Resuscitative endovascular balloon occlusion of the aorta (REBOA) stands as a crucial intervention for managing noncompressible torso hemorrhage, a leading cause of preventable death in trauma patients. Its application has been increasingly recognized across Canadian medical centers as a vital component of hemorrhagic shock protocols. However, the implementation of REBOA is not without challenges and ongoing debate surrounds its optimal utilization. The Canadian Collaborative on Urgent Care Surgery (CANUCS), a collective of Canadian surgeons specializing in acute trauma care, brings forth evidence-based and experience-driven recommendations to guide the successful integration of REBOA programs within Canadian institutions. This includes a strong emphasis on multidisciplinary education, efficient logistical pathways, and robust quality assurance frameworks, all essential for maximizing patient benefits and mitigating potential risks associated with this life-saving technology, particularly in the context of enhancing acute care skills programs, such as those potentially found in Vancouver BC.
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a well-established technique for addressing noncompressible torso hemorrhage. 1–4 Global medical literature extensively documents the indications, procedural techniques, and patient outcomes associated with 7- to 12-French REBOA devices. 2, 4, 5 Several Canadian trauma centers have already incorporated REBOA into their local protocols for managing hemorrhagic shock. 6, 7 Since Health Canada’s approval of the 7-French ER-REBOA catheter in October 2017, coupled with the introduction of the Basic Endovascular Surgical Techniques (BEST) Course by the American College of Surgeons in Canada, interest in REBOA within the Canadian medical community has significantly surged. This growing interest underscores the need for specialized acute care skills programs, potentially in locations like Vancouver BC, to support the safe and effective implementation of REBOA.
Despite the growing national interest, it’s crucial to acknowledge that REBOA is associated with potential complications, and clinical equipoise persists concerning its use in trauma patients. 2, 8 Various organizations have published clinical position statements and practice guidelines to standardize REBOA implementation. 3, 9–13 However, these international guidelines may not be directly applicable to the unique Canadian healthcare setting, and the precise role of REBOA within Canadian trauma systems remains somewhat undefined. While a substantial body of international research is emerging, predominantly from the United States, South America, and Japan, there’s a relative scarcity of Canadian publications to inform nationally relevant recommendations. 6, 7, 14, 15 This gap highlights the importance of developing context-specific guidance, potentially through acute care skills programs in centers like Vancouver BC, to address the Canadian landscape.
The Canadian Collaborative for Urgent Care Surgery (CANUCS) comprises experienced surgeons providing acute trauma care across Canada, many with direct expertise in REBOA implementation and utilization. This paper aims to present consensus recommendations tailored to the Canadian context, aligning with the established consensus process of the Canadian Journal of Surgery. These recommendations are intended to assist Canadian centers considering REBOA program implementation, focusing on optimizing patient safety, quality assurance, and continuous improvement. They are grounded in available evidence and supplemented by expert opinion where evidence is limited, emphasizing the need for specialized acute care skills and training, potentially fostered through programs in Vancouver BC and similar centers.
Development of Statements and Recommendations
The development of these statements and recommendations for REBOA use in Canadian centers followed a structured, multi-stage approach. Initially, a comprehensive literature review was conducted by one investigator (N.L.B.) using MEDLINE and PubMed. The search encompassed articles mentioning REBOA in their titles or abstracts, including primary studies, systematic reviews, and clinical practice guidelines. Keywords used were “resuscitative balloon occlusion of the aorta” or “REBOA,” as specific Medical Subject Heading (MeSH) terms were not yet available. Bibliographies of identified studies were also reviewed, and CANUCS members were consulted for additional relevant studies, unpublished data (e.g., hospital-specific REBOA deployment data), or society/college statements pertinent to the Canadian context. To address potential gaps in trauma-specific literature, secondary searches were performed in related surgical and interventional disciplines (e.g., vascular surgery, interventional radiology) with the assistance of a CANUCS member with fellowship training in vascular and endovascular surgery (D.J.R.). This was crucial for identifying relevant techniques, such as safe vascular access methods, applicable to trauma patients. This thorough literature review underscores the importance of a strong foundation in acute care skills, which can be enhanced through specialized programs offered in locations like Vancouver BC.
