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Resuscitative endovascular balloon occlusion of the aorta for hemorrhage control: Past, present, and future

D the past 5 years, resuscitative endovascular balloon occlusion of the aorta (REBOA), an endovascular technique for hemorrhage control and resuscitation, has been reappraised in large animal models and increasingly used in clinical care. This review provides a historical perspective on the development of REBOA and presents a summary of clinical and translational research spearheading further advances and transformation of the technology. Hemorrhage is an important cause of mortality worldwide in both civilian and military trauma patients. Recently, a new definition of noncompressible torso hemorrhage (NCTH) was introduced; it includes bleeding into the chest, abdominal cavity, and/or pelvis, which is difficult or impossible to control with direct pressure. In their recent review of the epidemiology of US combat fatalities in Iraq and Afghanistan, Eastridge et al. determined that among the potentially survivable injuries seen on the battlefield before arrival at a medical treatment facility, 91% of deaths were caused by truncal (67.3%), junctional (19.2%), and extremity (13.5%) hemorrhage. A similar percentage (85.5%) was cited in a recent British study. Combat-related trauma differs in several important respects from that observed in the civilian setting in that the former consists of more severe injuries with a higher incidence of penetrating and explosivemechanisms. However, even in the civilian environment, mortality from NCTH is high at approximately 45%. With advancements in the understanding of the pathophysiology of hemorrhage and resuscitation coupled with technological improvements, more patients with NCTH survive to hospital admission. Emergency resuscitative thoracotomy is one option for the treatment of exsanguination from NCTH, with a history much longer than that of REBOA (Fig. 1). The purpose of this procedure is threefold. First, it allows for control of bleeding from chest injuries and drainage of pericardial tamponade if present. Second, the procedure increases cerebral and coronary blood flow and allows initiation of direct cardiac massage. Third, cross-clamping of the descending aorta permits some degree of control of noncompressible torso, junctional, and even extremity hemorrhage. In 2001, the American College of Surgeons published practice management guidelines for emergency department thoracotomy (EDT), which reported an overall survival rate of approximately 8%. The rate was higher for penetrating injuries (approximately 11%) and as high as 31% for penetrating cardiac injuries. The American College of Surgeons guidelines recommended EDT for trauma patients with penetrating thoracic injuries or exsanguinating abdominal hemorrhage and signs of life. Clearly, EDT has an important role to play in a subset of critically injured patients. However, since EDT is highly invasive and exposes providers to a risk of blood-borne diseases, REBOA is an attractive alternative that offers a lower risk of exposure. What are the origins of the REBOA concept?