Nationwide Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta in Civilian Trauma

Resuscitative endovascular balloon of the aorta is feasible in penetrating chest trauma with major hemorrhage: Proposal of a new institutional deployment algorithm

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emerging option for hemorrhage control, but its use is limited in scenarios such as penetrating chest trauma. The aim of this study was to describe the use of REBOA as a resuscitative adjunct in these cases with major hemorrhage and to propose a new clinical management algorithm.

METHODS

This was a prospective, observational study conducted at a single Level I trauma center in Colombia. We included all patients older than 14 years with severe trauma who underwent REBOA from January 2015 to December 2019. Patients received REBOA if they were in hemorrhagic shock and were unresponsive to resuscitation.

RESULTS

A total of 56 patients underwent REBOA placement of which 37 had penetrating trauma and 23 had chest trauma. All patients were hemodynamically unstable upon arrival to the emergency department, with a median systolic blood pressure of 69 mm Hg (interquartile range [IQR], 57-90 mm Hg) and median Injury Severity Score was 25 (IQR, 25-41). All REBOAs were deployed and inflated in zone 1, median inflation time was 40 minutes (IQR, 26-55 minutes), and no adverse neurologic outcomes were observed. Fifteen patients had REBOA and a median sternotomy. Eleven patients had concomitant abdominal wounds. Overall mortality was 28.6%, and there was no significant difference between penetrating versus blunt trauma patients (21.6% vs. 42.1%, p = 0.11). The survival rate of thoracic injured patients was similar to the predicted survival (65.2% vs. 63.3%).

CONCLUSION

Resuscitative endovascular balloon occlusion of the aorta can be used safely in penetrating chest trauma, and the implementation of a REBOA management algorithm is feasible with a well-trained multidisciplinary team.

LEVEL OF EVIDENCE

Therapeutic, level V.

Validation of a Novel Clinical Criteria to Predict Candidacy for Aortic Occlusion: An Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery Study

For trauma patients with noncompressible truncal hemorrhage (NCTH), aortic occlusion (AO) is attempted with either resuscitative thoracotomy (RT) or the resuscitative endovascular balloon occlusion of the aorta (REBOA). However, it is often challenging to identify the group of patients who would benefit from AO procedures. We hypothesized that patients who met simple clinical criteria would have better outcomes following AO procedures. This is a retrospective cohort study using the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database (November 2013-August 2019) which included patients who arrived with signs of life and underwent AO procedures (RT or zone 1 REBOA). Outcomes were compared between patients who met the criteria (admission vital signs: Glasgow Coma Scale (GCS) ≥9 and systolic blood pressure <90 mm Hg) and those who did not. Subgroup analyses were then conducted on patients who had a REBOA placed and those who underwent RT. A total of 998 patients met our inclusion criteria. Of those, a REBOA was placed in 364 patients (37%), while 634 (64%) underwent RT. The overall mortality rate in the criteria (+) group was significantly lower than that in the criteria (-) group (62 vs. 79%, P < .001). In patients who survived beyond the emergency department following AO procedures, those who met the criteria underwent hemorrhage control procedures more frequently (83% vs. 57%, P < .001). Our data suggest that simple clinical criteria could guide the provider for proceeding with AO in patients with suspected NCTH.

Outcomes and management approaches of resuscitative endovascular balloon occlusion of the aorta based on the income of countries

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) could provide a survival benefit to severely injured patients as it may improve their initial ability to survive the hemorrhagic shock. Although the evidence supporting the use of REBOA is not conclusive, its use has expanded worldwide. We aim to compare the management approaches and clinical outcomes of trauma patients treated with REBOA according to the countries' income based on the World Bank Country and Lending Groups.

METHODS

We used data from the AORTA (USA) and the ABOTrauma (multinational) registries. Patients were stratified into two groups: (1) high-income countries (HICs) and (2) low-to-middle income countries (LMICs). Propensity score matching extracted 1:1 matched pairs of subjects who were from an LMIC or a HIC based on age, gender, the presence of pupillary response on admission, impeding hypotension (SBP ≤ 80), trauma mechanism, ISS, the necessity of CPR on arrival, the location of REBOA insertion (emergency room or operating room) and the amount of PRBCs transfused in the first 24 h. Logistic regression (LR) was used to examine the association of LMICs and mortality.

RESULTS

A total of 817 trauma patients from 14 countries were included. Blind percutaneous approach and surgical cutdown were the preferred means of femoral cannulation in HICs and LIMCs, respectively. Patients from LMICs had a significantly higher occurrence of MODS and respiratory failure. LR showed no differences in mortality for LMICs when compared to HICs; neither in the non-matched cohort (OR = 0.63; 95% CI: 0.36‑1.09; p = 0.1) nor in the matched cohort (OR = 1.45; 95% CI: 0.63‑3,33; p = 0.3).

CONCLUSION

There is considerable variation in the management practices of REBOA and the outcomes associated with this intervention between HICs and LMICs. Although we found significant differences in multiorgan and respiratory failure rates, there were no differences in the risk-adjusted odds of mortality between the groups analyzed. Trauma surgeons practicing REBOA around the world should joint efforts to standardize the practice of this endovascular technology worldwide.

