REBOA-facilitated hybrid endovascular control of exsanguinating penetrating perineal trauma with internal iliac arterial hemorrhage: a case report

Background: Penetrating perineal trauma can cause life-threatening non-compressible pelvic arterial hemorrhage. Resuscitative endovascular balloon occlusion of the aorta (REBOA) provides temporary proximal aortic control while definitive hemostasis is arranged, although its clinical benefit in trauma remains uncertain. Case presentation: A 28-year-old man presented with a penetrating perineal stab wound, profound hemorrhagic shock, and ongoing bleeding despite packing and local Foley-catheter tamponade. Examination under anesthesia and proctoscopy demonstrated a 13 cm wound tract without rectal mucosal injury; exploratory laparotomy was not performed. Failed percutaneous femoral cannulation necessitated a left common femoral artery cutdown for REBOA placement. Computed tomography angiography (CTA) during balloon deflation identified a 6 × 8 cm pelvic hematoma, right internal iliac arterial extravasation, and a catheter tip in zone II, prompting repositioning to zone III. Selective angiography via the left brachial artery demonstrated bleeding from two anterior-division branches that was controlled using three detachable coils. A perineal wound infection was treated with antibiotics and local care. No recurrent bleeding or reported procedure-related complications were identified at 3-month follow-up. Discussion: This case illustrates the procedural choices and uncertainties associated with temporary aortic occlusion, imaging-based localization, and definitive pelvic embolization. The initial balloon occlusion zone could not be confirmed retrospectively from the deflated catheter-tip position seen on CTA; non-femoral angiographic access was chosen despite other potential access routes. Conclusion: In this patient, temporary REBOA support was followed by CTA localization and selective coil embolization for deep pelvic arterial hemorrhage. REBOA must remain a carefully selected bridge to definitive control, not a substitute for it.