Distal Placement of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) to Restore Hemodynamic Stability in a Patient With Proximal Aortic Rupture

PURPOSE: To report unconventional use of the resuscitative endovascular balloon occlusion of the aorta (REBOA) technique to restore hemodynamic stability in a patient who was hemorrhaging from aortic injury proximal to the target zone of occlusion. CASE REPORT: A 72-year-old woman underwent urgent thoracic stent-graft repair of a ruptured 8×8-cm mycotic pseudoaneurysm. Two months later, follow-up imaging revealed that the proximal aortic stent seal zone had degenerated, so a percutaneous procedure was performed 2 months later to preemptively reinforce the segment of stented aorta. Shortly after obtaining femoral access, the patient's condition abruptly deteriorated with profound hypotension, presumably a result of an access complication. REBOA was established in the supraceliac aorta, which sustained the mean arterial pressure while the anesthesiologist resuscitated the patient. Unexpectedly, angiography showed a rupture of the descending thoracic aorta immediately proximal to the upper stent-graft. Balloon inflation distal to the rupture site was maintained while the patient's hypotension was treated. Another stent-graft was quickly placed over the area of concern, overlapping proximal to the prior grafts. Once the aortic perforation was sealed, the patient stabilized hemodynamically. Inotropic support was weaned, and the REBOA occlusion catheter was deflated. Final angiograms of the arch and thoracic aorta confirmed no extravasation; angiograms of the infrarenal aorta and iliac arteries showed no evidence of injury. CONCLUSION: This case illustrates that applying REBOA distal to the injury site in certain clinical scenarios may sufficiently increase peripheral resistance to compensate temporarily for cardiovascular collapse secondary to aortic injury.