Over-the-scope clip hemostasis assisted by resuscitative endovascular balloon occlusion of the aorta for life-threatening duodenal ulcer bleeding

Resuscitative endovascular balloon occlusion of the aorta (REBOA) temporarily controls hemorrhage by inflating an aortic balloon inserted via femoral arterial access ([ Fig. 1 ]). It has been used mainly in trauma and obstetric hemorrhage,[ 1​ ] [ ​2​ ] whereas reports in gastrointestinal bleeding remain limited.[ 3​ ] In nonvariceal gastrointestinal bleeding, Zone I occlusion can reduce splanchnic arterial inflow; however, complete occlusion should be minimized, optimally to < 30 minutes because of distal ischemia and related adverse effects, including ischemia–reperfusion injury, renal impairment, bowel or lower-limb ischemia, and access-site vascular complications,[ 4​ ] ([ Fig. 2 ]). Rapid mechanical hemostasis with an over-the-scope clip (OTSC) may therefore be useful.[ 5​ ] Fig. 1 A photograph of the REBOA balloon catheter used in this case. Fig. 2 Schematic illustration of REBOA zones. Zone I extends from the origin of the left subclavian artery to the celiac artery, and the balloon is positioned in Zone I. A man in his 50 s with alcohol-related cirrhosis developed cardiac arrest after hematemesis and was resuscitated. Contrast-enhanced computed tomography showed extravasation in the descending duodenum ([ Fig. 3 ]). On arrival, he had hemorrhagic shock despite intubation and vasopressors. As surgery and interventional radiology were not immediately available, a REBOA catheter was inserted via the left femoral artery and positioned in Zone I, with the balloon deflated, before emergency endoscopy. Fig. 3 Contrast-enhanced computed tomography obtained at the referring hospital. Active contrast extravasation was observed in the descending part of the duodenum (red arrowheads). [ Video 1 ] demonstrates the REBOA-assisted hemostatic strategy. First, balloon inflation was delayed until massive duodenal bleeding was confirmed and the endoscope had reached the presumed source. Inflation reduced bleeding and revealed a deep ulcer on the inferior wall of the superior duodenal angle, but the exact bleeding point was obscured under complete occlusion. Second, brief titrated deflation to partial aortic occlusion under hemodynamic and endoscopic monitoring revealed focal active bleeding from the right side of the ulcer; a marking clip was placed and the balloon was reinflated. Third, rapid mechanical hemostasis was achieved by deploying an OTSC using the marking clip as a landmark. Final deflation showed no rebleeding, bridging the patient to definitive coil embolization ([ Fig. 4 ]). No subsequent rebleeding or renal impairment occurred. Video 1 Over-the-scope clip hemostasis assisted by resuscitative endovascular balloon occlusion of the aorta for life-threatening duodenal ulcer bleeding, highlighting delayed inflation, brief planned deflation, and rapid mechanical hemostasis. Download Video Fig. 4 An angiographic image after definitive transcatheter arterial embolization. The red arrow indicates the OTSC, and the red arrowheads indicate the embolization coils. Endoscopy_UCTN_Code_TTT_1AO_2AD Publication History Received: 22 May 2026 Accepted after revision: 29 May 2026 Article published online: 19 June 2026 © 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany