Intraoperative REBOA: an analysis of the American Association for the Surgery of Trauma AORTA registry

Abstract

BackgroundResuscitative endovascular balloon occlusion of the aorta (REBOA) is a less-invasive technique for aortic occlusion (AO). Commonly performed in the emergency department (ED), the role of intraoperative placement is less defined. We hypothesized that operating room (OR) placement is associated with increased in-hospital mortality.MethodsThe American Association for the Surgery of Trauma AORTA registry was used to identify patients undergoing REBOA. Injury characteristics and outcomes data were compared between OR and ED groups. The primary outcome was in-hospital mortality; secondary outcomes included total AO time, transfusion requirements, and acute kidney injury.ResultsLocation and timing of catheter insertion were available for 305 of 321 (95%) subjects. 58 patients underwent REBOA in the OR (19%). There were no differences with respect to sex, admission lactate, and Injury Severity Score. The OR group was younger (33 years vs. 41 years, p=0.01) and with more penetrating injuries (36% vs. 15%, p<0.001). There were significant differences with respect to admission physiology. Time from admission to AO was longer in the OR group (75 minutes vs. 23 minutes, p<0.001) as was time to definitive hemostasis (116 minutes vs. 79 minutes, p=0.01). Unadjusted mortality was lower in the OR group (36.2% vs. 68.8%, p<0.001). There were no differences in secondary outcomes. After controlling for covariates, there was no association between insertion location and in-hospital mortality (OR 1.8, 95% CI 0.30 to 11.50).DiscussionOR REBOA placement is common and generally employed in patients with more stable admission physiology. OR placement was not associated with increased in-hospital mortality despite longer times to AO and definite hemostasis when compared with catheters placed in the ED.Level of evidenceIV; therapeutic/care management.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) in patients with major trauma and uncontrolled haemorrhagic shock: a systematic review with meta-analysis

“…Furthermore, many variables can affect survival in this category of patients: pre-hospital time, prompt recognition of bleeding site(s), availability of expert surgeon, time to operating room, appropriate transfusion protocol, physiology of the patient. Time to operating room and physiologic state of patients may predict outcome as importantly as does whether a REBOA is used [ 41 ]. Due to these considerations, further investigations with an adequate volume of cases considering all possible confounders can help to understand the efficacy of REBOA in torso haemorrhages.…”

Determination of optimal deployment strategy for REBOA in patients with non-compressible hemorrhage below the diaphragm

“… 16 17 The rate of AKI in REBOA, specifically, has been previously reported to be 19% in a cohort with an in-hospital mortality rate of 63%. 18 Although the rate of AKI in the subjects of our study is much higher, the total mortality rate is much lower (49.1%). We find it paramount to note that complications such as AKI and MOF can only develop in a patient that is alive and in the ICU.…”

Hate to Burst Your Balloon: Successful REBOA Use Takes More Than a Course

“…First, individual trauma surgeons have varied practices with regards to the management of the hypotensive trauma patient, and surgeons with prior REBOA experience may be more likely to choose this intervention. Two patients had REBOA placed despite not meeting algorithm indications as they were never hypotensive; however, these were placed due to intraoperative hemorrhage and previous research has found that intraoperative REBOA placements are more likely to occur in patients with stable initial hemodynamics [17]. Two patients had REBOA placed despite widened mediastinum on CXR.…”