First use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in traumatic hemorrhage in Ecuador: A technical case report

Abstract

Non-compressible torso hemorrhage is one of the main causes of preventable death in severe trauma, especially in hospitals with limited resources. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as an adjunctive tool within damage control resuscitation, allowing temporary redistribution of blood flow to vital organs and decreasing bleeding distal to the occlusion, generating a surgical window for definitive control. We present the first documented case in Ecuador of the use of REBOA in trauma. A 22-year-old female patient who presented in profound hemorrhagic shock 8 h after a traffic accident, with grade IV hepatic trauma, grade V right renal trauma, and inferior vena cava injury. During exploratory laparotomy, a REBOA was placed in zone I through an open approach to the right common femoral artery, achieving transient hemodynamic improvement that allowed completion of damage control surgery maneuvers, including hepatic packing, nephrectomy, and vascular repair. The occlusion was maintained for 40 min. Despite intensive resuscitation and a second surgery, the patient died 58 h later from multiorgan failure. This case demonstrates the technical feasibility of implementing REBOA in second-level hospitals when specialized training exists, and highlights the need to strengthen trauma systems, optimize transfer routes, and promote structured training programs.

Highlights

• •REBOA was successfully implemented in a second-level hospital without interventional radiology or a hybrid suite.
• •Balloon positioning was achieved using external anatomical landmarks, demonstrating feasibility in resource-limited settings
• •The procedure provided a critical physiological window to manage complex vascular and visceral injuries
• •Specialized trauma training and multidisciplinary coordination proved more critical for adoption than advanced infrastructure.
• •This case serves as a starting point for establishing institutional damage control protocols and trauma referral networks.

Introduction

Trauma is one of the main causes of death in young adults worldwide [1], [2], [3], [4], and hemorrhage represents up to 30–40% of associated preventable deaths [2], [5], [6], [7], [8], [10], [11]. Non-compressible torso hemorrhage, which occurs in cavities where external pressure cannot control bleeding associated with hemodynamic instability, remains a challenge in management, especially in centers where access to endovascular or specialized surgical therapies is limited.

In second-level hospitals, damage control surgery continues to be the central strategy for managing hemorrhagic shock [12], [13], [14], [15]. Within this framework, resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as an adjunctive resource that allows temporary redistribution of blood flow to vital organs and reduction of bleeding distal to the occlusion [3], [6]. Its main role is to gain a physiological window that facilitates definitive surgical control.

This report presents the first documented case in Ecuador of the use of REBOA in trauma, performed in a second-level hospital. Its description allows analysis of the feasibility of implementation in resource-limited environments and reflection on the need to strengthen regional trauma systems.

Clinical case

A 22-year-old female patient, previously healthy, who suffered a traffic accident as a motorcycle passenger. She was initially treated at a basic hospital, where severe abdominal pain and hypotension were described, for which she received one unit of red blood cells and crystalloids. Due to the absence of specialized surgical management availability, and after an accumulated delay of approximately 8 h from the event, she was transferred as an emergency to a second-level hospital. Upon arrival, she was approached by a multidisciplinary team consisting of an emergency physician, general surgeon, trauma surgeon, anesthesiologists, intensivists, and residents in surgery, anesthesiology, and intensive care; the patient was conscious (Glasgow 15), tachycardic (135 bpm) and hypotensive (50/40 mmHg), with a distended, rigid and painful abdomen and a positive Focused Assessment with Sonography for Trauma (FAST). Hemorrhagic shock management was activated and immediate laparotomy was decided. During the intervention, the following were identified: massive hemoperitoneum (≈2500 ml), grade IV hepatic injury with biliary leak (segments IV, V and VIII), expansive retroperitoneal hematoma in zone II, grade V right renal trauma with hilar avulsion and inferior vena cava injury with two lacerations (1–2 cm). Hepatic packing, right nephrectomy and vena cava repair with 5-0 polypropylene were performed, with temporary closure of the cavity using a Barker-type negative pressure system. The severity scores were as follows: ISS: 25, NISS: 50, RTS: 6.38 and TRISS: 93.2%.

