Emergency IR · IR Playbook

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

Resuscitative endovascular balloon occlusion of the aorta is temporary complete or partial aortic occlusion through common femoral arterial access to reduce subdiaphragmatic hemorrhage and augment coronary and cerebral perfusion until definitive hemostasis. It is a time-critical bridge, not definitive treatment, and requires simultaneous damage-control resuscitation and immediate operative or endovascular hemorrhage control. Mortality benefit is not established for routine hypotensive subdiaphragmatic trauma; EAST 2025 conditionally recommends against routine use in that group but conditionally favors REBOA over resuscitative thoracotomy for traumatic cardiac arrest when thoracotomy has no other indication.

Learning objectives

• Select exceptional patients in whom temporary aortic occlusion may bridge directly to definitive hemorrhage control.
• Choose Zone 1 or Zone 3 from the suspected bleeding source and avoid Zone 2.
• Obtain accurate common femoral access and deploy a low-profile balloon without delaying hemostasis.
• Differentiate complete from partial REBOA and apply appropriate proximal and distal pressure targets.
• Prevent, detect and urgently treat ischemic, reperfusion and access-site complications.

Indications

• Traumatic cardiac arrest from suspected subdiaphragmatic hemorrhage without major thoracic injury or another indication for resuscitative thoracotomy; EAST 2025 conditionally favors REBOA over thoracotomy in this narrow group.
• Exceptionally selected impending arrest or profound refractory hemorrhagic shock from noncompressible hemorrhage below the diaphragm when a trained team can proceed immediately to operative or endovascular control; this is not routine use because EAST 2025 conditionally recommends against REBOA for the broader hypotensive trauma population.
• Uncontrolled pelvic, junctional groin or very proximal lower-extremity hemorrhage not controlled by direct pressure, pelvic stabilization or tourniquet, with Zone 3 used only after excluding significant abdominal bleeding.
• Planned prophylactic aortic balloon occlusion for placenta accreta spectrum in a hemodynamically stable patient within a multidisciplinary specialist protocol; EAST 2025 gives a conditional recommendation.
• Selected catastrophic nontraumatic subdiaphragmatic hemorrhage as a rescue bridge when standard control is not immediately effective; evidence is insufficient for a general recommendation.

Absolute contraindications

• Major intrathoracic hemorrhage, cardiac injury or pericardial tamponade requiring thoracotomy or sternotomy.
• No immediate capability for definitive hemorrhage control or simultaneous damage-control resuscitation.
• Known aortic dissection, rupture or traumatic aortic injury across the intended catheter or balloon segment.

Relative contraindications

• Hemodynamically unstable subdiaphragmatic trauma or blunt pelvic fracture without arrest; EAST 2025 conditionally recommends against routine REBOA in these populations.
• Severe traumatic brain injury, neck hemorrhage or proximal vascular injury that may worsen with abrupt proximal hypertension.
• Severe aortoiliac occlusive disease, marked calcification, previous aortoiliac reconstruction or a small diseased common femoral artery.
• Prolonged no-flow arrest, unsurvivable injury burden or absence of signs of life beyond locally accepted resuscitative-aortic-occlusion criteria.
• Pediatric patient or very small vessel caliber because clinical evidence and device compatibility are limited.

Equipment

• Ultrasound with high-frequency linear transducer, sterile cover and gel
• 5 Fr micropuncture set or 18 G femoral arterial-line access set
• Device-compatible 0.035-inch guidewire long enough for arterial-line exchange and sheath placement
• Modern REBOA introducer sheath, usually 7 Fr, with dilator and side-arm
• Complete-occlusion REBOA catheter or partial-flow-capable REBOA catheter compatible with the selected sheath
• Device-specified balloon syringe, usually 30 mL, three-way stopcock and inflation medium prepared exactly according to the instructions for use
• Two arterial pressure transducers or validated inline pressure monitors for proximal and distal pressures during partial REBOA
• Large-bore venous or intraosseous access, rapid infuser, blood warmer and massive-transfusion supplies
• Sterile preparation, full drapes, local anesthetic, #11 or #15 scalpel and suture or catheter-securement device
• Portable radiography, fluoroscopy or ultrasound capability for position confirmation when physiology permits
• Open femoral exposure and vascular-repair set with Fogarty catheter, vessel loops, patch and graft material immediately available
• Doppler device and access to duplex ultrasound or angiography for limb and access-site assessment