Identified studies were then disseminated to CANUCS members, followed by iterative virtual meetings (using Zoom Video Communications) and email discussions to explore critical issues related to REBOA implementation in Canadian trauma centers. Many co-authors possessed firsthand experience with REBOA insertion, application, and education in Canada, the US, and Africa. These discussions centered on the existing literature and clinical practice guidelines identified during the literature search, facilitating a comprehensive understanding of the current state of REBOA practice and the specific needs within the Canadian healthcare system. This collaborative approach is vital for developing relevant and practical recommendations, and highlights the value of networking and knowledge sharing facilitated by acute care skills programs and professional development opportunities, potentially accessible in Vancouver BC.
Subsequently, a modified Delphi process was employed to formulate context-specific statements (providing rationale for recommendations and literature-based benchmarks) and actionable recommendations for REBOA implementation in Canada. This process involved careful consideration of the applicability of international REBOA guidelines to the Canadian context. The primary objective of these meetings was to achieve consensus on each recommendation. In cases where consensus could not be reached, no recommendation was issued, ensuring that all recommendations reflected a strong level of expert agreement. Statements and recommendations were presented along with supporting literature and the rationale for their development (Box 1). This methodology was chosen over the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) guidelines due to the limited robust literature available for a formal GRADE evaluation of REBOA program implementation. 16 This rigorous process emphasizes the need for well-informed and evidence-based guidelines, which can be further supported by incorporating findings from acute care skills program evaluations and outcomes research, potentially conducted in centers like Vancouver BC.
Box 1: Clinical practice recommendations .
REBOA placement
- Recommendation 1: Individual institutions should be responsible for credentialing REBOA providers and developing protocols to optimize patient care.
- Recommendation 2: Access for REBOA placement should be limited to the common femoral artery, directly over the femoral head.
- Recommendation 3: The position of the REBOA balloon should be confirmed before inflation.
- Recommendation 4: REBOA deployment should follow manufacturers’ instructions for use.
- Recommendation 5: Institutions must have physician resources to monitor the patient during balloon deployment.
Patient management after REBOA inflation
- Recommendation 6: Zone 1 aortic occlusion should be less than 30 minutes and should not be performed without a certified trauma, acute care or vascular surgeon present, with institutional capacity to meet these constraints.
- Recommendation 7: Zone 3 occlusion should be less than 60 minutes.
- Recommendation 8: Institutions transferring patients with zone 3 aortic occlusion to an interventional radiology suite must have in-suite capacity for resuscitative interventions.
- Recommendation 9: REBOA should be deployed only in sites with the capacity for definitive hemorrhage control.
- Recommendation 10: Institutional protocols for device removal and patient monitoring after REBOA are necessary and should be developed in conjunction with colleagues from vascular and endovascular surgery and from critical care medicine.
Quality assurance and quality improvement
- Recommendation 11: Institutions implementing REBOA should have multidisciplinary education, simulation, review and maintenance of skills programs.
- Recommendation 12: Institutions implementing REBOA should have a surgical REBOA coordinator.
REBOA = resuscitative endovascular balloon occlusion of the aorta.
At the time of literature synthesis, only two directly relevant reports were identified: a single-center study detailing the first year of a REBOA program with a focus on system improvement [17](#b17-065e310], and a guideline outlining a multidisciplinary approach to institutional REBOA programs based on a panel of US Level 1 trauma and vascular surgeons 10. No published randomized controlled trials on REBOA in human subjects were found; the ongoing UK-REBOA trial is anticipated to provide valuable future insights. The majority of existing primary publications on REBOA use in humans consist of retrospective reviews, prospective observational studies, and case series or case reports 2. This evidence base is categorized as Level III or IV according to the Oxford Centre for Evidence-Based Medicine, while expert opinion guidelines are considered Level V evidence. This reinforces the need for robust data collection and analysis, potentially through participation in registries and quality improvement initiatives linked to acute care skills programs and training centers, such as those that might be located in Vancouver BC.
