Part 12/Chapter 66/4-min read

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

Endovascular trauma management is presented as a trained, team-owned hemorrhage-control pathway in which REBOA and aortic occlusion may bridge selected patients to definitive operative, endovascular, or hybrid source control. The chapter keeps EVTM/JEVTM context visible for terminology and implementation background, while clinical recommendations are bounded by current trauma-system, REBOA, registry, target-trial, vascular-guideline, and complications evidence.

Reviewed ·5 sections · 18 references

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Emergency handoff / trauma debrief: Urgent but calm: frame the initial recognition, the sequence of decisions, transfer/workflow, and what changes the plan.

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Definition and presentation

Endovascular trauma management (EVTM) integrates early vascular access, temporary endovascular hemorrhage control, and rapid transition to definitive operative, endovascular, or hybrid source control . Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct for temporary proximal hemorrhage control. It acts as a physiologic bridge to sustain perfusion to the heart and brain while the patient is transferred to definitive source control, rather than functioning as a definitive treatment itself .

Patients present with profound shock, periarrest physiology, or a transient response to resuscitation, alongside suspected exsanguinating torso or pelvic hemorrhage. The initial physiologic assessment determines whether the hemorrhage is potentially salvageable and whether proximal occlusion will successfully facilitate the transition to definitive operative or endovascular treatment.

Treatment decision and pathway

REBOA is a conditional activation pathway reserved for patients whose hemorrhage pattern responds to proximal occlusion. It is not indicated for stable patients, those with isolated compressible hemorrhage, or when the bleeding territory is not addressed by the intended occlusion zone .

DiagnosticREBOA deployment criteria and actions
Exsanguinating shock
Bleeding territory
Plausible source below intended occlusion zone
Action pathway
Activate REBOA, obtain access, and confirm definitive control destination
Citation
Exsanguinating shock
Bleeding territory
Bleeding proximal to or unaddressed by occlusion zone
Action pathway
Avoid REBOA; proceed directly to operative control or alternate pathway
Citation
Controlled or compressible source
Bleeding territory
Hemorrhage anatomically accessible
Action pathway
Proceed with definitive control without aortic occlusion
Citation

The decision to intervene follows a sequenced workflow rather than isolated balloon inflation :

  1. Physiology and bleeding territory are confirmed to align with the selected proximal occlusion zone.
  2. Arterial access is secured. Femoral access is often rate-limiting in profound shock, requiring explicit plans for ultrasound guidance or open surgical exposure.
  3. The destination is explicitly identified. Deployment is paired concurrently with laparotomy, pelvic packing, angioembolisation, or hybrid control.
  4. Temporary control is established, and the team prepares for immediate definitive source control.

Occlusion strategies

Aortic occlusion dictates a direct trade-off between proximal hemodynamic support and distal ischemia. Techniques vary by the degree of flow reduction:

  • Complete occlusion temporarily arrests all distal flow to maximize proximal pressure. It carries the highest ischemia and reperfusion risk.
  • Partial occlusion permits limited distal perfusion while maintaining proximal support, reducing the ischemic burden during source control.
  • Intermittent occlusion alternates periods of inflation and deflation to manage the ischemic trade-off over time.

These are distinct physiologic strategies with different verification requirements and risk profiles . A blood pressure response confirms proximal occlusion but does not indicate that the bleeding source is treated or that the ongoing ischemic debt is acceptable.

Complications and surveillance

Aortic occlusion introduces specific iatrogenic risks that alter the survival balance. Primary failure modes include access-site injury, limb ischemia, distal organ ischemia, reperfusion burden, and renal failure . The femoral sheath requires active surveillance and a formal removal or repair plan.

Deflation initiates a period of hemodynamic transition that can unmask recurrent hemorrhage and reperfusion acidosis. The intervention pathway remains active until temporary control, definitive source control, and reperfusion are managed. Post-deflation reassessment includes :

  • Access-site integrity checks to identify bleeding, dissection, arterial thrombosis, or pseudoaneurysm.
  • Distal limb perfusion assessment utilizing pulses, Doppler signals, and motor-sensory exams.
  • Monitoring of hemodynamics and renal-risk indicators.
  • Confirmation of definitive hemorrhage control to rule out missed, venous, or coagulopathic bleeding.
  • Formal transfer documentation detailing the occlusion course, ongoing risks, and clinical follow-up ownership.

Areas of controversy

The universal mortality benefit of REBOA compared to alternative interventions remains unsettled. Registries and target-trial emulations demonstrate heterogeneous outcomes that are heavily influenced by the patient shock phenotype, the bleeding territory, and whether the comparator is direct operative control, angioembolisation, or resuscitative thoracotomy . The clinical superiority and standardized application of partial and intermittent occlusion strategies over complete occlusion require further definition . In the AORTA registry cohort, partial Zone I REBOA carried lower adjusted mortality than both complete Zone I REBOA (adjusted hazard ratio 1.84) and emergency department thoracotomy (adjusted hazard ratio 3.32), though the partial-REBOA subgroup was small (84 of 921 patients).

References

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