Simultaneously, and given the extreme instability and complexity of the injuries, a second trained surgical team, led by the trauma surgeon (trauma surgeon trained at Universidad del Valle, Cali) placed a 7Fr REBOA catheter (ER-REBOA) through an open approach to the right common femoral artery (Fig. 1), with positioning in zone I. In the absence of intraoperative interventional radiology, positioning was ensured by direct external measurement from the insertion site to the sternal notch.

Fig. 1.

Intraoperative images of the surgical procedure: exploratory laparotomy and endovascular aortic occlusion. 1 REBOA catheter, 2. Arterial introducer in the right common femoral artery, 3. Right inguinal region surgical incision. A: Balloon inflation to achieve endovascular aortic occlusion. B: Open technique for REBOA placement. C: Intra-abdominal injury management with REBOA placed in Zone I.

Source: Images obtained by the authors.

The decision was made not to perform open supraceliac aortic occlusion to avoid crowding the surgical field, as it was necessary to simultaneously address complex injuries to the inferior vena cava, kidney, and liver. Similarly, thoracotomy was ruled out to avoid increasing the morbidity associated with opening a second cavity. The occlusion was maintained for 40 min with improvement in vital signs (Fig. 2), which allowed for the completion of definitive procedures on the inferior vena cava and kidney, as well as damage control maneuvers on the liver and temporary closure of the abdominal wall. As a point for improvement in future cases, we believe that transitioning to partial occlusion or deflating the balloon immediately after controlling the renal artery could have reduced the visceral ischemic burden, a critical factor in delayed interventions such as this one.

Fig. 2.

Vital sign response after REBOA placement in Zone I. Occlusion time: 09:43; balloon deflation: 10:25.

Source: Prepared by the authors.

Intraoperatively, 4 units of red blood cells and 3 units of fresh frozen plasma were transfused, which was possible thanks to the immediate proximal control of REBOA. However, the magnitude of the injury and consumption coagulopathy required massive resuscitation in the ICU. The decision to initiate transfusion was made based on a shock index of 2.7, positive FAST, tachycardia of 135, and systolic blood pressure of 50 mmHg. She developed acute kidney injury and persistent coagulopathy (linked to prolonged initial resuscitation with crystalloids before transfer). Despite a reintervention at 48 h, she died at 58 h from multiorgan failure.

Discussion

The use of aortic occlusion to control hemorrhage has historical precedents dating back to the Korean War, when Colonel Carl W. Hughes described its application in soldiers with devastating injuries in the 1950s. Although those cases did not result in survival, the maneuver demonstrated the potential of aortic occlusion as a bridge for hemorrhagic control [16]. Subsequently, the technique was abandoned until the development of endovascular devices for ruptured aortic aneurysms in the 1980s, and it was during the conflicts in Iraq and Afghanistan when REBOA resurfaced as a key tool in resource-limited scenarios [17]. Since then, its adoption has expanded to civilian trauma centers around the world.

In the context of severe trauma, non-compressible torso hemorrhage continues to be a significant cause of preventable mortality. The concept of the “golden hour” highlights the importance of early access to definitive bleeding control; however, its effectiveness depends not only on time but also on the appropriate selection of the hospital destination [18]. In systems without a structured trauma network, delay in transfer from initial centers without resolving capacity can decisively compromise the prognosis, as observed in this case, where the patient arrived 8 h after the initial event [19], [20].

REBOA was indicated by the combination of profound hypovolemic shock, massive intra-abdominal hemorrhage, and major vascular injury, in accordance with current practices and described physiological thresholds (SBP < 90 mmHg, ideal 60–80 mmHg) [21], [22]. Its application allowed temporary redistribution of blood flow to vital organs and secondary decrease in bleeding distal to the occlusion, generating a window to complete damage control maneuvers [23]. REBOA was prioritized over resuscitative thoracotomy due to its lower morbidity and possibility of simultaneous execution with laparotomy [24], [25], [26], [27]. This case illustrates that the viability of REBOA in middle-income countries depends more on human factor training than on advanced technological infrastructure. The surgeon maintained competence through formal academic training and simulation, which is vital in centers without interventional radiology.