A recent systematic review of REBOA for major exsanguination included 89 studies, with a significant proportion (57 of 61 case series and cohort studies) identified as having a high risk of bias according to the Cochrane Collaboration tool (this tool was not applied to 28 case reports) 13. Current primary studies would likely be classified as having moderate, serious, or critical risk of bias based on the Risk Of Bias In Non-Randomized Studies of Interventions (ROBINS-I) tool, and were not designed to assess care processes within REBOA programs. The available information was interpreted with these limitations in mind, guided by a thorough understanding of both REBOA application and the specific nuances of the Canadian healthcare system. The primary focus was on prioritizing patient safety during REBOA program implementation. As the body of literature expands and Canadian experience with REBOA grows, these recommendations are expected to be updated and refined accordingly, potentially incorporating insights from acute care skills programs and their impact on REBOA outcomes, particularly in regions like Vancouver BC.
Clinical Practice Statements
Statement 1: The busiest trauma centres in Canada may expect fewer than 15 trauma patients who could potentially benefit from REBOA per year
A REBOA device. This image illustrates the components of a REBOA device, crucial for understanding its application in acute care settings.
Rationale
While the Trauma Quality Improvement Program (TQIP) database in the US reported a median of 6 (interquartile range 4–7) REBOA cases annually in 2019 [3](#b3-065e310], the most active trauma centers in the US report up to 70 REBOA deployments per year 9. The frequency of REBOA utilization in Canada appears to align more closely with reports from Japan (6 cases per year) 18, 19 and the United Kingdom (3–8 cases per year) 20. A recent gap analysis from two trauma centers in Alberta identified 30 patients who could have potentially benefited from REBOA over a two-year period 14. This aligns with estimates of up to 15 annual REBOA-eligible cases at Vancouver General Hospital (N. Garraway, personal communication, 2020) and up to 6 cases by the Nova Scotia Trauma Program, based on internal needs assessments (unpublished data). In the two years following REBOA program implementation at Montreal General Hospital, Vancouver General Hospital, and St. Michael’s Hospital in Toronto in 2018, there were 27, 5, and 4 REBOA deployments, respectively (unpublished data; N. Garraway, personal communications, 2021). These figures highlight the relatively low volume of REBOA cases in even busy Canadian trauma centers, underscoring the importance of consistent training and skills maintenance, which could be supported by acute care skills programs in Vancouver BC and other major centers.
Statement 2: In Canada, trauma team members and leaders have variable training and skill sets for accessing the common femoral artery percutaneously or via open surgical cutdown
Femoral artery access. This diagram shows the anatomical location of the common femoral artery, the primary site for REBOA access, emphasizing the need for precise acute care skills.
Rationale
Initial data from the AORTA (Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery) registry indicated that open surgical cutdowns were required in up to 50% of REBOA placements 1. More recent data suggest a lower rate, with 17%–24% of REBOA placements requiring surgical cutdown for common femoral artery (CFA) access 4, 21. A six-year review of the International ABOTrauma Registry reported percutaneous CFA access in 72% of cases (51% using anatomic landmarks, 21% using ultrasonography) and open surgical cutdown in 24% of cases 21. The impact of the novel COBRA system (utilizing a 4-French sheath and balloon) on procedure success and complication rates in trauma patients remains to be clinically evaluated 22. Patients in cardiac arrest are more likely to require surgical cutdown to facilitate REBOA placement 1, 3, 23. Immediate availability of proficient CFA access skills is a predictor of both rapid REBOA deployment and reduced procedural complication rates 19, 23. Given the diverse trauma care models across Canada, where trauma team leadership is often shared between surgeons and non-surgeon physicians, and trauma team leaders are not always immediately on-site, experience with CFA access varies significantly. Consequently, advanced surgical techniques like open surgical cutdown for CFA access may not be consistently available in many Canadian trauma centers. Furthermore, general surgery residency programs in Canada offer inconsistent training in vascular and endovascular surgery. While general surgery trainees are often present early in trauma resuscitations, many have limited surgical experience with femoral artery procedures or CFA access for endovascular interventions. Conversely, the Royal College of Canada’s direct-entry vascular surgery program has resulted in current vascular surgery trainees having less experience in managing multisystem trauma patients compared to previous general surgery fellows. This variability in training and experience highlights the critical need for standardized acute care skills programs, potentially located in centers like Vancouver BC, to address these gaps and ensure consistent competency in vascular access techniques for REBOA.
