Resuscitative endovascular balloon occlusion of the aorta associated with improved survival in hemorrhagic shock

Current trends in the management of out of hospital cardiac arrest (OHCA)

Sudden cardiac arrest remains a relevant problem with a significant number of deaths worldwide. Although survival rates have more than tripled over the last 20 years (4% in 2001 vs. 14% in 2020), survival rates with good neurological outcomes remain persistently low, representing a major socioeconomic problem. Every minute of delay from patient collapse to start cardiopulmonary resuscitation (CPR) and early defibrillation reduces the chance of survival by approximately 10-12%. Therefore, the time to treatment is a crucial factor in the prognosis of patients with out-of-hospital cardiac arrest (OHCA). Research teams working in the pre-hospital setting are therefore looking for ways to improve the transmission of information from the site of an emergency event and to make it easier for emergency medical dispatch centres (EMDC) to recognise life-threatening conditions with minimal deviation. For emergency unit procedures already at the scene of the event, methods are being sought to efficiently and temporarily replace a non-functioning cardiopulmonary system. In the case of traumatic cardiac arrest (TCA), the focus is mainly on effective affecting non-compressible haemorrhage.

The Role of Resuscitative Endovascular Balloon Occlusion of the Aorta

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been utilized by trauma surgeons at the bedside for over a decade in both civilian and military settings. Both translational and clinical research suggest it is superior to resuscitative thoracotomy for specific patient populations. Technological advancements in recent years have significantly enhanced the safety profile of REBOA. Resuscitative balloon occlusion of the aorta has also swiftly found implementation in patients in shock from non-traumatic hemorrhage.

Balloon Rises Above: REBOA at Zone 1 May Be Superior to Resuscitative Thoracotomy

BACKGROUND

The use of Zone 1 REBOA for life-threatening trauma has increased dramatically.

STUDY DESIGN

The Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database was queried for blunt and penetrating trauma between 2013 and 2021. Outcomes were examined both for mechanisms of injury combined and separately and for combinations of abdominal injury with and without traumatic brain injury and chest injuries (Abbreviated Injury Scale [AIS] score >2).

RESULTS

A total of 531 patients underwent REBOA (408 with blunt injury and 123 with penetrating injury) and 1,603 (595 with blunt injury and 1,008 with penetrating injury) underwent resuscitative thoracotomy (RT). Mean age was 38.5 ± 16 years and mean injury severity score was 34.5 ± 21; 57.7% had chest AIS score of more than 2, 21.8% had head AIS score of more than 2, and 37.3% had abdominal AIS score of more than 2. Admission Glasgow Coma Scale was 4.9 + 4, and systolic blood pressure at aortic occlusion (AO) was 22 + 40 mmHg. No differences in outcomes in REBOA or RT patients were identified between institutions (p > 0.5). After inverse probability weighting, Glasgow Coma Scale, age, injury severity score, systolic blood pressure at AO, CPR at AO, and blood product transfusion, REBOA was superior to RT in both blunt (odds ratio [OR] 4.7, 95% CI 1.9 to 11.7) and penetrating (OR 4.9, 95% CI 1.7 to 14) injuries, across all spectrums of injury (p < 0.01). Overall mortality was significantly higher for AO more than 90 minutes compared with less than 30 minutes in blunt (OR 4.6, 95% CI 1.5 to 15) and penetrating (OR 5.4, 95% CI 1.1 to 25) injuries. Duration of AO more than 60 minutes was significantly associated with mortality after penetrating abdominal injury (OR 5.1, 95% CI 1.1 to 22) and abdomen and head (OR 5.3, 95% CI 1.6 to 18).

CONCLUSIONS

In-hospital survival is higher for patients undergoing REBOA than RT for all injury patterns. Complete AO by REBOA or RT should be limited to less than 30 minutes. Neither hospital and procedure volume nor trauma verification level impacts outcomes for REBOA or RT.

