Today, I got to interview one of the superstars at Shock Trauma on REBOA (resuscitative endovascular balloon occlusion of the aorta).
Balloon occlusion of the aorta was first described in 1954 (Surgery 1954;36(1):65). Other older articles include (Ann Emerg Med 1986;15(12):1466, J Endovasc Ther 2000;7(1):1, Endovasc Ther 2005;12(5):556).
The Shock Trauma Center (STC) Approach to REBOA
Gain Access to the Common Femoral Artery with Femoral A-line Kit
- Just like normal, except make sure you are hitting common femoral and not superficial femoral artery. The point of entry should be 2cm below inguinal ligament (estimate ligament by anterior superior iliac to pubic tubercle). This may be much higher than you are used to.
- Use either 18 arterial line set or Cook 5f Central Venous Cath (G02070)
Float the Wire
- STC uses Boston Scientific Amplatz superstiff wires (0.035in/260 cm/straight floppy tip)
- Measure externally from the catheter to the level of the 2nd rib–mark this level on the wire (At STC, they use Avery 5422 stickers)
- Advance the wire floppy-end first to the marked depth
- Confirm location with either radiograph or fluoro before proceeding
- Mark the proximal end of the wire with a pen on the sterile drape
Place the Sheath
- At STC, they use a Check-Flo Performer Introducer (12 fr, 30cm)
- Remove the femoral artery catheter
- Measure the introducer externally from groin to just below the umbilicus (make sure you are measuring the catheter, not the dilator). Mark with a sticker
- In some cases, you need to dilate the vessel to accept the introducer; in most cases the internal dilator is sufficient
- Place the introducer to the previously marked level
- Critical Move: Removal of the dilator can screw everything up. The operator should lock the sideport of the dilator between their fingers and grip tight and with the other hand, hold the wire proximally. Allow assistant to pin and pull the dilator. If they mess up, you are still controlling the sheath and the wire. If some of the wire gets pulled, have your assistant reinsert without you letting go of sheath or wire.
Place the Coda Catheter/Balloon
- Grab a CODA balloon catheter (32 mm-balloon)
- Measure externally; Zone 1 is measured to the xiphoid, Zone 3 is measured to just above the umbilicus. Measure at the proximal portion of the balloon
- Remove all air from the balloon using saline syringe
- Insert the CODA catheter
- The wire stays stationary throughout
Inflate the Balloon
- Use a 30 ml syringe, ideally filled with 20 ml of NS and 10 ml of omnipaque (lohexol); use just saline if contrast not available
- Inflate until resistance goes to moderate (would love to know what luminal pressure this corresponds to). In general, this corresponds to 12-22 mls depending on the size of the aorta–but this must be individualized to the patient. The actual infaltion is far harder than you may think. For me, it is the maximal force I can apply with 1 hand.
Secure Everything for Transport
- Here's how they do it at STC
- Mark the levels of everything so you can verify there has been no migration
Get an Xray when time allows
Go to Definitive Management
- The introducer sheath will need to be removed under direct observation after cutdown, with arterial repair (at least until smaller catheters are developed)
Shock Trauma Center Protocol
REBOA review article (J Trauma. 2011 Dec;71(6):1869-72)
Case series: Martinelli T et al. J Trauma 2010 Apr;68(4):942-8
Case Series: Brenner M et al. J Trauma Acute Care Surg. 2013 Sep;75(3):506
Update: Dr. Brenner's new article on training with a REBOA simulator [cite source='doi']10.1097/TA.0000000000000310[/cite] and the ESTARs Course Curriculum
Update: How should you bill? Possibilities include: 36140 Introducer into arterial system, 36200 Aortic Cath, 36245 Selective cath placement, Placement of IABP, Transcath occlusion vessel, non-neck, non-extremity
Retrospective Series (Journal of Trauma and Acute Care Surgery 2015;78(1):132–135)