Statement 3: In Canada, nearly one-quarter of the population lives more than a 1-hour drive from a level 1 or 2 trauma centre
Trauma center access in Canada. This map visually represents the geographic challenges in accessing trauma centers in Canada, relevant to REBOA implementation strategies.
Rationale
Geographic data reveals that 22.5% of the Canadian population resides more than a one-hour drive from a Level 1 or 2 trauma center 24. Consequently, the presenting physiology of trauma patients from rural Canada may differ from their urban counterparts. Even when patients are ultimately transferred to urban centers, transferred trauma patients exhibit significantly higher risk-adjusted mortality rates compared to those admitted directly 25. Therefore, REBOA outcomes in Canadian trauma patients may deviate from results reported in other countries. These geographic realities present challenges in identifying appropriate REBOA candidates and logically staffing REBOA programs at Canadian trauma hospitals, factors that must be carefully considered prior to institutional REBOA implementation. These challenges also underscore the need for specialized training and outreach programs, potentially originating from acute care skills programs in urban centers like Vancouver BC, to support trauma care in remote and rural areas.
Clinical Practice Recommendations
REBOA Placement
Recommendation 1: Individual institutions should be responsible for credentialling REBOA providers and developing protocols to optimize patient care
Rationale
It is recommended that REBOA privileges be granted only to providers with adequate training and proficiency in both percutaneous and open surgical cutdown techniques for CFA access 4, 10. Certification from a recognized REBOA course should be a mandatory component of the credentialing process. While course completion alone does not guarantee system-wide success 17, it establishes a fundamental baseline for developing a robust institutional REBOA program 26. Developing institutional REBOA protocols requires the collaborative involvement of representatives from vascular and endovascular surgery, trauma and acute care surgery, emergency and critical care medicine, anesthesiology, interventional radiology, nursing, and hospital administration. These protocols must also address the tracking and management of REBOA-related complications 9, 10, 17, 27. This recommendation highlights the importance of institutional ownership and the need for standardized credentialing and protocol development, which can be further enhanced by leveraging acute care skills programs and training resources available in Vancouver BC and other major centers.
Recommendation 2: Access for REBOA placement should be limited to the common femoral artery, directly over the femoral head
Rationale
Arterial access for REBOA should be restricted to the CFA, specifically directly over the femoral head. This anatomical landmark facilitates arterial compression against the underlying femoral head and minimizes potential complications, including access site hematomas, pseudoaneurysm formation, retroperitoneal hemorrhage, and limb loss 2, 13, 23.
The use of ultrasonography to guide CFA access is strongly recommended whenever feasible 3. Recognizing that percutaneous access may not always be achievable, all necessary equipment for both percutaneous access and open surgical CFA cutdown should be readily available in designated locations for REBOA cannulation 10. Furthermore, a comprehensive REBOA placement and securement kit should be assembled locally and undergo simulation-based practice prior to clinical use 10, 27. This recommendation emphasizes the importance of anatomical precision and preparedness for various access techniques, skills that are central to acute care training and can be honed through programs offered in locations like Vancouver BC.
Recommendation 3: The position of the REBOA balloon should be confirmed before inflation
Rationale
Current evidence supports the use of plain radiography or fluoroscopy to confirm the REBOA balloon position in aortic zone I (between the left subclavian and celiac artery) or zone III (between the lowest renal artery and aortic bifurcation) prior to deployment 3, 5, 9. While ultrasonography can identify guidewire placement within the aorta, it is not yet validated for confirming balloon position 28.
