Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): The Pendulum swings

Bleeding remains the most common cause of potentially preventable deaths, in both, the civilian and military settings. Non-compressible intra-abdominal and pelvic bleeding accounts for a significant number of these deaths. This challenge led to the development of the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for use in pre-hospital, emergency department, operating room, and intensive care unit settings. The REBOA device is inserted through the femoral artery and the balloon is inflated in the lower thoracic or abdominal aorta to establish temporary aortic occlusion and hemorrhage control, acting as a bridge to definitive surgical or angiointervention bleeding control. The earlier versions of the REBOA device were associated with significant local complications and required radiological confirmation to confirm the position of the inflated balloon. In the last decade, the interest in the REBOA stimulated the development of smaller diameter catheters and safer devices, which resulted in the reduction of local catheter related complications. New insertion techniques, using body surface landmarks, eliminated the need for fluoroscopy. New training methods and standarized training have been introduced. The enthusiasm on REBOA was fuelled by earlier studies which showed improved hemodynamics and also extended survival beyond the golden hour, after the inflation of the balloon. However, other experimental work showed that the ischemia and reperfusion associated with the REBOA deployment was associated with an increased risk of organ dysfunction. In order to address this problem, new approaches such as partial REBOA, intermittent REBOA and optimal balloon inflation pressures to allow regulated distal perfusion were introduced. Despite of these advances, in the last few years there has been increasing evidence that REBOA may be associated with increased adverse outcomes, such as mortality, organ failure, venous thromboembolic complications, lower extremity compartment syndrome and amputations. Some studies suggested that short term physiological improvement does not necessarily translate to better long-term survival and other outcomes. The collection of these articles, published in the last 5 years, provide a useful overview of the technical advances, optimal training, experimental work on early physiological outcomes, studies based on large national trauma databases, and editorials. Some of these publications cast major doubts on the role of REBOA, at least as used with the current indications and techniques. Hopefully, this collection will encourage more research in this field to identify the optimal selection of patients, the timing of REBOA deployment and the safest technique.