Resuscitative Endovascular Balloon Occlusion of the Aorta vs Pre-Peritoneal Packing in Patients with Pelvic Fracture

BACKGROUND

Pelvic hemorrhage is potentially lethal despite homeostatic interventions such as pre-peritoneal packing (PP), resuscitative endovascular balloon occlusion of the aorta (REBOA), surgery, and/or angioembolization. REBOA may be used as an alternative/adjunct to PP for temporizing bleeding in patients with pelvic fractures. Our study aimed to compare the outcomes of REBOA and/or PP, as temporizing measures, in blunt pelvic fracture patients. We hypothesized that REBOA is associated with worsened outcomes.

STUDY DESIGN

We performed a 2017 review of the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) and identified trauma patients with blunt pelvic fractures who underwent REBOA placement and/or PP before laparotomy and/or angioembolization. Propensity score matching was performed, adjusting for demographics, vitals, mechanism of injury, ISS, each body region-AIS, and pelvic fracture type. Outcomes were complication rates and mortality.

RESULTS

A total of 156 patients (PP: 52; REBOA: 52; REBOA+PP: 52) were matched and included. Mean age was 43 ± 18 years, Injury Severity Score (ISS) was 28 (range 17-32), and 74% were males. Overall mortality was 42%. The 24-hour mortality (25% vs 14% vs 35%; p = 0.042), in-hospital mortality (44% vs 29% vs 54%; p = 0.034), and 4-hour pRBC units transfused (15 [9-23] vs 10 [4-19] vs 16 [9-27]; p = 0.017) were lower in the REBOA group. The REBOA group had faster times to both laparotomy (p = 0.040) and/or angioembolization (p = 0.012). There was no difference between the groups in acute kidney injury, lower limb amputations, or hospital and ICU length of stay among survivors.

CONCLUSIONS

REBOA is a less invasive procedure compared with PP and is associated with improved outcomes. Further clinical trials are needed to define the optimal patient who will benefit from REBOA.

The use of resuscitative endovascular balloon occlusion of the aorta (REBOA) for non-traumatic cardiac arrest: A review

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been proposed as a novel approach to managing non-traumatic cardiac arrest (NTCA). During cardiac arrest, cardiac output ceases and perfusion of vital organs is compromised. Traditional advanced cardiac life support (ACLS) measures and cardiopulmonary resuscitation are often unable to achieve return of spontaneous circulation (ROSC). During insertion of REBOA a balloon-tipped catheter is placed into the femoral artery and advanced in a retrograde manner into the aorta while the patient is undergoing cardiopulmonary resuscitation (CPR). The balloon is then inflated to fully occlude the aorta. The literature surrounding the use of aortic occlusion in non-traumatic cardiac arrest is limited to animal studies, case reports and one recent non-controlled feasibility trial. In both human and animal studies, preliminary data show that REBOA may improve coronary and cerebral perfusion pressures and key physiologic parameters during cardiac arrest resuscitation, and animal data have demonstrated improved rates of ROSC. Multiple questions remain before REBOA can be considered as an adjunct to ACLS. If demonstrated to be effective clinically, REBOA represents a potentially cost-effective and generalizable intervention that may improve quality of life for patients with non-traumatic cardiac arrest.

The utility and promise of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the pediatric population: An evidence-based review

Hemorrhage is the main cause of preventable death in both military and civilian trauma, and many of these patients die from non-compressible torso injuries. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive method used for hemodynamic control of the hemorrhaging patient and has been compared to resuscitative thoracotomy (RT) with cross clamping of the aorta. REBOA has received a great deal of attention in recent years for its applicability and promise in adult trauma and non-trauma settings, but its utility in children is mostly unknown. The purpose of this review article is to summarize and consolidate what is currently known about the use of REBOA in children. Some of the challenges in implementing REBOA in children include small vascular anatomy and lack of outcomes data. Although the evidence is limited, there are established instances in the literature of children and adolescents who have undergone endovascular occlusion of the aorta for hemorrhage control with positive outcomes and survival rates equivalent to their adult counterparts. There is a need for further formal evaluation of REBOA in pediatric patients with prospective studies to look at the safety, feasibility and efficacy of the technique. STUDY TYPE: Narrative Literature Review LEVEL OF EVIDENCE: IV.

Impact of a streamlined trauma management approach and determinants of mortality among hemodynamically unstable patients with severe multiple injuries: a before-and-after retrospective cohort study

Background

Trauma management requires a multidisciplinary approach, but coordination of staff and procedures is challenging in patients with severe trauma. In October 2014, we implemented a streamlined trauma management system involving emergency physicians trained in severe trauma management, surgical techniques, and interventional radiology. We evaluated the impact of streamlined trauma management on patient management and outcomes (study 1) and evaluated determinants of mortality in patients with severe trauma (study 2).

Methods

We conducted a retrospective cohort study of 125 patients admitted between January 2011 and 2019 with severe trauma (Injury Severity Score ≥16) and persistent hypotension (≥2 systolic blood pressure measurements <90 mm Hg). Patients were divided into a Before cohort (January 2011 to September 2014) and an After cohort (October 2014 to January 2019) according to whether they were admitted before or after the new approach was implemented. The primary outcome was in-hospital mortality.

