• Making the decision to perform REBOA too late. Mortality is high after loss of pulses has occurred, as it is with ERT.
• Difficulty locating the common femoral artery in the groin. Early CFA access is recommended even if REBOA not utilized. The clinician must be very familiar with open, percutaneous, and ultrasound guided femoral access techniques.
• Insertion of the REBOA below the femoral artery bifurcation (into the superficial femoral artery). The catheter should be placed in the common femoral artery, just below the inguinal ligament (typically above the groin crease). Insertion into the superficial femoral artery is associated with an increased risk of thrombosis and limb loss.
• Failure to address chest pathology. Always evaluate the chest by X-ray, ultrasound, or bilateral chest tube placement to identify and treat significant hemothorax or pneumothorax. Convert to thoracotomy to address massive hemothorax.
• Failure to recognize complete aortic occlusion when partial occlusion is intended. This may occur when below-balloon pressures are not monitored.⁶⁴ A validated miniaturized handheld pressure monitor is a convenient alternative to problematic traditional arterial line and monitoring apparatus especially in austere environments.⁶⁴
• Unrecognized proximal femoral or iliac artery transection preventing endovascular access on the side of the injury. This may occur with penetrating pelvic trauma or severe pelvic fracture. Check bilateral femoral pulses and access the side with a stronger pulse if there is a difference. Do not hesitate to switch to the opposite groin or convert to thoracotomy.
• Catheter or guidewire does not pass freely. This could indicate injury to the vessel. Do not inflate balloon. Consider accessing the opposite groin or convert to thoracotomy.
• Over-inflating the balloon. The ER REBOA-Plus™ balloon capacity is 24 ml. Zone 1 may require as little as 8 ml and Zone 3 as little as 2 ml to achieve occlusion. Over-inflation may rupture the balloon or injure the aorta. The pREBOA-PRO™ catheter comes equipped with an overinflation safety valve to minimize risk of increased balloon pressures (> 1 atm) that could cause vascular injury.
• Leaving the balloon inflated too long. Only 30 - 60 minutes of Zone 1 complete occlusion with the ER REBOA-Plus™ or COBRA-OS® balloon is advised, and the shorter the better. Achieve rapid control of bleeding sites with temporizing measures such as clamping to allow the earliest reperfusion; most suturing, ligating, solid organ removal, and vascular shunting may be done after balloon deflation. Death secondary to ischemic injury has been reported with longer complete occlusion times.
• Failure to work with a heightened level of urgency once REBOA is placed. Some patients may regain “stability,” however, complete balloon occlusion is just like a cross clamp, with the same complications of visceral and spinal ischemia. Every effort should be made to restore perfusion as soon as possible to limit ischemia.
• Failure to adequately secure the REBOA catheter after balloon inflation, resulting in migration of the balloon. The catheter position must be maintained during and after inflation to avoid distal migration until aortic pressure and pulsatility are restored.
• Deflating the balloon too quickly before adequate volume resuscitation. Ensure that the anesthesia team is prepared for reperfusion prior to balloon deflation.
• Premature removal of the arterial sheath. The sheath should remain in place if the patient is coagulopathic, may have ongoing bleeding in the abdomen or pelvis, or is being transported within theater to a higher level of care.
• Injury to the arterial access point. After removal of the sheath, monitor the instrumented leg closely for re-bleeding and thrombus/intimal injury. Decreased lower extremity perfusion may require further angiography, thrombectomy, or direct arterial repair.
• Committing multiple resources to a futile resuscitation. Anticipate massive transfusion, personnel required, surgical supplies, diversion of resources from more salvageable casualties, etc.