ABSTRACT
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emerging intervention for noncompressible torso hemorrhage. We report the case of a 64-year-old man who presented with abdominal pain and hypotension due to a ruptured abdominal aortic aneurysm in Korea. Upon clinical deterioration, temporary aortic occlusion was achieved using antegrade REBOA via the left brachial artery in the operating room. A balloon catheter was successfully placed proximal to the aneurysm using the Seldinger technique, resulting in rapid stabilization of vital signs. Definitive surgical repair with aortic replacement was then performed without complications. The patient fully recovered and was discharged 1 month later. This case demonstrates the clinical utility of antegrade REBOA when retrograde insertion is contraindicated, particularly in juxtarenal aneurysms. REBOA can provide a critical window for hemodynamic stabilization and surgical control in cases of life-threatening hemorrhage. Careful consideration of access site, balloon positioning, and imaging guidance is essential for safely and effectively deploying this technique.
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Keywords: Abdominal aortic aneurysm; Abdominal pain; Balloon occlusion; Hemodynamics; Hemorrhage; Case reports
INTRODUCTION
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emerging technique that serves as an alternative to resuscitative thoracotomy with aortic cross-clamping for the treatment of noncompressible torso hemorrhage [
1,
2]. REBOA is primarily indicated for intra-abdominal hemorrhage secondary to trauma, intrapelvic hemorrhage associated with pelvic bone fracture, and peripartum hemorrhage [
3,
4]. This report aims to describe the successful use of antegrade REBOA via the left brachial artery as a life-saving intervention for a ruptured abdominal aortic aneurysm (AAA) in a hemodynamically unstable patient in Korea.
CASE REPORT
Ethics statement
This study was approved by the Ethics Committee of Dankook University Hospital (No. 2022-10-002).
Patient information
A 64-year-old man presented to the emergency room with right buttock and lower back pain. He had no prior medical history, including hypertension. He had experienced intermittent abdominal pain for a week, but the symptoms had been tolerable.
Clinical and diagnostic findings
On admission, his vital signs were stable, with a blood pressure of 127/87 mmHg and a pulse rate of 67 beats per minute (bpm). A pulsatile abdominal mass was palpable. The patient requested pain relief, and analgesics were administered by the emergency physician; however, the pain remained refractory. Approximately 2 hours later, he developed severe abdominal pain, and his blood pressure dropped to 45/33 mmHg with a pulse rate of 72 bpm. After resuscitation with fluids, his blood pressure improved to 108/52 mmHg and pulse rate to 83 bpm. Abdominal computed tomography revealed a large impending rupture of an AAA.
Therapeutic intervention
Aortic replacement was planned because the aneurysm was massive, ruptured, and located just below the right renal artery, making aortic replacement more suitable than stent graft placement (
Fig. 1). Despite aggressive resuscitation with fluids and blood transfusion, his blood pressure gradually declined while waiting for transfer to the operating theater. Temporary aortic occlusion using REBOA was therefore planned. After inserting a 7F sheath (Standard Kit, Terumo Vietnam Medical Equipment) into the left brachial artery, a REBOA catheter was advanced into the abdominal aorta using the Seldinger technique in the operating room. A guidewire (0.025-inch diameter, 145-cm guidewire, Tokai Medical Products) was passed through the sheath lumen. Chest x-ray confirmed the position of the guidewire in the abdominal aorta, just proximal to the aneurysm (
Fig. 2). A balloon catheter (Tokai Medical Products) was advanced, and the balloon was inflated with 20 mL of normal saline for complete occlusion. Following balloon inflation, blood pressure was restored to 130/70 mmHg, and the pulse rate increased to 105 bpm. Under general anesthesia, a median laparotomy was performed for aortic replacement. A large volume of blood and clots was present in the abdominal cavity. The ruptured aneurysm (about 9 cm in diameter) and hematoma with fresh blood were observed in the retroperitoneum. The aneurysm extended from just below the right renal artery to the aortic bifurcation. The rupture site was at the proximal part of the aneurysm. With the balloon in place, the abdominal aorta was completely occluded, and no blood loss occurred during repair (
Fig. 3). Balloon occlusion facilitated aortic replacement, and no visual disturbance was noted due to aortic clamping. The balloon was deflated 1 hour after inflation, and the catheter was removed 5 hours and 45 minutes after insertion. The operation was completed uneventfully.