Although the patient died from multiorgan failure, REBOA fulfilled its main objective: prolonging viable physiological time for surgical control. Additionally, this case highlights the importance of considering the dynamic physiology of hemorrhagic shock. The favorable initial response after occlusion suggests that flow redistribution allowed a period of more adequate cerebral and coronary perfusion, which coincides with what has been described in recent experimental and clinical studies [26], [28]. However, the duration of occlusion is a critical point, as prolonged periods increase the risk of ischemia-reperfusion injury and multiorgan failure. In this patient, occlusion was maintained within the range recommended by current guidelines; however, the prior physiological state and prolonged transfer time conditioned the final evolution. The current case is physiologically complex but technically successful; what failed was the trauma system (incorrect primary transfer and 8-hour delay), which leads us to reflect on the comprehensive management of trauma.

Similarly, the use of REBOA in hospitals without immediate access to embolization or advanced vascular surgery underscores its role as a bridge tool rather than a definitive solution, reinforcing the need for defined transfer routes and referral networks. This case is relevant to the literature because it demonstrates the implementation of REBOA in an environment where it has traditionally not been available, showing that with formal training, planning, and clear protocols, it is possible to expand the resolving capacity of second-level hospitals.

Rather than salvaging a clinical outcome that unfortunately was not the best, this report underscores the function of REBOA as a bridge tool that allows gaining physiological time for definitive hemorrhage control. Its dissemination is important because it provides useful knowledge for middle-income countries, where the availability of hemodynamics or vascular surgery may be limited. Despite having an institutional protocol, the use of REBOA in this case was based on international guidelines. Likewise, it reinforces the need to strengthen regional trauma systems, improve referral and counter-referral processes, and establish continuous training programs to ensure safe and effective implementation, all from the prehospital level (paramedics) to the intrahospital level (emergency physicians, trauma surgeons, anesthesiologists, intensivists, nurses) where the philosophy in trauma is damage control resuscitation.

Conclusions

This case documents the first use of REBOA in Ecuador in the context of trauma, demonstrating its technical feasibility in a second-level hospital without interventional radiology. While the device provided a critical physiological window for hemorrhage control, the fatal outcome highlights that REBOA cannot offset prolonged pre-hospital delays. Its implementation in resource-limited settings such as in our case should serve as a starting point for developing multidisciplinary institutional damage control protocols and strengthening regional trauma referral networks. Ultimately, specialized training and logistical coordination are more critical for REBOA adoption in middle-income countries than advanced hospital infrastructure.

CRediT authorship contribution statement

Edison Angamarca Angamarca: Writing – review & editing, Writing – original draft, Methodology, Investigation, Conceptualization. Carlos Aguilar Gaibor: Writing – review & editing, Writing – original draft, Methodology, Investigation, Conceptualization. Orlando Villavicencio Cedeño: Writing – original draft, Investigation. Henry Triviño Yépez: Writing – original draft, Conceptualization. Óscar Quijije Mejía: Writing – original draft, Methodology, Conceptualization. Tamara Matute Sánchez: Writing – review & editing, Writing – original draft, Investigation, Conceptualization. Magaly Angamarca Angamarca: Conceptualization, Formal analysis, Validation. Doris Sarmiento Altamirano: Methodology, Investigation, Conceptualization.

Informed consent

This case has informed consent granted by the patient's husband for its publication for scientific and academic purposes.

Declaration of Generative AI and AI-assisted technologies in the writing process

Artificial intelligence was used only to improve writing aspects. It was not used for searching, analyzing information, or preparing clinical or scientific content.

Funding sources

No funding was received from institutions or individuals for the preparation of this case.

Declaration of competing interest

The authors declare that there are no conflicts of interest that may have influenced the development or publication of this manuscript.