Trauma surgeons as the vanguard for safe REBOA implementation - response to letter to the editor.

To the editor,

We thank Drs. Nieto-Calvache, Holguín, and Delgado for their inciteful comments regarding our manuscript “Resuscitative endovascular balloon occlusion of the aorta— interest is widespread but need for training persists”.¹ We agree with the authors that REBOA presents an opportunity for prevention of severe hemorrhage particularly in the setting placenta accreta. This is especially true when REBOA is implemented in a planned, organized manner. The authors present such a protocol in which this can be accomplished that minimizes risk to patients and maximizes potential for success. We have recently initiated a similar collaborative effort with our obstetric colleagues for the exact situations the authors describe and have employed a similar approach.

As we discussed in our manuscript, this approach can be used in several other settings. For example, oncologic operations in which significant blood loss is anticipated, a small femoral sheath can be placed at the onset of the operation and, in the event of severe hemorrhage, rapidly upsized with subsequent REBOA placement and zone 1 inflation until hemorrhage control is achieved. As emphasized, this would provide further opportunity for trauma and other surgeons to develop and maintain the skills necessary for REBOA placement, providing a valuable tool in the management of a wide variety of causes of hemorrhagic shock.

Given the paucity of data regarding REBOA usage in non-traumatic causes of hemorrhagic shock, it is important that data are collected for outcomes following implementation in such settings. This will determine appropriate indications for REBOA implementation and provide opportunities for improvement to reduce complications. Given the infrequency of such events, this will likely need to occur with a multicenter registry. We thank the editors for the opportunity to discuss our work further.