REBOA

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Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a temporizing technique for **noncompressible torso hemorrhage (NCTH)** in profoundly unstable patients, intended as a **bridge** to definitive hemorrhage control (operating room [OR], hybrid OR, or interventional radiology [IR]). [@bulger2019] [@wagner2025][@wagner2025-endovascular]

Appropriate systems require training, governance, and time targets. [@bulger2019]

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**Table 16.1. REBOA Aortic Zones and Deployment Guidelines** [@bulger2019]

| **Zone** | **Anatomical Boundaries** | **Typical Indication** | **Practical Time Target** |
| --- | --- | --- | --- |
| **Zone I** | Left subclavian artery to celiac axis | Suspected intra-abdominal/torso hemorrhage | Keep as short as possible (often ≤30 min) |
| **Zone II** | Celiac axis to lowest renal artery | **Avoid inflation** | N/A |
| **Zone III** | Infrarenal aorta to bifurcation | Pelvic/junctional hemorrhage | Keep as short as possible (often ≤60 min) |

**Patient selection (systems-level safety)**

- Consider REBOA when: **profound shock** with suspected NCTH and an immediately available pathway to definitive hemostasis (hybrid OR/OR/IR). [@bulger2019] [@wagner2025][@wagner2025-endovascular]
- Avoid/strongly caution when: major thoracic bleeding proximal to Zone I, suspected aortic rupture/dissection, or when definitive control is not rapidly achievable (risk of prolonged ischemia). [@bulger2019] [@isselbacher2022]

**Technique essentials**

- Prefer ultrasound-guided common femoral artery (CFA) access; confirm intraluminal wire position prior to upsizing. [@bulger2019]
- Inflate using physiologic endpoints (proximal blood pressure [BP] response) and confirm position with imaging when available.
- Define the “bridge endpoint” before inflation: **(1) laparotomy, (2) pelvic packing + angio, (3) endograft/covered stent**, or a hybrid combination. [@trauma2016-endovascular]

**Partial and intermittent REBOA**

Titrated balloon deflation, including partial REBOA (pREBOA) or intermittent REBOA (iREBOA), may reduce distal ischemia and reperfusion burden during bridging, particularly when transport or procedural delays occur; it requires continuous hemodynamic monitoring and an experienced team. [@sadeghi2018-partial] [@wagner2025][@wagner2025-endovascular]

**Evidence and limitations**

- Multicenter observational data (e.g., AORTA registry) demonstrate feasibility and define complication profiles, but outcomes are highly dependent on indication, timing, and comparator choice. [@trauma2016-aorta]
- Comparative observational analyses versus resuscitative thoracotomy show mixed results and are vulnerable to selection bias; REBOA benefit is most plausible when used early with rapid transition to definitive hemostasis. [@brenner2018-survival]
- National datasets also suggest substantial practice variability and reinforce the need for protocolized use. [@matsumura2020]
- Updated systematic reviews and clinical practice guidelines reinforce the role of endovascular resuscitation and trauma management (EVTM) for hemorrhage and associated vascular lesions in severely injured patients, emphasizing protocolized use and multidisciplinary coordination. [@wagner2025][@wagner2025-endovascular]

See also: [[Damage Control Surgery]] and [[Massive Transfusion]] for coordinated damage control resuscitation (DCR) during balloon occlusion and deflation. [@spahn2019]