Results

Compared with the Before cohort (n=59), the After cohort (n=66) had a significantly lower in-hospital mortality (36.4% vs. 64.4%); required less time from hospital arrival to initiation of surgery/interventional radiology (median, 41.0 vs. 71.5 minutes); and was more likely to undergo resuscitative endovascular balloon occlusion of the aorta (24.2% vs. 6.8%). Plasma administration before initiating hemostasis (adjusted OR 1.49 (95% CI 1.04 to 2.14)), resuscitative endovascular balloon occlusion of the aorta (9.48 (95% CI 1.25 to 71.96)), and shorter time to initiation of surgery/interventional radiology (0.97 (95% CI 0.96 to 0.99)) were associated with significantly lower mortality.

Discussion

Implementing a streamlined trauma management protocol improved outcomes among hemodynamically unstable patients with severe multiple trauma.

Level of evidence

Level III.

Intraoperative balloon occlusion of the aorta for blood management in sacral and pelvic tumor resection: A systematic review and meta-analysis

BACKGROUND

Neoplasms of the sacrum and pelvis are challenging to manage due to their complex vascularity and size and are at high risk of bleeding during resection. Intra-aortic balloon occlusion (IABO) has been used in trauma to control massive blood loss, but its efficacy and safety in oncologic sacral and pelvic surgery are unknown. The primary objective of this systematic review and meta-analysis was to assess the effectiveness of IABO in providing hemorrhage control during resection of sacral and pelvic tumors.

METHODS

This PROSPERO pre-registered study meta-analyzed all studies reporting on the use of IABO in the setting of pelvic and sacral tumour resection, in accordance with the PRISMA guidelines. The primary outcome of the meta-analysis was intraoperative blood loss, with secondary outcomes consisting of transfusion volume, post-operative blood loss, operative time, complication rate, and mortality.

RESULTS

Across studies, IABO was associated with a large, significant reduction in intraoperative blood loss (SMD -0.81, 95% CI -1.01 to -0.60, P < 0.0001) and transfused red blood cell volume (SMD 0.92, 95% CI -1.30 to -0.53, P < 0.0001). Two studies reported that complication rates were comparable between patients receiving IABO and patient receiving conventional surgery (Odds ratio = 1.29, 95% CI: 0.59 to 2.83, P = 0.52). All studies descriptively reported improved visualization of the operative field with IABO.

CONCLUSIONS

Our findings demonstrated that IABO is an effective technique to decrease blood loss and transfusion requirements during sacral and pelvic tumor surgery. Future clinical trials should be conducted to establish the safety of this method and explore potential contraindications.

The management of patients with placenta percreta: A case series comparing the use of resuscitative endovascular balloon occlusion of the aorta with aortic cross clamp

Due to the rising caesarean section (CS) rate, there has been an increase in placenta percreta (PP) cases. Resuscitative endovascular balloon occlusion of the aorta (REBOA) use has been successful in obstetric surgery for PP. In our institution, it has been introduced for prophylactic and therapeutic management in patients with PP. In our environment, the risks, benefits, and associated cost of REBOA use needed to be determined. In this case series, we report on five patients with PP where REBOA or aortic cross clamp were used and examine the associated outcomes.

Feasibility and Clinical Outcome of Reboa in Patients with Impending Traumatic Cardiac Arrest

BACKGROUND

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) may improve Systolic Blood Pressure (SBP) in hypovolemic shock. It has, however, not been studied in patients with impending traumatic cardiac arrest (ITCA). We aimed to study the feasibility and clinical outcome of REBOA in patients with ITCA using data from the ABOTrauma Registry.

METHODS

Retrospective and prospective data on the use of REBOA from 16 centers globally were collected. SBP was measured both at pre- and post-REBOA inflation. Data collected included patients' demography, vascular access technique, number of attempts, catheter size, operator, zone and duration of occlusion, and clinical outcome.

RESULTS

There were 74 patients in this high-risk patient group. REBOA was performed on all patients. A 7-10Fr catheter was used in 66.7% and 58.5% were placed on the first attempt, 52.1% through blind insertion and 93.2% inflated in Zone I, 64.8% for a period of 30 to 60 min, 82.1% by ER doctors, trauma surgeons, or vascular surgeons. SBP significantly improved to 90 mm Hg following the inflation of REBOA. 36.6% of the patients survived.

CONCLUSIONS

Our study has shown that REBOA may be performed in patients with ITCA, SBP can be elevated, and 36.6% of the patients survived if REBOA placement is successful.

Pre-peritoneal pelvic packing for early hemorrhage control reduces mortality compared to resuscitative endovascular balloon occlusion of the aorta in severe blunt pelvic trauma patients: A nationwide analysis

BACKGROUND

Early hemorrhage control after severe blunt pelvic trauma is life-saving. The aim of this study is to compare the efficacy and outcomes of pre-peritoneal packing (PPP) and Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) with a subsequent hemorrhage control procedure to control life-threatening pelvic hemorrhage in trauma patients.

METHODS

A 3-year (2015-2017) retrospective analysis of the Trauma Quality Improvement Program (TQIP) was performed. All blunt trauma patients (aged ≥15 years) who underwent PPP or Zone 3 REBOA placement were included while deaths on arrival and transfers were excluded. Patients were matched on clinical characteristics using propensity score matching (PSM). Univariate analysis was performed to compare mortality, time to procedure, time in ED, transfusion requirements, complications rates, and ICU and hospital length of stay (LOS) amongst patient groups.

