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Field and en route resuscitative endovascular occlusion of the aorta: A feasible military reality?

Reva, Viktor A. MD, PhD; Hörer, Tal M. MD, PhD; Makhnovskiy, Andrey I. MD; Sokhranov, Mikhail V. MD, PhD; Samokhvalov, Igor M. MD, PhD; DuBose, Joseph J. MD

Journal of Trauma and Acute Care Surgery: July 2017 - Volume 83 - Issue 1 - p S170–S176
doi: 10.1097/TA.0000000000001476
Special Report

BACKGROUND Severe noncompressible torso hemorrhage remains a leading cause of potentially preventable death in modern military conflicts. Resuscitative endovascular occlusion of the aorta (REBOA) has demonstrated potential as an effective adjunct to the treatment of noncompressible torso hemorrhage in the civilian early hospital and even prehospital settings—but the application of this technology for military prehospital use has not been well described. We aimed to assess the feasibility of both field and en route prehospital REBOA in the military exercise setting, simulating a modern armed conflict.

METHODS Two adult male Sus Scrofa underwent simulated junctional combat injury in the context of a planned military training exercise. Both underwent zone I REBOA in conjunction with standard tactical combat casualty care interventions—one during point of injury care and the other during en route flight care. Animals were sequentially evacuated to two separate forward surgical teams by rotary wing platform where the balloon position was confirmed by chest x-ray. Animals then underwent different damage control thoracic and abdominal procedures before euthanasia.

RESULTS The first swine underwent immediate successful REBOA at the point of injury 7 minutes and 30 seconds after the injury. It required 6 minutes total from initiation of procedure to effective aortic occlusion. Total occlusion time was 60 minutes. In the second animal, the REBOA placement procedure was initiated immediately after take off (17 minutes and 40 seconds after the injury). Although the movements and vibration of flight were not significant impediments, we only succeeded to put a 6-French (Fr) sheath into a femoral artery during the 14 minutes flight due to lighting and visualization challenges. After the sheath had been upsized in the forward surgical team, the REBOA catheter was primarily placed in zone I followed by its replacement to zone III. Both animals survived to study completion and the termination of training. No complications were observed in either animal.

CONCLUSION Our study demonstrates the potential feasibility of REBOA for use during tactical field and en route (flight) care of combat casualties. Further study is needed to determine the optimal training and utilization protocols required to facilitate the effective incorporation of REBOA into military prehospital care capabilities.

Supplemental digital content is available in the text.

From the Department of War Surgery (V.A.R., A.I.M., M.V.S., I.M.S.), Kirov Military Medical Academy, Saint-Petersburg, Russian Federation; Department of Cardiothoracic and Vascular Surgery (T.M.H.), Örebro University Hospital, Örebro, Sweden; Travis Air Force Base Medical Center (J.J.D.), University of California, Davis Medical Center, Sacramento, CA.

Submitted: October 12, 2016, Revised: January 31, 2017, Accepted: February 18, 2017, Published online: April 27, 2017.

This study was presented at the annual meeting of the Ambroise Pare International Military Surgical Forum, October 2–3, 2016, in Berlin, Germany.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (

Address for reprints: Viktor A. Reva, MD, PhD, Kirov Military Medical Academy, Saint-Petersburg, Russian Federation, Saint-Petersburg, Russia; email:

© 2017 Lippincott Williams & Wilkins, Inc.