Deferring radiologic confirmation of balloon position should be limited to exceptional circumstances, such as patients undergoing cardiopulmonary resuscitation; in such cases, radiologic confirmation should be obtained as soon as clinically possible. Therefore, radiologic technologists and imaging capabilities must be immediately accessible in locations where REBOA is deployed. The use of patient stretchers that permit radiography without repositioning patients with REBOA in situ is recommended. This recommendation underscores the need for accurate device placement and the integration of imaging modalities in REBOA procedures, skills that are integral to acute care and can be enhanced through specialized training programs, potentially found in Vancouver BC.
Recommendation 4: REBOA deployment should follow the manufacturers’ instructions for use
Rationale
Balloon inflation must strictly adhere to the manufacturer’s instructions for use. An arterial line setup connected to the REBOA catheter is essential for continuous monitoring of blood pressure response to aortic occlusion. Overinflation carries the risk of balloon or arterial rupture 3, 9. Although partial balloon inflation has been advocated by some centers and providers [29](#b29-065e310], its efficacy and safety in civilian settings have not been adequately studied. A partially inflated balloon may migrate, potentially causing intimal injury or iliac artery positioning 3, 9. Based on current evidence and the anticipated low volume of REBOA cases in Canadian institutions, partial inflation is not recommended as part of standard institutional protocols. This recommendation stresses the importance of standardized procedures and adherence to manufacturer guidelines, fundamental aspects of acute care practice that are reinforced through skills programs and simulation training, potentially available in Vancouver BC.
Recommendation 5: Institutions must have physician resources to monitor the patient during balloon deployment
Rationale
Post-REBOA deployment, increases in blood pressure can lead to balloon migration or blood flow around the balloon, compromising effective occlusion 9. Institutions implementing REBOA must ensure dedicated physician resources, appropriately trained, are available to continuously monitor balloon position, ensure adequate occlusion, and manage the balloon until definitive hemorrhage control is achieved. This recommendation highlights the necessity of continuous patient monitoring and dedicated physician presence during REBOA procedures, emphasizing the critical role of well-trained acute care professionals, whose skills can be honed through programs and training initiatives, such as those potentially in Vancouver BC.
Patient Management after REBOA Inflation
Recommendation 6: Zone 1 aortic occlusion should be less than 30 minutes and should not be performed without a certified trauma, acute care or vascular surgeon present, with institutional capacity to meet these constraints
Rationale
Randomized controlled trials have not yet defined a definitive safe duration for zone 1 REBOA occlusion in trauma patients. Animal studies suggest that balloon inflation times up to 30 minutes are generally well-tolerated, but 60 minutes can result in overwhelming physiological derangement that negates any potential benefit 30. A case series from Japan reported a 50% mortality rate with a median balloon occlusion time of 65 minutes 18. Therefore, the target occlusion time in zone 1 should be less than 30 minutes 3, 11, 13. To achieve this, zone 1 occlusion should only be initiated if hemorrhage control procedures can commence within 15 minutes of occlusion 9. Consequently, zone 1 occlusion should not be performed without the immediate presence of a trauma or acute care surgeon [9](#b9-065e310]. Furthermore, zone 1 occlusion should not be undertaken in institutions lacking immediate operating room availability. This recommendation underscores the time-sensitive nature of zone 1 REBOA and the need for rapid access to definitive hemorrhage control, emphasizing the critical role of specialized acute care teams and readily available surgical expertise, which can be supported by focused training and skills maintenance programs, potentially in locations like Vancouver BC.