RESULTS

Of 420 trauma patients, 307 underwent PPP and 113 REBOA. Patients had similar hemodynamics and ISS upon presentation, but PPP patients had a higher GCS (P = 0.037) and more blunt kidney injuries (P = 0.015). After PSM, 206 trauma patients were included in the analysis. There were no significant differences in blood transfusion, LOS, or major complications. Time to REBOA was shorter than time to PPP (52 vs 77.5 min; P<0.001) with longer time in ED (65 vs 51 min; p = 0.023). The 24-hour (32.4 vs 17.7%; P = 0.23) and in-hospital mortality (52.0 vs 37.3%; P = 0.048) were higher after REBOA.

CONCLUSION

PPP is associated with improved survival compared to REBOA placement. Delay in definitive hemorrhage control may provide a potential explanation, but causation remains unresolved. This data suggests that early PPP may offer a benefit over REBOA in the setting of hemorrhage after blunt pelvic trauma. Further, large, multi-institutional studies are warranted to support these findings.

LEVEL OF EVIDENCE

Prognostic study, level III.

Delays in Surgical Intervention and Temporary Hemostasis Using Resuscitative Endovascular Balloon Occlusion of the aorta (REBOA): Influence of Time to Operating Room on Mortality

BACKGROUND

The optimal candidates for resuscitative endovascular balloon occlusion of the aorta (REBOA) remain unclear. We hypothesized that patients who experience delays in surgical intervention would benefit from REBOA.

METHODS

Using the Japan Trauma Databank (2014-2019), patients transferred to the operating room (OR) within 3 h were identified. Patients treated with REBOA were matched with those without REBOA using propensity scores, and further divided based on the transfer time to OR: ≤ 1 h (early), 1-2 h (delayed), and >2 h (significantly-delayed). Survival to discharge was compared.

RESULTS

Among 5258 patients, 310 underwent REBOA. In 223 matched pairs, patients treated with REBOA had improved survival (56.5% vs. 31.8%; p < 0.01), although in-hospital mortality was reduced by REBOA only in the delayed and significantly-delayed subgroups (HR = 0.43 [0.28-0.65] and 0.42 [0.25-0.71]).

CONCLUSIONS

REBOA-treated trauma patients who experience delays in surgical intervention (>1 h) have improved survival.

A New Pressure-Regulated, Partial Resuscitative Endovascular Balloon Occlusion of the Aorta Device Achieves Targeted Distal Perfusion

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) reduces blood loss and improves hemodynamics. Complete occlusion results in distal ischemia, limiting its use for prolonged care. This study evaluated two next-generation partial REBOA (pREBOA) catheters and their ability to achieve targeted distal aortic flow.

MATERIALS AND METHODS

Swine underwent hemorrhagic shock, complete aortic occlusion, controlled continuous balloon deflation, and targeted distal perfusion (TDP; 300-mL/min) phases. They were randomized into three groups (n = 6/group), one managed with the current ER-REBOA (ER), and two with the new pREBOA technologies: a bilobed (BL) device and a semicompliant pREBOA-PRO (PRP). Hemodynamics including flow rates and mean arterial pressures at the carotid artery and infrarenal aorta were recorded.

RESULTS

Hemodynamics were comparable between groups during hemorrhage and complete occlusion phases. During the controlled continuous balloon deflation phase, the distal aortic flow rate strongly correlated with percent balloon volume in BL and PRP groups, suggesting a precise control of distal perfusion. The slope of flow-balloon-volume curves was greater in the ER group than BL and PRP groups, indicating the change in distal aortic flow rate was more sensitive to the balloon volume (less titratable) when using ER. During the TDP phase, variation in distal aortic flow and mean arterial pressure with respect to the target flow was lower in ER and PRP groups, than the BL group.

CONCLUSIONS

Pressure-regulated occlusion using the next-generation pREBOA catheters is more controlled than the first-generation ER-REBOA catheter and allow for targeted and precise distal perfusion.

Resuscitative Endovascular Balloon Occlusion of Aaorta Use in Nontrauma Emergency General Surgery: A Multi-institutional Experience

BACKGROUND

The aim of this study was to determine the current utilization patterns of resuscitative endovascular balloon occlusion of aorta (REBOA) for hemorrhage control in nontrauma patients.

METHODS

Data on REBOA use in nontrauma emergency general surgery patients from six centers, 2014-2019, was pooled for analysis. We performed descriptive analyses using Fisher's exact, Student's t, chi-squared, or Mann-Whitney U tests as appropriate.

RESULTS

Thirty-seven patients with acute hemorrhage from nontrauma sources were identified. REBOA placement was primarily performed by trauma attendings (20/37, 54%) and vascular attendings (13/37, 35%). In seven patients (19%), balloons were positioned prophylactically but never inflated. In 24 (65%) of 37 patients, REBOA was placed in the operating room. 28/37 balloons (76%) were advanced to zone 1, 8/37 (22%) were advanced to zone 3, and there was one REBOA use in the inferior vena cava. Most common indications were gastrointestinal and peripartum bleeding. In the 30 cases of balloon inflation, 24 of 30 (80%) resulted in improved hemodynamics. Eleven of 30 patients (37%) died before discharge. One patient developed a distal embolism, but there were no reports of limb loss. Twelve patients (40% of all REBOA inflations and 63% of survivors) were discharged to home.

CONCLUSIONS

REBOA has been used in a range of acutely hemorrhaging emergency general surgery patients with low rates of access-related complications. Mortality is high in this patient population and further research is needed; however, appropriate patient selection and early use may improve survival in these life-threatening cases.

