Resuscitative endovascular balloon occlusion of the aorta (REBOA) and endovascular resuscitation and trauma management (EVTM): a paradigm shift regarding hemodynamic instability
The management of hemodynamically unstable trauma patients has dramatically changed in the last decades. The concept of damage control, permissive hypotension, and usage of tourniquets and many more exciting developments have probably helped save many lives, both in civilian and military environment [1, 2, 3, 4, 5, 6, 7, 8, 9, 10]. Also, the concept of using endovascular tools for bleeding control has been developed over the last 20 years, with major advances such as embolization, endografts, and, lately, the use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) [3, 4, 5, 11, 12, 13, 14]. These tools are now gathered together into a new concept called endovascular resuscitation and trauma management (EVTM) [15, 16, 17] (http://www.jevtm.com). Many trauma and emergency procedures (i.e., aneurysm repair, visceral and pelvic bleeding, and others) are going through major changes as endovascular and hybrid approaches become available. That is, hemostasis can be achieved with minimally invasive methods, and further surgical trauma to stop bleeding can be avoided. Hemostasis can also be obtained using a hybrid approach, where endovascular and open surgery are combined. It might be speculated that not only mortality but also morbidity might be affected by these methods. More importantly, the EVTM concept, and REBOA within it, may help a team with patients in extremes, convert a difficult bleeding scenario into a more controlled one, or just gain some time . As said, the use of these hybrid and endovascular tools is not limited to trauma, but also applies to other types of bleedings, such as vascular emergencies, post-partum hemorrhages (PPH), and gastrointestinal and iatrogenic or spontaneous bleeders. EVTM might also be used for other hemodynamic instabilities with the potential use of extracorporeal membrane oxygenation (ECMO) in different medical emergencies as part of emerging endovascular cardio-pulmonary resuscitation (eCPR). It might be suggested that even patients not undergoing CPR but receiving general resuscitation treatment might benefit from the EVTM concept, thus incorporating eCPR into EVTM (EVTM2018 round table symposium debate, http://www.jevtm.com). REBOA as a trauma procedure has attracted attention in recent years due to its potential to contribute to hemodynamic stability in patients in shock due to non-compressible-torso bleeding [18, 19, 20, 21]. REBOA has been used for many years within acute endovascular surgery, and is now spreading into the trauma world and into some trauma guidelines [22, 23, 24, 25, 26]. The use of REBOA for ruptured aorta aneurysm has been shown, in the last 20 years, to be effective in facilitating aneurysm repair in unstable patients [17, 22, 26]. Trauma REBOA has gained popularity in the last few years and has been used now in several thousand trauma cases worldwide [11, 19, 20, 27, 28, 29]. A huge development in the field has been the introduction of REBOA catheters with smaller diameter (sheaths) that has made REBOA use easier, faster, and available to trauma surgeons, and also might be associated with better outcomes [19, 29]. It should be remembered that, although REBOA seems to be a very effective hemodynamic tool, its use has not yet shown a mortality benefit in trauma patients, and clear indications/contra-indications for use are not yet well established. It has been shown, though, that it can be used as a bridge to definitive surgical or endovascular treatment [24, 27]. Obviously, REBOA, as a bridge, is never a solution in itself, and there is still a lack of high-grade evidence about the correct indications, selections of patients, and ways for it to be used. REBOA is also associated with ischemia–perfusion injuries and multiple organ failure when used for a prolonged period of time, but data are still lacking regarding the time limits of REBOA use. Newer methods, such as partial REBOA (pREBOA), intermitted REBOA (iREBOA), and others, might prove to be beneficial in practical use, and hopefully will decrease ischemia–perfusion injuries [30, 31, 32, 33, 34]. There is also an ongoing debate on the use, and possible overuse, of REBOA in trauma and other patients, and there is much to learn about the correct use of REBOA and EVTM methods in bleeding patients .
There is a very low level of evidence about REBOA’s use for other types of hemodynamic instabilities (such as PPH and others), and there is much research to do in this area (EVTM2018 round table symposium debate, http://www.jevtm.com). It must be remembered, though, that REBOA is just one of the tools in EVTM, and there must be a clear plan for its use in definitive bleeding control.
In this issue of the European Journal of Trauma and Emergency Surgery, REBOA is given its place as an evolving technique for bleeding management. Hörer et al.  report on their single-center experiences REBOA, and on the lessons learned from endovascular and hybrid ruptured aortic aneurysm treatment that will lead to the development of the EVTM concept. Matsumura et al.  report on evidence in the DIRECT-IABO registry on using REBOA for non-hemorrhagic shock. Reva et al.  investigate the optimal period for aortic balloon occlusion in an animal model. Manzano-Nunez et al. reviewed the literature on the use of REBOA for bleeding control in patients with adherent placenta  and the relevance of hypotension . Finally Dongen et al.  provide a review on the use of REBOA in major exsanguination.
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