Endovascular Trauma Management, REBOA, Aortic Occlusion, and Hybrid Trauma Workflows

66.1Origins and current framing

Endovascular trauma management (EVTM) is a hybrid trauma-workflow concept that links early vascular access, temporary endovascular hemorrhage control, and rapid transition to definitive open, endovascular, or hybrid source control. In this chapter, the EVTM/JEVTM material is used as background for terminology and implementation context, not as stand-alone proof of outcome benefit EVTM Practical Aspects 2021 · Top Stent Manual 2017. Current clinical practice should be interpreted through contemporary vascular-trauma guidance and REBOA/aortic-occlusion evidence, including the ESVS 2025 vascular trauma guideline ESVS 2025.

For the vascular surgeon, EVTM ensures that endovascular thinking is present early in hemorrhage care. A trauma team that waits until laparotomy has failed before asking who can obtain femoral access, where the balloon should sit, whether angioembolisation is available, or who can manage vascular complications has not truly built an EVTM pathway. Conversely, a team that places a balloon without a credible source-control destination has converted a bridge into a cul-de-sac. The EVTM frame is strongest when it teaches sequence: obtain appropriate access, establish temporary control when the patient phenotype supports it, move quickly to definitive open, endovascular, or hybrid hemorrhage control, and reassess the limb, access site, physiology, kidneys, and bleeding source after occlusion.

66.2REBOA is a bridge workflow, not a default reflex

REBOA enters the trauma workflow when the team believes temporary aortic control can keep the patient alive long enough to reach definitive hemorrhage control. It should not be introduced as an automatic treatment for all hypotensive trauma patients, all abdominal bleeding, or all noncompressible torso hemorrhage. The decision is conditional: the patient must have a hemorrhage pattern that could plausibly respond to proximal aortic occlusion, the team must be able to obtain and confirm arterial access, the intended occlusion zone must match the suspected bleeding territory, and a trained operator must be present inside a system that can deliver operative, endovascular, or hybrid source control Civilian REBOA Delphi 2024 · Clinical use resuscitative 2019 · Joint statement 2018. REBOA therefore functions as an activation pathway.

The initial physiologic assessment determines whether the patient is failing from hemorrhage that is still potentially salvageable, and whether proximal control will improve the chance of reaching the next definitive step. A pulseless or near-pulseless patient with suspected exsanguinating torso bleeding, an unstable patient with a compressible source already controlled, and a patient whose bleeding territory is not addressed by the selected occlusion site are not the same clinical problem. The same device can be rational in one scenario and distracting in another. Trauma-system statements and consensus work support a selective, trained-system approach rather than unstructured diffusion of REBOA across teams without clear indications, operators, or destinations Civilian REBOA Delphi 2024 · Clinical use resuscitative 2019 · Joint statement 2018.

Destination planning must occur simultaneously. Aortic occlusion may buy time, but it does not close a pelvic arterial branch, pack a liver, repair a major vascular injury, or stop all venous bleeding by itself. The team should know before or immediately after balloon deployment whether the patient is moving to laparotomy, pelvic packing, angioembolisation, vascular repair, hybrid control, or another definitive pathway. Contemporary work describing REBOA as an enabler of surgery and angioembolisation supports this operational framing: the value lies in connecting temporary proximal control to a source-control act, not in treating balloon inflation as the endpoint Expanding role REBOA 2026. After placement, the priority shifts from the immediate blood pressure response to ensuring the next source-control step is already happening.

Access is the next critical consideration. Femoral arterial access is often the rate-limiting step, especially in profound shock, obesity, pelvic disruption, groin contamination, small-caliber vessels, or ongoing cardiopulmonary resuscitation. Access should be planned before the balloon is treated as available: who obtains it, whether ultrasound or surgical exposure is needed, how position is confirmed, and how the sheath will be removed or repaired must be explicit. Reports of intraoperative REBOA use and implementation-focused literature make clear that balloon placement is embedded in a chain of decisions that includes access, confirmation, occlusion management, and immediate movement toward source control Intraoperative REBOA analysis 2019 · Resuscitative Endovascular Balloon 2021.

