https://doi.org/10.1177/1526602818757012 Journal of Endovascular Therapy 1–4 © The Author(s) 2018 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1526602818757012 www.jevt.org Case Report Introduction Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an endovascular method of obtaining tempo- rary hemostasis in the setting of severe hypovolemic shock secondary to aortic aneurysm rupture or traumatic injury to the abdomen or pelvis. 1,2 By reducing blood loss, REBOA helps to maintain perfusion to the heart and brain until hemodynamic stabilization is possible. The conventional use of REBOA is to occlude the aorta proximal to the site of injury in order to maintain proximal aortic pressure. 3 Logically, one might expect that occlusion of distal outflow would pressurize the area of proximal hemorrhage, leading to further decline in hemodynamic sta- bility and rapid exsanguination of the patient. Current REBOA guidelines reflect this reasoning, with high clinical or radiological suspicion of proximal traumatic aortic injury serving as a contraindication. 4 We present a clinical case in which a proximal injury to the aorta was unknown at the time of the procedure, and intraoperative distal REBOA 757012JET XX X 10.1177/1526602818757012Journal of Endovascular TherapyStrauss et al case-report 2018 1 Michael G. Degroote School of Medicine, McMaster University, Hamilton, Ontario, Canada 2 Divisions of General Surgery and Critical Care, McMaster University, Hamilton, Ontario, Canada 3 Division of Vascular Surgery, Hamilton Health Sciences, Hamilton, Ontario, Canada Corresponding Author: John Harlock, Division of Vascular Surgery, Hamilton General Hospital, 237 Barton Street East, 5 North, Room 508, Hamilton, Ontario, L8L 2X2, Canada. Email: harlocj@mcmaster.ca Distal Placement of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) to Restore Hemodynamic Stability in a Patient With Proximal Aortic Rupture Shira Strauss, MD 1 , Paul Engels, MD, FRCSC 2 , and John Harlock, MD, FRCSC 1,3 Abstract Purpose: To report unconventional use of the resuscitative endovascular balloon occlusion of the aorta (REBOA) technique to restore hemodynamic stability in a patient who was hemorrhaging from aortic injury proximal to the target zone of occlusion. Case Report: A 72-year-old woman underwent urgent thoracic stent-graft repair of a ruptured 8×8- cm mycotic pseudoaneurysm. Two months later, follow-up imaging revealed that the proximal aortic stent seal zone had degenerated, so a percutaneous procedure was performed 2 months later to preemptively reinforce the segment of stented aorta. Shortly after obtaining femoral access, the patient’s condition abruptly deteriorated with profound hypotension, presumably a result of an access complication. REBOA was established in the supraceliac aorta, which sustained the mean arterial pressure while the anesthesiologist resuscitated the patient. Unexpectedly, angiography showed a rupture of the descending thoracic aorta immediately proximal to the upper stent-graft. Balloon inflation distal to the rupture site was maintained while the patient’s hypotension was treated. Another stent-graft was quickly placed over the area of concern, overlapping proximal to the prior grafts. Once the aortic perforation was sealed, the patient stabilized hemodynamically. Inotropic support was weaned, and the REBOA occlusion catheter was deflated. Final angiograms of the arch and thoracic aorta confirmed no extravasation; angiograms of the infrarenal aorta and iliac arteries showed no evidence of injury. Conclusion: This case illustrates that applying REBOA distal to the injury site in certain clinical scenarios may sufficiently increase peripheral resistance to compensate temporarily for cardiovascular collapse secondary to aortic injury. Keywords aortic rupture, balloon occlusion, hemorrhagic shock, mycotic aneurysm, pseudoaneurysm, stent-graft, thoracic aorta