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Original Investigation
April 2017

Fixed-Distance Model for Balloon Placement During Fluoroscopy-Free Resuscitative Endovascular Balloon Occlusion of the Aorta in a Civilian Population

Author Affiliations
  • 1Ministère de la Défense, Service de Santé des Armées, Ecole de Santé des Armées, Lyon-Bron, France
  • 2Unité Mixte de Recherche T9405, Laboratoire d’Anatomie, Faculté de Médecine Lyon Est, Université Lyon 1, Lyon, France
  • 3Unit of Emergency Surgery, Department of Surgery, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, France
  • 4Protypon Neurological-Neuromuscular Center, Thessaloniki, Greece
  • 5Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
  • 6Institut de Recherche Biomédicale des Armées, Soutien médico-chirurgical des forces, Brétigny sur Orge, France
  • 7Department of Radiology, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre-Bénite, France
  • 8Department of Anaesthesia and Critical Care Medicine, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre-Bénite, France
JAMA Surg. 2017;152(4):351-358. doi:10.1001/jamasurg.2016.4757
Key Points

Question  When implementing resuscitative endovascular balloon occlusion of the aorta (REBOA), is the distance from the point of entry of the catheter to the balloon position in zones I and III the same for the entire general population?

Findings  In this cohort study performed using 280 computed tomographic scans, the same distances were recorded in 97% of the sample population. These distances are expected to exist in more than 94% of the general population.

Meaning  By marking these 2 distances on the catheter, we found that REBOA could be implemented without fluoroscopy, in emergency prehospital and hospital settings and for every patient regardless of morphometric and medical background data.


Importance  Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an innovative procedure in the treatment of noncompressible truncal hemorrhage. However, readily available fluoroscopy remains a limiting factor in its widespread implementation. Several methods have been proposed to perform REBOA without fluoroscopic guidance, and these methods were adapted predominantly from the military theater.

Objective  To develop a method for performing REBOA in a civilian population using a standardized distance from a set point of entry.

Design, Setting, and Participants  A retrospective study of whole-body computed tomographic (CT) scans from a cohort of 280 consecutive civilian trauma patients from University Hospitals of Lyon, France, was used to calculate the endovascular distances from both femoral arteries at the level of the upper border of the symphysis pubis to aortic zone I (descending thoracic aorta) and zone III (infrarenal aorta). These whole-body CT scans were performed between 2013 and 2015. Data were analyzed from July 16 to December 7, 2015.

Main Outcomes and Measures  Two segments (1 per zone) common to all CT scans were isolated, and their location, length, prevalence in the cohort, and predicted prevalence in the general population were calculated by inverting 99% certainty tolerance limits.

Results  Among the 280 trauma patients (140 men and 140 women) in this study, the mean (SD) height was 170.7 (8.7) cm, and the mean (SD) age was 38.8 (16.5) years. The common segment in zone I (414-474 mm) existed in all CT scans. The common segment in zone III (236-256 mm) existed in 99.6% and 97.9% of CT scans from the right and left femoral arteries, respectively. These segments are expected to exist in 98.7% (zone I) and 94.9% (zone III) of the general population.

Conclusions and Relevance  Target distances for blind placement of REBOA exist with more than 94% prevalence in a civilian population. These findings support the expanded use of REBOA in emergency department and prehospital settings. Validation for safety and efficacy on cadaveric and clinical models is necessary.