66.3Evidence should be read by phenotype and comparator

The REBOA evidence base provides a set of phenotype-specific signals. Studies differ in who is treated, when occlusion is applied, whether the patient is in extremis or still has organized physiology, whether bleeding is pelvic, abdominal, junctional, or mixed, and what the comparator actually is. A comparison against resuscitative thoracotomy asks a different question from a comparison against direct operative control, no REBOA, angioembolisation, or a mixed institutional pathway. Registry analyses, target-trial emulation, real-world comparator studies, and critical analyses therefore cannot be collapsed into a universal statement that REBOA is either lifesaving or harmful in all trauma patients Resuscitative endovascular balloon 2025 · Partial REBOA Zone 2025 · REBOA resuscitative thoracotomy 2025 · REBOA trauma life-saving 2024.

Interpreting the literature requires evaluating four variables. First, shock phenotype: transient responders, profound shock, periarrest patients, and patients already undergoing operative exposure do not share the same baseline risk. Second, bleeding territory: infradiaphragmatic hemorrhage, pelvic hemorrhage, abdominal solid-organ or vascular injury, and mixed bleeding require different source-control plans. Third, the comparator: emergency department thoracotomy, operating-room control, angioembolisation, and institutional no-REBOA cohorts represent different alternatives rather than one interchangeable control group. Fourth, the downstream path: a balloon followed by rapid definitive control is not equivalent to a balloon followed by delay, uncertainty, or failed access to the required room or operator. These distinctions are central to contemporary registry and comparator analyses Resuscitative endovascular balloon 2025 · REBOA resuscitative thoracotomy 2025 · REBOA trauma life-saving 2024.

Clinically, the apparent success of occlusion can be misleading. A pressure response after balloon inflation may confirm that proximal control has changed the physiology, but it does not prove that the patient is now safe, that the correct bleeding source has been treated, or that ongoing ischemic debt is acceptable. The surgeon should ask whether the response is buying time for a defined act and whether the team is actively reducing risk by shortening occlusion, moving to definitive control, reassessing distal perfusion, and preparing for reperfusion. Current studies are most useful when they sharpen those questions: which patient, which bleeding pattern, which occlusion strategy, which comparator, and which source-control pathway Resuscitative endovascular balloon 2025 · Partial REBOA Zone 2025 · REBOA resuscitative thoracotomy 2025.

Complete, partial, and intermittent aortic occlusion also require separate physiologic reasoning. Complete occlusion maximizes proximal pressure and temporarily arrests distal aortic flow, but it also intensifies distal ischemia and reperfusion concerns. Partial occlusion attempts to preserve some distal perfusion while maintaining enough proximal pressure to support the heart, brain, and immediate source-control work. Intermittent or reduced-occlusion approaches are attempts to manage the same trade-off over time rather than treating full occlusion as the only possible state. Existing literature on partial Zone 1 REBOA, complete and partial techniques, and temporal changes in REBOA practice supports separating these strategies conceptually rather than using the terms as synonyms Partial REBOA Zone 2025 · Temporal Changes REBOA 2021 · Complete Partial Resuscitative 2022.

66.4Temporary control can create new failure modes

Aortic occlusion is useful only when it changes the balance between imminent exsanguination and the risks created by temporary proximal control. The maneuver can stabilise central pressure, improve perfusion of the heart and brain, and create a window for operative, endovascular, or hybrid source control, but the same maneuver can add access injury, limb ischemia, distal organ ischemia, reperfusion burden, renal-risk signals, and delay if the team mistakes temporary control for definitive treatment. Complication syntheses and noncompressible torso hemorrhage updates support making these risks visible whenever REBOA or related aortic-occlusion adjuncts are used Management non-compressible torso 2021 · Complications associated Resuscitative 2018 · Noncompressible Torso Hemorrhage. 2017.

Access complications deserve particular attention from vascular surgeons because they are both procedural and pathway problems. A difficult femoral puncture in shock can create bleeding, dissection, thrombosis, limb malperfusion, or an unrecognised injury that becomes clinically evident only after the hemorrhage crisis has moved elsewhere. The sheath is not a neutral object once the patient leaves the acute phase; it needs a removal plan, a repair plan when required, and repeated limb assessment. The complication literature supports active surveillance for access-site injury and limb ischemia rather than assuming that a successful balloon inflation means the access problem is over Complications associated Resuscitative 2018.