Recommendation 7: Zone 3 occlusion should be less than 60 minutes
Rationale
Definitive data on the safe duration of zone 3 aortic occlusion in trauma patients are still lacking. However, expert consensus suggests that zone 3 occlusion should only be initiated if hemorrhage control procedures can begin within 30 minutes, allowing for hemorrhage control to be achieved within a total of 60 minutes 2, 3, 11, 13, 30, 31. While survival after longer zone 3 occlusion times has been reported, it is associated with a higher incidence of serious complications. This recommendation reinforces the importance of time limits in REBOA application and the need for efficient pathways to definitive hemorrhage control, highlighting the crucial role of coordinated acute care teams and well-defined protocols, which can be optimized through training and simulation programs, potentially offered in centers like Vancouver BC.
Recommendation 8: Institutions transferring patients with zone 3 aortic occlusion to an interventional radiology suite must have in-suite capacity for resuscitative interventions
Rationale
To ensure patient safety and preparedness for potential complications, interventional radiology suites receiving patients with zone 3 aortic occlusion must have in-suite capacity for resuscitative interventions. This capacity includes readily available supplies and established protocols for procedures such as thoracostomy and central line placement, as well as massive transfusion capabilities. Furthermore, it requires the immediate availability of personnel, including surgeons, anesthesiologists, and respiratory therapists. Institutions implementing REBOA without a hybrid operating room should develop a clear protocol for efficient patient transfer between the operating room and interventional radiology suite 32. This recommendation emphasizes the need for comprehensive resuscitative capabilities in interventional radiology settings and well-defined transfer protocols, highlighting the importance of multidisciplinary acute care skills and system readiness, which can be enhanced through collaborative training initiatives and drills, potentially facilitated by acute care skills programs in Vancouver BC.
Recommendation 9: REBOA should only be deployed in sites with the capacity for definitive hemorrhage control
Rationale
Successful REBOA use has been documented in austere, prehospital, rural, and patient transfer environments 33–37. However, Canadian paramedic and air ambulance services exhibit variability in provider models, resources, and transfer times. Currently, in Canada, transferring a patient with REBOA in situ such that appropriately trained healthcare professionals can manage the REBOA and achieve the recommended timelines for operating room or interventional radiology access at the receiving site is not consistently feasible. This recommendation stresses that REBOA deployment should be limited to facilities with the capacity for definitive hemorrhage control, underscoring the importance of appropriate patient selection and system-wide readiness, which can be supported by regional trauma networks and outreach programs, potentially coordinated with acute care skills programs in major centers like Vancouver BC.
Recommendation 10: Institutional protocols for device removal and patient monitoring after REBOA are necessary and should be developed in conjunction with colleagues from vascular and endovascular surgery and from critical care medicine
Rationale
Following hemorrhage control, the REBOA balloon must be deflated, and the catheter and sheath should be removed as promptly as possible 3, 9. An ankle-brachial index (ABI) measurement should be recorded after balloon deflation and prior to the patient leaving the operating room or interventional radiology suite. An ABI of 1.0–1.2 is considered within the normal range in patients with compressible, noncalcified arteries. To maintain invasive blood pressure monitoring, radial arterial access is recommended before REBOA removal.
Institutional protocols for device removal and post-REBOA patient monitoring are essential. These protocols should be developed in collaboration with vascular and endovascular surgery, as well as critical care medicine specialists 10, 27. If vascular and endovascular surgeons are not present during REBOA device removal, clear indications for consultation must be defined. Vascular examinations of the lower extremity and access site must be performed for at least 24 hours post-removal 10. Hourly neurovascular assessments should be conducted according to local protocols. A low threshold for computed tomographic angiography (CTA) assessment is recommended in cases of abnormal physical examination findings, including an ABI less than 0.9. Furthermore, assessment for pseudoaneurysm formation within 48 hours after percutaneous sheath removal is recommended 3, 9. This recommendation emphasizes the importance of standardized post-REBOA management protocols, including device removal and vigilant patient monitoring, highlighting the need for multidisciplinary collaboration and well-defined care pathways, which can be enhanced through interprofessional training and protocol development initiatives, potentially facilitated by acute care skills programs in Vancouver BC.