Postoperatively, the patient recovered without complications and was discharged 1 month after surgery. Regular outpatient follow-up for 6 months revealed no additional complications.
DISCUSSION
In recent years, REBOA has increasingly been used as a resuscitative adjunct for trauma patients with life-threatening noncompressible torso hemorrhage. By temporarily occluding the aorta with an inflated balloon, REBOA preserves cerebral and coronary perfusion while reducing exsanguination distal to the balloon, thus providing time for resuscitation and definitive bleeding control [
3,
5]. This case demonstrates the successful use of antegrade REBOA for impending cardiac arrest due to a ruptured AAA.
Endovascular balloon occlusion is considered a safe method to rapidly restore hemodynamics and allow for definitive repair of ruptured AAA [
6]. Traditionally, an endovascular balloon is retrogradely inserted through the femoral artery [
6], and hemodynamic stability is achieved after balloon inflation [
7]. However, in this case, retrograde insertion via the femoral artery would have interfered with the surgical field and potentially hastened the impending rupture. Therefore, antegrade insertion of the endovascular balloon through the brachial artery was performed.
REBOA involves inserting a balloon into the aorta, which carries risks of puncture site complications and aortic injury. Retrograde balloon insertion can potentially contribute to multiple organ dysfunction syndrome, including mesenteric ischemia and renal failure [
6]. Additionally, advancing the balloon through a diseased aorta may precipitate rupture, presenting further challenges. If there is an impending rupture or the patient is unstable, as in this case, REBOA should be considered a life-saving procedure.
The endovascular balloon minimizes distal bleeding and prevents further hemorrhage. Distal perfusion can be preserved by carefully controlling ballooning time and balloon size. Hemorrhage control and distal perfusion can also be optimized by adjusting the balloon’s position. In cases of juxtarenal or pararenal AAA, bleeding and mesenteric ischemia can be managed either by direct aortic clamping or by tailoring ballooning time, size, and position according to the anastomosis.
The guidewire position should be assessed using angiography or serial x-rays. In this case, the left brachial artery was selected, and no difficulty was encountered when advancing the guidewire into the descending aorta. Subsequently, a small amount of air was used to inflate the balloon, and it was positioned in the descending aorta without difficulty. We do not recommend right brachial artery access, as REBOA introduced from the right side may inadvertently enter the ascending aorta. However, we do recommend fluoroscopy or serial x-rays to ensure safety during balloon insertion and positioning.
In this case, REBOA was performed in a situation of impending cardiac arrest due to hypotension resulting from rupture. Although the procedure was carried out in the operating theater, antegrade REBOA can also be considered in the emergency department or intensive care unit for urgent situations approaching cardiac arrest.
ARTICLE INFORMATION
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Author contributions
Conceptualization: DN, JWR; Investigation: SH; Methodology: SH; Writing–original draft: DN; Writing–review & editing: all authors. All authors read and approved the final manuscript.
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Conflicts of interest
The authors have no conflicts of interest to declare.
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Funding
The authors received no financial support for this study.
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Data availability
Data sharing is not applicable as no new data were created or analyzed in this study.
Fig. 1.Large impending rupture of an abdominal aortic aneurysm was detected on abdominal computed tomography.
Fig. 2.Position of the guidewire. (A) A guidewire (arrows) was advanced through the lumen of the sheath. A chest x-ray was used to confirm the position of the guidewire in the abdominal aorta, just proximal to aneurysm. (B) Illustration of aortic occlusion shows the position of resuscitative endovascular balloon occlusion of the aorta, just proximal to the aneurysm.
Fig. 3.Due to ballooning (arrow), the abdominal aorta was completely blocked, impeding blood flow.
REFERENCES
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