Ischemia and reperfusion risk are the second failure mode. Aortic occlusion deliberately sacrifices distal flow to preserve proximal perfusion and buy time. That trade-off becomes more dangerous as occlusion persists, when complete occlusion is used without reassessment, when the patient already carries severe shock physiology, or when definitive control is delayed. Every minute of occlusion requires the team to ask what has been achieved, what remains uncontrolled, whether partial or reduced occlusion is possible in the local protocol, and what reperfusion physiology will need to be managed after deflation. Evidence syntheses on noncompressible torso hemorrhage and REBOA complications support this risk-based framing without requiring unsupported universal complication rates Management non-compressible torso 2021 · Noncompressible Torso Hemorrhage. 2017.

The third failure mode is organizational. A temporary bridge can hide a stalled pathway: the blood pressure improves, the room is not ready, the bleeding source is uncertain, or no one owns the next decision. Implementation and intraoperative experience show that access, confirmation, occlusion management, distal perfusion checks, and source-control ownership must be assigned as part of the same pathway rather than improvised after balloon placement Intraoperative REBOA analysis 2019 · Expanding role REBOA 2026 · Resuscitative Endovascular Balloon 2021. The vascular surgeon’s role is often to keep that whole risk field visible: access, limb, ischemia-reperfusion, kidneys, recurrent hemorrhage, and the clock to definitive control.

66.5Post-deflation checks are part of the pathway

A REBOA or hybrid-control pathway does not end when the balloon is deflated, the sheath is secured, or the patient leaves the first room. Deflation is a physiologic transition: recurrent hemorrhage can declare itself, distal ischemic burden can return as acidosis and instability, access injury can become apparent, and limb perfusion can change quickly. A usable pathway therefore includes post-deflation and post-control checks for the access site, distal pulses or Doppler signals, limb temperature and motor-sensory status when assessable, hemodynamic trend, recurrent bleeding concern, renal-risk signals, and the status of definitive source control Clinical use resuscitative 2019 · Resuscitative Endovascular Balloon 2021 · Complications associated Resuscitative 2018.

Post-occlusion assessment begins by confirming whether hemorrhage control is truly complete. A patient who becomes unstable during deflation may have ongoing arterial bleeding, venous bleeding, coagulopathic bleeding, inadequate packing, missed pelvic bleeding, or another source not addressed by the initial maneuver. The team should explicitly document whether definitive control has been achieved, whether further laparotomy, angioembolisation, vascular repair, packing, or re-exploration is expected, and who is responsible for that decision. REBOA implementation literature and civilian trauma-system statements support treating occlusion as part of a coordinated system rather than a stand-alone resuscitation trick Clinical use resuscitative 2019 · Resuscitative Endovascular Balloon 2021.

Attention then turns to whether the access limb has been protected. Every patient leaving the acute occlusion phase should have an access-site assessment and distal perfusion assessment that are visible to the receiving team. This is especially important when shock, vasopressors, hypothermia, coagulopathy, small arterial caliber, prolonged sheath dwell, or difficult puncture make bedside examination less reliable. Complication literature supports surveillance for access injury and limb ischemia after REBOA, and the vascular service should be involved early when pulse loss, expanding groin hematoma, arterial thrombosis, dissection, pseudoaneurysm concern, or uncertain sheath removal is present Complications associated Resuscitative 2018.

Finally, the team must establish who owns ongoing reassessment. A clear transfer note serves as a critical safety intervention. It should identify the occlusion course in qualitative terms, the current source-control status, the access plan, the limb-perfusion findings, the renal and reperfusion concerns, the next imaging or operative trigger when relevant, and the clinician or service responsible for the next check. EVTM/JEVTM sources explain the pathway language and implementation context, while post-deflation checks, access-limb surveillance, and complication management should be guided by current REBOA, trauma-system, and complications evidence ESVS 2025 · EVTM Practical Aspects 2021 · Clinical use resuscitative 2019 · Resuscitative Endovascular Balloon 2021 · Complications associated Resuscitative 2018. The pathway is complete only when temporary control, definitive source control, access safety, limb perfusion, physiology, and follow-up responsibility have all been closed.