REBOA: A novel life-saving tool for non-compressible traumatic hemorrhage

To the Editor: Non-compressible traumatic hemorrhage (NCTH) is a critical and life-threatening condition characterized by bleeding that cannot be stopped through direct pressure. This type of hemorrhage most commonly occurs in trauma to the torso, pelvis, or junctional areas, regions that are hard to compress. Effective treatment of NCTH necessitates swift medical interventions, such as surgical procedures, to control the bleeding, presenting great challenges in immediate on-site management. As such, NCTH contributes substantially to morbidity and mortality, underscoring its importance in trauma care and emergency medicine. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is critical emergency procedure deployed to manage severe, life-threatening hemorrhages when standard resuscitation methods are ineffective or unfeasible. REBOA involves inserting a balloon catheter into the aorta through the femoral artery. Once positioned, the balloon is inflated to temporarily block blood flow to the lower body, thereby effectively minimizing blood loss while preserving circulation to critical organs such as the heart and brain. REBOA is particularly beneficial in cases of NCTH, where direct pressure fails to control bleeding. This procedure serves as an interim solution to stabilize the patient and allows time for more definitive surgical interventions.1 REBOA is primarily indicated in traumatic scenarios such as road accidents, gunshot, or stabbing wounds. The procedure entails the minimally invasive insertion of a catheter into the aorta always via the femoral artery. The specific placement of the balloon depends on the hemorrhage location, including Zone 1, which spans from the left subclavian artery to the celiac artery, and Zone 3, situated below the renal arteries but above the aortic bifurcation.2 Zone 1 is typically used for managing abdominal or junctional hemorrhages, while Zone 3 is applied in cases of pelvic hemorrhaging. REBOA is a sophisticated technique for managing NCTH, though it comes with several challenges and potential complications. First, accessing the femoral artery for catheter insertion can be difficult, particularly in patients experiencing traumatic shock or those who are obese. Second, prolonged aortic occlusion can lead to ischemia in the lower extremities and abdominal organs. Current guidelines recommend that the balloon should not remain inflated for more than 30–60 min to prevent potential tissue damage or organ failure.3 Additionally, there is also a risk of mechanical complications, such as aortic dissection or rupture if the balloon is overinflated, as well as thrombosis or embolization. While REBOA is typically reserved for life-threatening situations where other resuscitation methods have failed, it requires vigilant post-procedural monitoring and care. The successful saving of patients with severe hemorrhagic injuries often hinges on the timely performance of definitive surgical interventions following the temporary stabilization provided by REBOA. REBOA is increasingly recognized as a critical tool in improving survival rates in critical, potentially fatal hemorrhagic situations. However, REBOA is not one-size-fits-all and has not been widely utilized. Its efficacy remains a subject of debate.4,5 Ongoing clinical trials are designed to better define REBOA's role, confirm its safety, optimize its use, and improve outcomes for patients with NCTH Table 1. Furthermore, timely completion is crucial in managing NCTH. REBOA requires implementation by trained specialists to ensure quick and precise balloon placement, particularly in emergency care settings. Current research is investigating the effectiveness of simulation training in enhancing the competency of clinical doctors in performing REBOA for treating severe hemorrhage. Additional efforts, including the development of new devices and techniques, are essential to reduce deployment time and minimize the risk of complications.6,7 Table 1 - The registered clinical trials on REBOA for hemorrhage. Identifiers Conditions Control arm Experimental arm Primary outcome Study type Status NCT05598502 Post-partum hemorrhage National guidelines Addition of REBOA Adverse outcome Interventional study Recruiting NCT05062928 Simulation training of REBOA for saving hemorrhage Human instructor Virtual coaching Virtual coach is non-inferior in REBOA training to an average human instructor Interventional study Recruiting NCT06312436 Uncontrolled hemorrhage Resuscitative measures except REBOA REBOA 30-day in-hospital mortality Case-control study Not recruiting NCT05941572 Non-compressible torso hemorrhage – REBOA 30-day mortalityOccurrence of complicationsTransfusion of blood products Retrospective cohort study Recruiting ISRCTN16184981 Life-threatening torso hemorrhage Standard treatment Addition of REBOA 90-day mortalityLifetime incremental cost per QALY gained Randomized controlled trial Completed REBOA: Resuscitative endovascular balloon occlusion of the aorta; QALY: Quality-adjusted life years; – : Not applicable. Conflicts of interest None.