Resuscitative endovascular balloon occlusion of the aorta may contribute to improved survival

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an increasingly used trauma resuscitation procedure, however, there are no reports of whether or not the survival of patients treated with REBOA increases over time.

METHODS

This retrospective cohort study from a nationwide trauma registry in Japan was conducted between 2004 and 2015. Patients treated with REBOA were divided into three calendar year periods: early-period (2004-2007), mid-period (2008-2011), and late-period (2012-2015). The primary outcome of in-hospital survival was compared between the periods (early-period: reference) using mixed effects logistic regression analysis after adjustment for characteristics, trauma severity, and therapeutic choices.

RESULTS

Of 236,698 trauma patients, 633 patients treated with REBOA were analyzed. Distribution of the patients across periods was as follows: early-period (91), mid-period (276), and late-period (266). In-hospital survival was 39, 49, and 60% in the early-period, mid-period, and late-period, respectively. In regression modeling, the late-period (OR = 2.976, 95% CI = 1.615-5.482) was associated with improved in-hospital survival compared to the early-period, however, the mid-period (OR = 1.614, 95% CI = 0.898-2.904) was not associated with improved survival.

CONCLUSIONS

Survival of patients treated with REBOA during the late-period improved compared with survival during the early-period, after adjustment for characteristics, trauma severity, and therapeutic choices. REBOA may be one of the important factors related to progression of modern trauma treatment.

Prospective Observational Evaluation of the ER-REBOA Catheter at 6 U.S. Trauma Centers

OBJECTIVE

To describe the current use of the ER-REBOA catheter and associated outcomes and complications.

INTRODUCTION

Noncompressible truncal hemorrhage is the leading cause of potentially preventable death in trauma patients. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a novel strategy to obtain earlier temporary hemorrhage control, supporting cardiac, and cerebral perfusion before definitive hemostasis.

METHODS

Prospective, observational study conducted at 6 Level 1 Trauma Centers over 12-months. Inclusion criteria were age >15 years of age with evidence of truncal hemorrhage below the diaphragm and decision for emergent hemorrhage control intervention within 60 minutes of arrival. REBOA details, demographics, mechanism of injury, complications, and outcomes were collected.

RESULTS

A total of 8166 patients were screened for enrollment. In 75, REBOA was utilized for temporary hemorrhage control. Blunt injury occurred in 80% with a median injury severity score (ISS) 34 (21, 43). Forty-seven REBOAs were placed in Zone 1 and 28 in Zone 3. REBOA inflation increased systolic blood pressure from 67 (40, 83) mm Hg to 108 (90, 128) mm Hg 5 minutes after inflation (P = 0.02). Cardiopulmonary resuscitation was ongoing during REBOA insertion in 17 patients (26.6%) and 10 patients (58.8%) had return of spontaneous circulation after REBOA inflation. The procedural complication rate was 6.6%. Overall mortality was 52%.

CONCLUSION

REBOA can be used in blunt and penetrating trauma patients, including those in arrest. Balloon inflation uniformly improved hemodynamics and was associated with a 59% rate of return of spontaneous circulation for patients in arrest. Use of the ER-REBOA catheter is technically safe with a low procedural complication rate.

[Resuscitative endovascular balloon occlusion of the aorta (REBOA) : Current aspects of material, indications and limits: an overview]

Hintergrund

„Resuscitative endovascular balloon occlusion of the aorta“ (REBOA) stellt ein endovaskuläres Verfahren dar, bei dem ein Blockballon in die Aorta eingeführt wird, um eine distal des Ballons gelegene Blutung zu verringern und gleichzeitig die kardiale und zerebrale Oxygenierung zu verbessern.

Ziel der Arbeit

Vorstellung der REBOA-Technik, der möglichen Indikationen, der benötigen Materialien und der möglichen Komplikationen des Verfahrens.

Material und Methoden

Nichtsystematischer Übersichtsartikel über die aktuelle Literatur.

Ergebnisse

REBOA stellt gerade bei traumatisch bedingten Blutungen und rupturierten Aortenaneurysmen ein mögliches additives Verfahren zur hämodynamischen Stabilisierung dar. Die Komplikationsrate des Verfahrens liegt bei ungefähr 5 %, wobei Zugangskomplikationen im Vordergrund stehen, jedoch auch letale Komplikationen möglich sind.

Diskussion

Eine aortale Ballonblockade wird bei der Versorgung rupturierter Aortenaneurysmen standardmäßig eingesetzt. Es gibt wachsende Evidenz, dass REBOA bei der Versorgung polytraumatisierter Patienten mit einem hämorrhagischen Schock aufgrund einer abdominellen oder viszeralen Blutung eine vergleichsweise minimal-invasive Alternative zur offen chirurgischen Aortenklemmung mittels Thorakotomie darstellt. Mit der Entwicklung neuer Ballonkatheter, die ohne Führungsdraht und mit geringeren Schleusendurchmessern auskommen, wird auch ein Einsatz bei anderen Krankheitsbildern wie postoperativen abdominellen Nachblutungen, gynäkologischen Blutungen oder als additives Verfahren bei der kardiopulmonalen Reanimation diskutiert.

