Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for Hemorrhagic Shock

SUMMARY OF CHANGES

  1. Addition of treatment algorithm to include prolonged use of REBOA with partial aortic occlusion.
  2. Clarification on prolonged partial occlusion times for both Zone 1 and Zone 3.
  3. Addition of techniques to monitor above and below aortic balloon pressures.
  4. Addition of balloon and sheath management during resuscitation and balloon deployment.
  5. Addition of balloon deflation guidelines during prolonged partial REBOA use.
  6. Rapid Update 22 Apr 2026: Infographic corrections, updates to REBOA pitfalls, and updates to the catheter removal process, including algorithms for appendices G-I. 

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Purpose

This CPG reviews the range of accepted management approaches for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as a hemorrhage control adjunct in traumatic shock and post-traumatic cardiac arrest in combat casualties. Prior CPGs focused on the technique of complete aortic occlusion with shortened occlusion times secondary to the risk of increasing distal ischemia with prolonged use. In review of civilian data, the median occlusion time was found to be 40 minutes, significantly beyond the recommended 30-minute complete aortic occlusion distal ischemia limit with first generation complete aortic occlusion devices.1 Updated fourth generation REBOA devices allow for controlled partial flow past the site of aortic occlusion to allow for prolonged REBOA use beyond the previous ischemia time limitations. This guideline is meant to reflect the growing use of partial REBOA in the care of the injured patient. Recommendations for use in the military setting must consider the unique challenges of the deployed environment. Mission parameters, tactical situation, casualty’s physical location and evacuation capability also determine the capabilities available for combat casualty care. Mechanisms and patterns of injury as well as the availability and experience level of surgical resources and resuscitation teams all influence the care rendered. The optimal management is best determined by the clinician at the bedside. This document addresses the use of REBOA for traumatic hemorrhage.

Partial REBOA cannot be adequately achieved with earlier generation catheters; therefore, this CPG contains guidance on both complete and partial aortic occlusion catheters while the DoD transitions to the newest generation catheter (pREBOA-PRO™).