Advanced resuscitation teams may be utilized in austere environments as a bridge to surgical hemorrhage control. Data on the effectiveness of this approach are lacking. REBOA in this setting may be considered in the rare circumstance that all of the following conditions are met:

1. The casualty would otherwise die in 15-30 minutes without REBOA (NCTH, refractory hemorrhagic shock)
2. A physician experienced in REBOA therapy is present
3. Blood product resuscitation, preferably whole blood, is available but failing to resuscitate the patient
4. Time to definitive hemorrhage control is short (ideally <15 min Zone 1, <30 min Zone 3).

The narrow therapeutic window of aortic occlusion is the major limitation of REBOA. Techniques for lengthening aortic occlusion time are being investigated such as partial REBOA (pREBOA), intermittent REBOA (iREBOA), regional hypothermia, and pharmacologic interventions to decrease ischemia or enhance ischemia resistance. Multiple descriptions of pREBOA and iREBOA techniques in animal models have been described. One protocol recommended by the Committee on Tactical Combat Casualty Care (CoTCCC) describes iREBOA as an initial 15min of occlusion time, followed by balloon deflation and reassessment of the patient’s systolic blood pressure (SBP). If SBP > 80mmHg, the balloon should remain deflated. If SBP drops to < 80mmHg the balloon should be re-inflated. If the SBP dropped below 80mmHg in less than 3 minutes, balloon occlusion will be maintained for up to 30 min as resuscitation continues. If decompensation occurs after 3 minutes, the balloon should re-inflated and deflated again after 10 minutes for reassessment. This cycle continues for a total occlusion time up to 120 min or until the patient’s blood pressure remains stable above 80mmHg. iREBOA has come under criticism due to multiple limitations of the initial study and lack of other supportive studies.37-38,42,60