The impact of early administration of vasopressor agents for the resuscitation of severe hemorrhagic shock following blunt trauma

Background

When resuscitating patients with hemorrhagic shock following trauma, fluid volume restriction and permissive hypotension prior to bleeding control are emphasized along with the good outcome especially for penetrating trauma patients. However, evidence that these concepts apply well to the management of blunt trauma is lacking, and their use in blunt trauma remains controversial. This study aimed to assess the impact of vasopressor use in patients with blunt trauma in severe hemorrhagic shock.

Methods

In this single-center retrospective study, we reviewed records of blunt trauma patients with hemorrhagic shock and included patients with a probability of survival < 0.6. Vital signs on arrival, characteristics, examinations, concomitant injuries and severity, vasopressor use and dose, and volumes of crystalloids and blood infused were compared between survivors and non-survivors. Data are described as median (25–75% interquartile range) or number.

Results

Forty patients admitted from April 2014 to September 2019 were included. Median Injury Severity Score in survivors vs non-survivors was 41 (36–48) vs 45 (34–51) (p = 0.48), with no significant difference in probability of survival between the two groups (0.22 [0.12–0.48] vs 0.21 [0.08–0.46]; p = 0.93). Despite no significant difference in patient characteristics and injury severity, non-survivors were administered vasopressors significantly earlier after admission and at significantly higher doses. Total blood transfusion amount administered within 24 h after admission was significantly higher in survivors (8430 [5680–9320] vs 6540 [4550–7880] mL; p = 0.03). Max catecholamine index was significantly higher in non-survivors (2 [0–4] vs 14 [10–18]; p = 0.008), and administered vasopressors were terminated significantly earlier (12 [4–26] vs 34 [10–74] hours; p = 0.026) in survivors.

Although the variables of severity of the patients had no significant differences, vasopressor use (Odds ratio [OR] = 21.32, 95% confident interval [CI]: 3.71–121.6; p = 0.0001) and its early administration (OR = 10.56, 95%CI: 1.90–58.5; p = 0.005) indicated significant higher risk of death in this study.

Conclusion

Vasopressor administration and high-dose use for resuscitation of hemorrhagic shock following severe blunt trauma are potentially associated with increased mortality. Although the transfused volume of blood products tends to be increased when resuscitating these patients, early termination of vasopressor had better to be considered.

Association of resuscitative endovascular balloon occlusion of the aorta (REBOA) and mortality in penetrating trauma patients

PURPOSE

The purpose of this study was to examine the association of REBOA and mortality in a group of patients with penetrating trauma to the torso, treated in a level-I trauma center from Colombia.

METHODS

In a retrospective cohort study, patients with penetrating trauma, requiring emergency surgery, and treated between 2014 and 2018, were included. The decision to use or not use REBOA during emergent surgery was based on individual surgeon's opinion. A propensity score (PS) was calculated after adjusting for age, clinical signs on admission (systolic blood pressure, cardiac rate, Glasgow coma scale), severe trauma in thorax and abdomen, and the presence of non-compressive torso hemorrhage. Subsequently, logistic regression for mortality was adjusted for the number of red blood cells (RBC) transfused within the first six hours after admission, injury severity score (ISS), and quintiles of PS.

RESULTS

We included 345 patients; 28 of them (8.1%) were treated with REBOA. Crude mortality rates were 17.9% (5 patients) in REBOA group and 15.3% (48 patients) in control group (p = 0.7). After controlling for RBC transfused, ISS, and the PS, the odds of death in REBOA group was 78% lower than that in the control group (odds ratio [OR] 0.20, 95% confidence interval [95%CI] 0.05-0.77, p = 0.01).

CONCLUSION

We found that, when compared to no REBOA use, patients treated with REBOA had lower risk-adjusted odds of mortality. These findings should be interpreted with caution and confirmed in future comparative studies, if possible.

Potential resuscitative endovascular balloon occlusion of aorta candidates: defining the potential need using the National Trauma Registry

BACKGROUND

Most of the trauma patients who die in the first 24 h from arrival to the hospital do so as a result of haemorrhagic shock. Resuscitative endovascular balloon occlusion of the aorta (REBOA) facilitates expedient proximal aortic control, potentially bridging a needed gap for partial or non-responders to traditional resuscitation en route to emergent definitive haemostasis. This resuscitation tool continues to evolve and has recently achieved some consensus defined indications for its use. The aim of this study is designed to examine the potential utility of REBOA among trauma victims who die within 24 h of arrival.

METHODS

Data of all trauma patients who died in the first 24 h, from 2012 to 2017 were extracted from the National Trauma Registry in the Gertner Institute for Epidemiology and Health Policy Research. Patients who died in the first half an hour, and those with neck and thorax injuries were excluded. Demographics, clinical and injury data were collected.

RESULTS

Overall, 129 patients were included; 74% male and 26% female with the mean age of 46.4 years. A total of 76% suffered blunt trauma and 24% penetrating trauma. Mean survival time was 5.87 h. The cause of death was major abdominal organ injury in 47.2%, injury to major abdominal vessel in 23.3% and pelvic fractures in 21.7%. A total of 69 patients (53.5%) ultimately required delayed resuscitative thoracotomy in the operation room.

CONCLUSION

Registry data suggest that there is a subset of patients presenting to modern trauma centres who might benefit from REBOA in order to avoid death.

