The Importance of Early Femoral Access When REBOA Catheter Must Be Removed Prior to Hemorrhage Control

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a tool for hemorrhage control in non-compressible torso hemorrhage. REBOA is used as a temporizing measure until definitive hemorrhage control can be obtained either in the operating room or Interventional Radiology. Here, we describe a case where the REBOA Catheter needed to be removed prior to hemorrhage control to allow Interventional Radiology to gain vascular access and perform angioembolization.

A 40-year-old man with a past medical history of osteogenesis imperfecta presented following a motor vehicle collision. On arrival, his initial blood pressure was 80/50 mmHg. He received 1 unit of packed red blood cells and 1 unit of liquid plasma. Cavitary triage was performed including chest X-ray, pelvic X-ray, and FAST Exam. Pelvic X-ray demonstrated comminuted right and left superior pubic rami and inferior ischiopubic rami fractures. A 4 French right common femoral arterial line was placed which demonstrated systolic blood pressures in the 70s. With the identification of pelvic fractures and ongoing hypotension, the decision was made to place a REBOA Catheter. The arterial line was upsized to a 7 French sheath, and a zone III REBOA Catheter was placed. The patient was intubated for airway protection. Massive transfusion protocol was initiated. With the REBOA Catheter inflated and in place, the patient’s systolic blood pressure increased to greater than 90 mmHg systolic and he proceeded to the CT scanner. CT scan demonstrated active extravasation from the left inferior epigastric artery and branches of the left internal iliac artery. Due to the location of the bleeding, the Interventional Radiology team would only be able to successfully perform angioembolization from the contralateral side where the REBOA Catheter was already in place. Following discussion with the Interventional Radiology team, bilateral groins were prepped, and a 7 French sheath was placed in the left common femoral artery. Once contralateral vascular access had been obtained in the left common femoral artery, the REBOA Catheter was deflated and removed from the right side. The trauma team remained in the radiology suite available to deploy a new REBOA Catheter from the left side if the patient became hypotensive during the procedure. The Interventional Radiology team was able to successfully embolize the left inferior epigastric and branches of the left internal iliac arteries without the need for placement of a second REBOA Catheter. Ultimately, the patient had a prolonged hospitalization secondary to extremity fractures, acute kidney injury resulting in the need for continuous renal replacement, acute hypoxic respiratory failure requiring tracheostomy, and wound complications. He was discharged to a long-term acute care facility on hospital day 90.

We present a strategy for expeditious replacement of REBOA Catheters in situations where the catheter itself interferes with hemorrhage control procedures and must be removed before hemorrhage control is achieved. Common femoral artery access has been shown to be the rate-limiting step in REBOA Catheter deployment. ¹ In review of published REBOA trauma algorithms from 2022, early femoral access was included in the majority (60%) of centers’ algorithms. ² Additionally, outside of trauma, early femoral access has been a strategy that has been utilized in REBOA Catheter placement in patients with placenta accreta. ³ Although these algorithms refer to the initial vascular access, we show in this case how the concept of early vascular access can be applied when the REBOA Catheter itself interferes with the ability to achieve hemorrhage control. Obtaining additional vascular access prior to removal of the catheter allows expeditious placement of a new catheter.