REBOA

<!-- type: treatment -->

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]

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

<!-- type: classification -->

**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]
- 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"bridge endpoint”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] [@deng2026-d]

**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 management for hemorrhage in severely injured patients, emphasizing protocolized use and multidisciplinary coordination. [@wagner2025]

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