done with a t-test for continuous data and a Chi
Square Test for categorical data.
(Continued on next page)
* Correspondence:
The views expressed in this article are those of the authors and do not
reflect the official policy or position of the U.S. Army Medical Department,
Department of the Army, DoD, or the U.S. Government.
†
Marianne Thrailkill and Kevin Gladin contributed equally to this work.
2
Extracorporeal Life Support Capability Area, United States Army Institute of
Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX 78234, USA
5
Autonomous Reanimation and Evacuation Research Program, The Geneva
Foundation, San Antonio, TX, USA
Full list of author information is available at the end of the article
© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
changes were made. The images or other third party material in this article are included in the article's Creative Commons
licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons
licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.
, Thrailkill et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2021) 29:8 Page 2 of 15
(Continued from previous page)
Results: In a total of 44 cases performed outside of a hospital in both military and civilian settings, the overall
survival was found to be 88.6%, significantly higher than the 50.4% survival calculated from 1,807 cases of REBOA
performed within a hospital (p<.0001). We observe from human data a propensity to use Zone I in penetrating
trauma and Zone III in blunt injuries. We observe lower final metabolic markers in animal studies with shorter
REBOA time and longer follow-up times.
Conclusions: Further research related to human use of REBOA must be focused on earlier initiation of REBOA after
injury which may depend on development of rapid vascular access devices and techniques more so than on any
new improvements in REBOA. Future animal studies should provide detailed multisystem organ assessment to
accurately define organ injury and metabolic burden associated with REBOA application. Overall, animal studies
must involve realistic models of injury with severe clinical scenarios approximating human trauma and
exsanguination, especially with long-term follow-up after injury.
Keywords: REBOA, Non-compressible torso hemorrhage
Introduction Together with pioneering activities within the U.S.
Intravascular occlusion to control hemorrhage was first military, the availability of compact REBOA-specific
described during the Korean War by Lieutenant Colonel technology ushered in a new era of translational and
Hughes, who used an intra-aortic balloon to manage clinical research well summarized in recent reviews [7–
hemorrhage in two patients. Hughes postulated that an 11]. The purpose of this manuscript is to assess the state
earlier intervention using this method could have been of REBOA today with respect to out-of-hospital (OOH)
beneficial, and potentially life-saving, paving the way for vs. in-hospital (H) use in blunt and penetrating trauma,
utilization of an intravascular hemorrhage-control cap- as well as to discuss areas of promising research that
ability as a form of internal tourniquet and life-saving may be key in further advancement of REBOA applica-
intervention during exsanguination [1]. Decades later, tions. We also report on common metabolic markers
this initial vision for the management of difficult-to- during REBOA use in animals and revisit certain
control bleeding is generally still valid today. ischemia-reperfusion, coagulation and histological dis-
Numerous studies were performed in the subsequent de- turbances associated with REBOA use.
cades and raised concerns of complications from aortic blood
flow occlusion, such as mesenteric and lower body ischemia
and renal injury to name a few. Instead of balloon occlusion, Current use of REBOA
resuscitative thoracotomy (RT) with a descending aortic Originally conceived to manage non-compressible torso
clamp was adopted as a standard method of controlling ex- hemorrhage, the indications for the use of REBOA have
sanguinating hemorrhage in patients in extremis, and was come to address a broad array of morbidities, due to its
shown to improve survival, despite caution regarding inva- ability to induce occlusion of the aorta in multiple loca-
siveness not dissimilar to that of balloon occlusion [2–4]. tions or “Zones”. Deployment of REBOA in the supra-
Thus, despite the fact that RT involved invasive surgical ac- diaphragmatic location (Zone I) allows for control of
cess and was accompanied by the same complications that lower-torso/abdominal or lower extremity bleeding.
slowed the adoption of aortic balloon occlusion, RT was the Zone II deployment is problematic as it is highly
preferred method due to greater provider familiarity. These dependent on accurate placement between the celiac
and other aspects of balloon occlusion development were de- trunk and the renal arteries (Zone II), which is difficult
tailed in numerous reviews [5–7]. to achieve without contrast/visualization. Zone III in-
Beginning in 2010, improvements in balloon technol- volves placement below the renal arteries but proximal
ogy and a series of encouraging pre-clinical studies led to the iliac bifurcation. This is arguably the least compli-
to wider implementation of “Resuscitative Endovascular cated of the three zones, and is intended for control of
Balloon Occlusion of the Aorta” (REBOA). Importantly, bleeding in the pelvis and extremities [12]. Consensus
the appearance of purpose-designed prototypes circa opinions indicate that shorter periods of occlusion which
2011–2012, followed by U.S. Food and Drug Administra- minimize ischemic injury are best for patient survival,
tion (FDA) clearance of the REBOA-ER® (Prytime Med- with Zone III generally allowing for longer periods of oc-
ical Inc., Boerne, TX) in 2016, all led to a significant clusion than Zone I (60–90 min for Zone III vs. 30–60
inflection point (Fig. 1) in utilization of endovascular for Zone I) [13].
balloon technology specifically with the purpose of Over the last decade REBOA progressed to intense in-
hemorrhage control. vestigation in multiple clinical trials (Table 1).