Pre-hospital CPR and early REBOA in trauma patients - results from the ABOTrauma Registry

BACKGROUND

Severely injured trauma patients suffering from traumatic cardiac arrest (TCA) and requiring cardiopulmonary resuscitation (CPR) rarely survive. The role of resuscitative endovascular balloon occlusion of the aorta (REBOA) performed early after hospital admission in patients with TCA is not well-defined. As the use of REBOA increases, there is great interest in knowing if there is a survival benefit related to the early use of REBOA after TCA. Using data from the ABOTrauma Registry, we aimed to study the role of REBOA used early after hospital admission in trauma patients who required pre-hospital CPR.

METHODS

Retrospective and prospective data on the use of REBOA were collected from the ABOTrauma Registry from 11 centers in seven countries globally between 2014 and 2019. In all patients with pre-hospital TCA, the predicted probability of survival, calculated with the Revised Injury Severity Classification II (RISC II), was compared with the observed survival rate.

RESULTS

Of 213 patients in the ABOTrauma Registry, 26 patients (12.2%) who had received pre-hospital CPR were identified. The median (range) Injury Severity Score (ISS) was 45.5 (25-75). Fourteen patients (54%) had been admitted to the hospital with ongoing CPR. Nine patients (35%) died within the first 24 h, while seventeen patients (65%) survived post 24 h. The survival rate to hospital discharge was 27% (n = 7). The predicted mortality using the RISC II was 0.977 (25 out of 26). The observed mortality (19 out of 26) was significantly lower than the predicted mortality (p = 0.049). Patients not responding to REBOA were more likely to die. Only one (10%) out of 10 non-responders survived. The survival rate in the 16 patients responding to REBOA was 37.5% (n = 6). REBOA with a median (range) duration of 45 (8-70) minutes significantly increases blood pressure from the median (range) 56.5 (0-147) to 90 (0-200) mmHg.

CONCLUSIONS

Mortality in patients suffering from TCA and receiving REBOA early after hospital admission is significantly lower than predicted by the RISC II. REBOA may improve survival after TCA. The use of REBOA in these patients should be further investigated.

Feasibility study for implementation of resuscitative balloon occlusion of the aorta in peri-arrest, exsanguinating trauma at an adult level 1 Australian trauma centre

OBJECTIVE

This prospective, observational, interventional study sought to determine if the introduction of resuscitative balloon occlusion of the aorta (REBOA) at an Australian adult major trauma centre would improve survival for major trauma patients.

METHODS

Patients aged 18-60 years, transported directly from scene with exsanguinating, sub-diaphragmatic haemorrhage and hypovolaemic shock (systolic BP <70 mmHg or hypovolaemic cardiac arrest) were eligible for recruitment and followed up until hospital discharge (ACTRN12618000550202).

RESULTS

During the 14-month study period (17 January 2015 to 12 March 2016) 3032 patients were admitted direct from scene with an overall mortality of 97 (3.71%). Of these patients 3019 had trauma centre vital signs recorded in the data set (99.57%) and 1523 were between the ages of 18-60, including 143 patients with a shock index of >1.0 (4.74%). There were 13 (0.43%) patients with a systolic BP <70 mmHg and/or cardiorespiratory arrest on arrival. The mortality in this group was six out of 13 (46.15%). Of these 13 patients, there were two (0.07% of the total cohort) where REBOA was attempted. There were no eligible patients for whom REBOA was achieved. None of the six patients who died would have benefited from REBOA deployment.

CONCLUSIONS

Despite considerable training and resource allocation to ensure 24-h availability, the introduction of REBOA failed to effectively demonstrate any impact on patient outcome. Despite retrospective literature supporting the introduction of REBOA, in this 14-month prospective study there was no evidence of benefit. Further studies may define indications and subgroups of patients who may benefit.

Expanding indications and results for the use of resuscitative endovascular balloon occlusion of the aorta - REBOA

Currently, resuscitative endovascular balloon occlusion of the aorta (REBOA) is used in trauma surgery for controlling non-compressible torso hemorrhages, as a less invasive option and with fewer physiologic disturbances compared with an invasive emergent thoracotomy for aortic cross-clamping. This can allow improvements in hemodynamic parameters until definitive surgery is performed. REBOA is also used in trauma to prevent hemodynamic collapse in patients who are in severe hemorrhagic shock, as a method to maintain perfusion of the brain and heart while decreasing distal bleeding until hemorrhage control can take place. The major complications reported are acute kidney injury, lower leg amputations, and even death. As experience with REBOA in emergency surgery grows, new indications have been described in the literature. The aim of this study was to assess the expansion of the use of REBOA in other areas of medicine, as well as evaluating the current published series. We performed an online search of PubMed, Medline and SciELO with the term "REBOA" in the last five years, and the articles included were the 14 specifically describing the use of REBOA for non-traumatic conditions. The results suggest that the use of REBOA led to improved bleeding control and increased arterial pressure, reducing blood transfusion requirements and allowing patients to survive to definitive treatment of injuries. In conclusion, the expanded use of REBOA for non-traumatic emergencies appears to be effective. However, prospective studies and well-established protocols for specific indications should be developed to maximize patient outcomes.

