Resuscitative endovascular balloon occlusion of the aorta in combat and austere environments

doi:10.5492/wjccm.123705

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World Journal of Critical Care Medicine

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2220-3141

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

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World J Crit Care Med. Sep 9, 2026; 15(3): 123705
Published online Sep 9, 2026. doi: 10.5492/wjccm.123705

Resuscitative endovascular balloon occlusion of the aorta in combat and austere environments

Marcelo Augusto Fontenelle Ribeiro Junior, Rafael Dib Possiedi, Karine Matos de Albuquerque, Leticia Stefani Pacheco, Luiza Telles, Sariya Khan, Anaida Xacur-Trabulce, Nicolas de Cesaro Schpchacki

Marcelo Augusto Fontenelle Ribeiro Junior, Rafael Dib Possiedi, Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD 21201, United States

Marcelo Augusto Fontenelle Ribeiro Junior, Department of Surgery, Pontifical Catholic University of São Paulo - Campus Sorocaba, Sorocaba 18030070, São Paulo, Brazil

Rafael Dib Possiedi, Department of Surgery, Médecins Sans Frontières, Brussels 1050, Belgium

Rafael Dib Possiedi, Department of Surgery, UK-Med, Manchester M3 3WD, United Kingdom

Karine Matos de Albuquerque, School of Medicine, University of Porto, Porto 4200-319, Portugal

Leticia Stefani Pacheco, Health Sciences and Medical School of Sorocaba, Pontifical Catholic University of São Paulo - Campus Sorocaba, Sorocaba 18030070, Brazil

Luiza Telles, Discipline of Plastic Surgery, School of Medicine, University of São Paulo, São Paulo 01246-903, Brazil

Sariya Khan, General Medicine Practice Program, Batterjee Medical College, Jeddah 21442, Saudi Arabia

Anaida Xacur-Trabulce, Department of General Surgery, Angeles Lomas Hospital, National Autonomous University of Mexico, Huixquilucan 52763, Mexico

Nicolas de Cesaro Schpchacki, School of Medicine, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre 90619-900, Rio Grande do Sul, Brazil

Co-first authors: Marcelo Augusto Fontenelle Ribeiro Junior and Rafael Dib Possiedi.

Author contributions: Ribeiro Junior MAF and Dib Possiedi R contributed to concepts, literature research, manuscript editing, design and definition of intellectual content, they served as guarantors of the work and are co-first authors who contributed equally to this study; Matos de Albuquerque K and Telles L contributed to the data acquisition; Dib Possiedi R and Stefani Pacheco L contributed to the data analysis; Stefani Pacheco L and de Cesaro Schpchacki N contributed to the writing of the manuscript; Ribeiro Junior MAF, Dib Possiedi R, Xacur-Trabulce A, Khan S, Matos de Albuquerque K, Telles L, Stefani Pacheco L, and de Cesaro Schpchacki N contributed to manuscript preparation and manuscript review. All authors approved final revision of the paper.

AI contribution statement: AI tools were used to assist with deduplication and citation management (Zotero), study screening (Rayyan), and language editing (ChatGPT), during manuscript preparation. The authors reviewed and approved all AI generated content and are fully responsible for its accuracy and integrity.

Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.

PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.

Corresponding author: Marcelo Augusto Fontenelle Ribeiro Junior, MD, PhD, ACC (Hon), CBC (Hon), FACS, FISS, MAMSE, Professor, Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, Room P1Go4G. 22 South Greene Street, Baltimore, MD 21201, United States. mfribeiro@som.umaryland.edu

Received: May 27, 2026
Revised: July 18, 2026
Accepted: July 28, 2026
Published online: September 9, 2026
Processing time: 87 Days and 13.7 Hours

Abstract

BACKGROUND

Non-compressible torso hemorrhage (NCTH) is a leading cause of preventable death in austere environments. Extended evacuation times prioritize far-forward hemorrhage control. Resuscitative endovascular balloon occlusion of the aorta (REBOA) preserves proximal perfusion, shifting from specialized centers to prehospital combat settings.

AIM

To investigate the feasibility, safety, and clinical outcomes of REBOA for NCTH in combat and austere environments.

METHODS

A PRISMA-ScR-guided scoping review searched five databases, with reference-list screening of included studies and key reviews, of humans receiving REBOA for NCTH in combat, prehospital, or austere environments. Two independent reviewers extracted patient characteristics, procedural parameters, and clinical outcomes. Quality was assessed via Joanna Briggs Institute tools and the Newcastle-Ottawa Scale.

RESULTS

From 1138 records, 8 studies, met criteria: 35 individually reported cases and 15 eligible cases from one registry cohort, of 50. Because the registry reported aggregate data only, all denominators below refer to the 35 individually reported cases. Casualties were predominantly young men in severe hemorrhagic shock after penetrating or blast injury. Access was via the common femoral artery, percutaneous in 23 of 35 (65.7%), with the balloon in zone 1 in 31 of 35 (88.6%). Survival to transfer or discharge was 91.4% (32 of 35); crude mortality was 8.6% (3 of 35). Complications were access-site thrombosis or limb ischemia in 4 of 35 (11.4%), one balloon rupture, and one reperfusion-related acute kidney injury.

CONCLUSION

REBOA has been utilized in select combat and austere casualties, demonstrating hemodynamic improvement. However, this uncontrolled evidence precludes conclusions regarding efficacy or superiority, thereby not supporting its routine clinical deployment.

Keywords: Resuscitative endovascular balloon occlusion of the aorta; Combat trauma; Austere environment; Non-compressible torso hemorrhage; Prehospital hemorrhage control; Hemorrhagic shock

Core Tip: In austere and combat environments, non-compressible torso hemorrhage presents a critical challenge due to prolonged evacuation times and limited resources. Resuscitative endovascular balloon occlusion of the aorta has been increasingly described in these settings as an adjunctive intervention. This scoping review maps the current evidence on its use across diverse operational contexts, including prehospital and military care. However, available data are limited, heterogeneous, uncontrolled, and predominantly observational, highlighting variability in practice and important knowledge gaps that warrant further structured investigation.