Procedure steps

1. Mobilize damage-control resuscitation and the operating room or angiography pathway before arterial access. Treat compressible hemorrhage, tension pneumothorax and airway threats concurrently, and confirm that a trained clinician will continuously manage the balloon.
2. Assess the chest with eFAST, radiography and tube thoracostomy findings as appropriate. Do not deploy REBOA for major thoracic hemorrhage or tamponade; perform the indicated thoracic intervention.Pearl: Aortic occlusion increases proximal pressure and can accelerate bleeding above the balloon.
3. Select Zone 1 for abdominal or uncertain subdiaphragmatic hemorrhage and Zone 3 for isolated pelvic or distal hemorrhage after excluding an abdominal source. Mark the device-specific target depth and announce the intended zone.
4. Use ultrasound to puncture the uninjured common femoral artery above its bifurcation with a micropuncture or 18 G arterial set. If percutaneous access fails or pulses are absent in profound shock, proceed promptly to open femoral exposure rather than repeated blind punctures.Pearl: Early correctly positioned CFA arterial access is the main modifiable determinant of time to occlusion.
5. Advance a compatible wire and insert the smallest sheath required by the selected system, usually 7 Fr for modern devices. Secure the sheath, connect its side-arm for distal pressure monitoring when partial REBOA is planned, and maintain patency without forceful flushing.
6. Prime the arterial monitoring lumen and evacuate all air from the balloon system. Prepare the syringe and inflation medium exactly according to the specific catheter instructions; balloon volumes are not interchangeable between devices.
7. Advance the catheter to its validated Zone 1 or Zone 3 marker without force. When time permits, confirm both radiopaque balloon markers with radiography, ultrasound or fluoroscopy before inflation; in arrest, validated landmark-based placement may precede confirmation.Pearl: For the JTS-described adult 7 Fr catheter, Zone 1 is approximately 45–49 cm and Zone 3 approximately 26–29 cm at the sheath, but habitus and device design vary.
8. Inflate slowly while observing proximal pressure, distal pressure or waveform, hemorrhage and the contralateral femoral pulse. For partial REBOA, target proximal SBP 90–110 mmHg with pulsatile distal SBP 20–50 mmHg; for complete REBOA, use the minimum volume that achieves wall apposition and loss of distal flow.Pearl: Partial REBOA is conditionally preferred in the current JTS guideline when the device and team permit reliable titration.
9. Secure both sheath and catheter at the measured depth and assign a trained assistant to prevent migration. Announce and record zone, insertion depth, inflation time, balloon volume, partial versus complete mode, and proximal and distal pressures; reassess continuously.
10. Proceed immediately to laparotomy, pelvic packing, angioembolization, hysterectomy or vascular repair while continuing balanced transfusion and correction of calcium, temperature and coagulation. Minimize complete occlusion: Zone 1 is optimally under 30 minutes and neither Zone 1 nor Zone 3 complete occlusion should exceed 60 minutes under current JTS guidance.Pearl: Technical balloon deployment without rapid definitive hemostasis is procedural failure.
11. After definitive control and adequate volume resuscitation, coordinate slow balloon deflation with anesthesia and the operative team while monitoring pressure, bleeding, pH, potassium and calcium. A practical JTS approach for complete occlusion is approximately 1 mL per minute; with partial REBOA, staged adjustments may raise distal SBP by about 20 mmHg every 10 minutes. Pause or partially reinflate if collapse or renewed hemorrhage occurs.
12. Fully deflate the balloon before catheter removal; if it will not pass through the sheath, remove catheter and sheath together in a controlled vascular setting. After definitive hemostasis, assess distal perfusion by examination and preferably angiography or duplex, then remove the sheath with manual compression, closure device or open repair appropriate to the arteriotomy and coagulopathy. Do not remove a sheath immediately before transfer to a setting unable to manage vascular complications.Pearl: The 2026 JTS update recommends 30 minutes of direct CFA pressure when manual compression is used.

Complications

• Femoral access-site vascular complication; pooled incidence 8.6% in a 2023 meta-analysis
• Acute lower-limb ischemia or compartment syndrome
• Distal visceral, renal, spinal or muscular ischemia
• Reperfusion syndrome and cardiovascular collapse
• Aortic injury, dissection, perforation or balloon rupture
• Worsening proximal hemorrhage or pressure-related organ injury

Exam pearls

• REBOA is a bridge, not definitive hemorrhage control.
• Zone 1 controls abdominal and pelvic inflow; Zone 3 preserves renal and visceral perfusion but requires exclusion of important abdominal bleeding.
• Zone 2 is the no-occlusion zone.
• Correct common femoral access is the rate-limiting technical step and the major determinant of access complications.
• For complete REBOA, remember Zone 1 optimally under 30 minutes and both Zone 1 and Zone 3 no more than 60 minutes under current JTS guidance.
• A non-aspirating sheath is presumed thrombosed: do not flush it.

Viva questions

What is the physiological purpose of REBOA?

It temporarily reduces hemorrhage below the balloon and increases proximal aortic pressure to support coronary and cerebral perfusion. It is only a bridge to immediate definitive hemostasis.

Define the three REBOA zones.

Zone 1 is from the left subclavian artery to the celiac artery, Zone 2 from the celiac artery to the lowest renal artery, and Zone 3 from the lowest renal artery to the aortic bifurcation.

How do you choose between Zone 1 and Zone 3?

Use Zone 1 for abdominal or uncertain subdiaphragmatic hemorrhage and commonly in traumatic arrest without major chest injury. Use Zone 3 only for isolated pelvic, junctional or proximal lower-extremity hemorrhage after excluding significant abdominal bleeding.

Why is Zone 2 avoided?

Balloon inflation in Zone 2 can obstruct or injure the celiac, superior mesenteric or renal arterial origins, causing major visceral ischemia or thrombosis.

What is partial REBOA?

Partial REBOA maintains controlled pulsatile flow past the balloon while limiting hemorrhage. Current JTS guidance targets proximal SBP 90–110 mmHg and distal SBP 20–50 mmHg with a compatible device and two-level pressure monitoring.

What are the major contraindications?

Major thoracic hemorrhage, cardiac injury or tamponade; known aortic injury across the planned segment; and absence of immediate definitive hemorrhage-control and damage-control-resuscitation capability are key contraindications.

What does the current evidence say about survival?

The UK-REBOA randomized trial did not show benefit and suggested possible harm when REBOA was added routinely for exsanguinating trauma. EAST 2025 conditionally recommends against routine use in hypotensive subdiaphragmatic trauma and blunt pelvic fracture, but conditionally favors REBOA over thoracotomy in traumatic arrest when thoracotomy has no other indication.

Why must balloon deflation be gradual?

Sudden reperfusion decreases afterload and washes acid, potassium and metabolites into the central circulation, causing hypotension or arrest. Recurrent bleeding may also become apparent, so deflation must be coordinated with resuscitation and definitive hemostasis.

References