Quality Assurance and Quality Improvement
Recommendation 11: Institutions implementing REBOA should have multidisciplinary education, simulation, review and maintenance of skills programs
Rationale
Comprehensive stakeholder education, encompassing vascular and endovascular surgery, emergency medicine, nursing, interventional radiology, critical care, anesthesiology, trauma, and acute care surgery, is crucial for institutions preparing to introduce a REBOA program 10, 27. Multidisciplinary in situ simulation training, involving nurses, physicians, resident physicians, respiratory therapists, anesthesia assistants, and radiologists, is strongly recommended prior to in vivo REBOA deployment 10, 27.
Furthermore, all REBOA deployments should be reviewed by a multispecialist panel to assess appropriateness of indications 10, 17, 27. Ongoing competency assessment and skills maintenance are essential and should align with institutional requirements. Ideally, this would include wet laboratory sessions, task trainers, and multidisciplinary simulation exercises 10, 17. REBOA procedures should be coded using the International Classification of Diseases, 10th edition (ICD-10) code REBOA ICD-10 04L03DZ. Canadian centers performing REBOA deployments are encouraged to contribute to a quality assurance or improvement registry (e.g., the AORTA registry) 1, 3. This recommendation underscores the paramount importance of comprehensive and ongoing education, simulation training, and quality assurance mechanisms for successful REBOA program implementation, highlighting the potential role of specialized acute care skills programs in Vancouver BC and other centers in providing structured training, simulation resources, and quality improvement frameworks.
Recommendation 12: Institutions implementing REBOA should have a surgical REBOA coordinator
Rationale
A designated REBOA site coordinator is essential to guide the process of deployment, dwell time management, and removal. The coordinator should serve as the primary point of contact with consulting services and leadership within the operating room, interventional radiology, emergency department, and intensive care unit. While various specialties have been successfully trained to insert and deploy REBOA 3, 21, in the Canadian context, the hospital REBOA coordinator should ideally be a trauma or vascular and endovascular surgeon 10. This recommendation emphasizes the need for dedicated leadership and coordination for REBOA programs, highlighting the critical role of a surgical REBOA coordinator in ensuring efficient program operation and multidisciplinary communication, skills that are integral to acute care leadership and can be further developed through leadership training and mentorship programs, potentially accessible in Vancouver BC.
Conclusion
Resuscitative endovascular balloon occlusion of the aorta is a valuable intervention for managing noncompressible torso hemorrhage. However, the complexities of REBOA, including known complications and ongoing debates about its use, necessitate careful implementation. In Canada, unique factors such as lower case volumes, the composition of trauma teams, variable vascular access expertise, and geographic challenges create specific considerations for establishing and maintaining REBOA programs. This context-specific position paper offers guidance for Canadian trauma centers regarding REBOA credentialing, multidisciplinary education, logistical considerations, and quality assurance. By adhering to these recommendations and focusing on continuous improvement, Canadian institutions can maximize the benefits of REBOA for their patients while effectively minimizing potential risks, particularly through the development and utilization of robust acute care skills programs, potentially leveraging resources and expertise in centers like Vancouver BC.
Footnotes
Competing interests: Andrew Kirkpatrick has consulted for Zoll, Innovative Trauma Care, CSL Behring and SAM Medical Corporations, and is the principal investigator of a prospective randomized controlled trial that is partially supported by the Acelity Corporation (https://clinicaltrials.gov/ct2/show/NCT03163095). No other competing interests were declared.
Contributors: All of the authors contributed to the conception and design of the work. Nori Bradley, W. Robert Leeper and Derek Roberts drafted the manuscript. All of the authors revised it critically for important intellectual content, gave final approval of the version to be published and agreed to be accountable for all aspects of the work.
Disclaimer: Chad Ball is co-editor-in-chief of the Canadian Journal of Surgery. Andrew Beckett, Paul Engels, Neil Parry and Kelly Vogt are on the editorial board of the Canadian Journal of Surgery. They were not involved in the editorial decision-making process for this article.