Clinical use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in civilian trauma systems in the USA, 2019: a joint statement from the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, the National Association of Emergency Medical Services Physicians and the National Association of Emergency Medical Technicians

This is a joint statement from the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, the National Association of Emergency Medical Services Physicians and the National Association of Emergency Medical Technicians regarding the clinical use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in civilian trauma systems in the USA. This statement addresses the system of care needed to manage trauma patients requiring the use of REBOA, in light of the current evidence available in this patient population. This statement was developed by an expert panel following a comprehensive review of the literature with representation from all sponsoring organizations and the US Military. This is an update to the previous statement published in 2018. It has been formally endorsed by the four sponsoring organizations.

'Step Up' approach to the application of REBOA technology in a rural

Our group has developed a ‘Step Up’ approach to the application of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in a rural trauma system. This incorporates viewing REBOA as a spectrum of technology. Examples of REBOA technology use to improve outcomes and provision of our system’s clinical practice guideline for the Step-Up application of REBOA technology in the care of trauma patients are presented.

Resuscitative Endovascular Balloon Occlusion of the Aorta: Review of the Literature and Applications to Veterinary Emergency and Critical Care

While hemorrhagic shock might be the result of various conditions, hemorrhage control and resuscitation are the corner stone of patient management. Hemorrhage control can prove challenging in both the acute care and surgical settings, especially in the abdomen, where no direct pressure can be applied onto the source of bleeding. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as a promising replacement to resuscitative thoracotomy (RT) for the management of non-compressible torso hemorrhage in human trauma patients. By inflating a balloon at specific levels (or zones) of the aorta to interrupt blood flow, hemorrhage below the level of the balloon can be controlled. While REBOA allows for hemorrhage control and augmentation of blood pressure cranial to the balloon, it also exposes caudal tissue beds to ischemia and the whole body to reperfusion injury. We aim to introduce the advantages of REBOA while reviewing known limitations. This review outlines a step-by-step approach to REBOA implementation, and discusses common challenges observed both in human patients and during translational large animal studies. Currently accepted and debated indications for REBOA in humans are discussed. Finally, we review possible applications for veterinary patients and how REBOA has the potential to be translated into clinical veterinary practice.

For debate: advanced bleeding control potentially saves lives in armed forces and should be considered

INTRODUCTION

Advanced bleeding control options for truncal and junctional haemorrhage including resuscitative endovascular balloon occlusion of the aorta (REBOA) have been used in managing catastrophic bleeding. The primary aim is to report on potential indications for advanced bleeding control in combat casualties during the Dutch deployment in Uruzgan, Afghanistan, between August 2006 and August 2010. The secondary aim is to report on training methods for advanced bleeding control in (para)medical personnel.

METHODS

The trauma registry from the Dutch role 2 enhanced medical treatment facility at Tarin Kowt, Uruzgan, Afghanistan, was used to analyse patients who sustained a battle injury with major haemorrhage. Furthermore, a comprehensive search was performed on training (para)medical personnel in advanced bleeding control.

RESULTS

There were 212 possible indications for advanced bleeding control with mortality of 28.8% (61/212). These possible indications consisted of 1.9% (4/212) junctional lower extremity injuries with a 75% (3/4) mortality rate, 59% (125/212) visceral vascular injuries with a mortality rate of 12.5% (26/125). The junctional and visceral injuries (n=129) were all potential indications for advanced bleeding control options, such as REBOA. Further 39.2% (83/212) casualties with central thoracic or neck injuries had a mortality rate of 38.6% (32/83). Based on an Abbreviated Injury Scale chest or abdomen score ≥461 indications for advanced bleeding control were identified. A 24-hour average of 8.8 packets of red blood cells, 4.2 packets of plasma and 1.9 packets of platelets was used to prevent exsanguination. The total out-of-hospital survival rate was 64% (39/61).

CONCLUSION

Retrospective analysis revealed 212 potential indications for advanced bleeding control with a mortality of 28.8% (61/212). Advanced bleeding control, such as REBOA, might have improved survival in approximately 61 of 212 casualties. Advanced bleeding control could be used as an adjunct to improve outcomes in major truncal or junctional haemorrhage in prehospital, remote settings and implementation should be considered. Vascular access training and REBOA placement for (para)medical military personnel should be explored in future research.

Consensus on resuscitative endovascular balloon occlusion of the Aorta: A first consensus paper using a Delphi method

BACKGROUND

To further strengthen the evidence base on the use of Resuscitative Endovascular Balloon occlusion of the Aorta (REBOA) we performed a Delphi consensus. The aim of this paper is to establish consensus on the indications and contraindications for the use of REBOA in trauma and non-trauma patients based on the existing evidence and expertise.

STUDY DESIGN

A literature review facilitated the design of a three-round Delphi questionnaire. Delphi panelists were identified by the investigators. Consensus was reached when at least 70% of the panelists responded to the survey and more than 70% of respondents reached agreement or disagreement.

RESULTS

Panel members reached consensus on potential indications, contra-indications and settings for use of REBOA (excluding the pre hospital environment), physiological parameters for patient selection and indications for early femoral access. Panel members failed to reach consensus on the use of REBOA in patients in extremis (no pulse, no blood pressure) and the use of REBOA in patients with two major bleeding sites.

CONCLUSIONS

Consensus was reached on indications, contra indications, physiological parameters for patient selection for REBOA and early femoral access. The panel did not reach consensus on the use of REBOA in patients in pre-hospital settings, patients in extremis (no pulse, no blood pressure) and in patients with 2 or more major bleeding sites. Further research should focus on the indications of REBOA in pre hospital settings, patients in near cardiac arrest and REBOA inflation times.