Complications associated with the use of resuscitative endovascular balloon occlusion of the aorta (REBOA): an updated review

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has become part of the arsenal to temporize patients in shock from severe hemorrhage. REBOA is used in trauma to prevent cardiovascular collapse by preserving heart and brain perfusion and minimizing distal hemorrhage until definitive hemorrhage control can be achieved. Significant side effects, including death, ischemia and reperfusion injuries, severe renal and lung damage, limb ischemia and amputations have all been reported. The aim of this article is to provide an update on complications related to REBOA. REBOA has emerged as a critical intervention for managing severe hemorrhagic shock, aiming to temporize patients and prevent cardiovascular collapse until definitive hemorrhage control can be achieved. However, this life-saving procedure is not without its challenges, with significant reported side effects. This review provides an updated overview of complications associated with REBOA. The most prevalent procedure-related complication is distal embolization and lower limb ischemia, with an incidence of 16% (range: 4-52.6%). Vascular and access site complications are also noteworthy, documented in studies with incidence rates varying from 1.2% to 11.1%. Conversely, bleeding-related complications exhibit lower documentation, with incidence rates ranging from 1.4% to 28.6%. Pseudoaneurysms are less likely, with rates ranging from 2% to 14%. A notable incidence of complications arises from lower limb compartment syndrome and lower limb amputation associated with the REBOA procedure. Systemic complications include acute kidney failure, consistently reported across various studies, with incidence rates ranging from 5.6% to 46%, representing one of the most frequently documented systemic complications. Infection and sepsis are also described, with rates ranging from 2% to 36%. Pulmonary-related complications, including acute respiratory distress syndrome and multisystem organ failure, occur in this population at rates ranging from 7.1% to 17.5%. This comprehensive overview underscores the diverse spectrum of complications associated with REBOA.

Early experience with resuscitative endovascular balloon occlusion of the aorta for unstable pelvic fractures in the Republic of Korea: a multi-institutional study

PURPOSE

Recently, trauma centers in the Republic of Korea introduced resuscitative endovascular balloon occlusion of the aorta (REBOA) for application in severe pelvic fracture cases. This study aimed to determine the efficacy of REBOA and its associated factors in enhancing survival.

METHODS

Data from patients with severe pelvic injuries at two regional trauma centers from 2016 to 2020 were retrospectively reviewed. Patients were dichotomized into REBOA and no-REBOA groups, and patient characteristics and clinical outcomes were compared using 1:1 propensity score matching. Additional survival-based analysis was performed in the REBOA group.

RESULTS

REBOA was performed in 42 of the 174 patients with pelvic fractures. As patients in the REBOA group had more severe injuries than did patients in the no-REBOA group, 1:1 propensity score matching was performed to adjust for severity. After matching, 24 patients were included in each group and mortality was not significantly different (REBOA 62.5% vs. no-REBOA 41.7%, P = 0.149). Kaplan-Meier analysis revealed no significant differences in mortality between the two matched groups (log-rank test, P = 0.408). Among the 42 patients treated with REBOA, 14 survived. Shorter REBOA duration (63 [40-93] vs. 166 [67-193] min, P = 0.015) and higher systolic blood pressure before REBOA (65 [58-76] vs. 54 [49-69] mmHg, P = 0.035) were associated with better survival.

CONCLUSIONS

The effectiveness of REBOA has not been definitively established; however, it was not associated with increased mortality in this study. Additional studies are required to better understand how REBOA can be effectively used for treatment.

Use of Tranexamic Acid With Resuscitative Endovascular Balloon Occlusion of the Aorta is Associated With Higher Distal Embolism Rates: Results From the American Association of Surgery for Trauma Aortic Occlusion and Resuscitation for Trauma and Acute Care Surgery Trial

INTRODUCTION

Tranexamic acid (TXA) use has been associated with thrombotic complications.

OBJECTIVE

We aim to investigate outcomes associated with TXA use in the setting of high- (HP) and low-profile (LP) introducer sheaths for resuscitative endovascular balloon occlusion of the aorta (REBOA).

PARTICIPANTS

The Aortic Occlusion and Resuscitation for Trauma and Acute Care Surgery (AORTA) database was queried for patients who underwent REBOA using a low-profile 7 French (LP) or high-profile, 11-14 French (HP) introducer sheaths between 2013 and 2022. Demographics, physiology, and outcomes were examined for patients who survived beyond the index operation.

RESULTS

574 patients underwent REBOA (503 LP, 71 HP); 77% were male, mean age was 44 ± 19 and mean injury severity score (ISS) was 35 ± 16. 212 patients received TXA (181 [36%] LP, 31 [43.7%] HP). There were no significant differences in admission vital signs, GCS, age, ISS, SBP at AO, CPR at AO, and duration of AO among LP and HP patients. Overall, mortality was significantly higher in the HP (67.6%) vs the LP group (54.9%; P = .043). Distal embolism was significantly higher in the HP group (20.4%) vs the LP group (3.9%; P < .001). Logistic regression demonstrated that TXA use was associated with a higher rate of distal embolism in both groups (OR = 2.92; P = .021). 2 LP patients (one who received TXA) required an amputation.

CONCLUSION

Patients who undergo REBOA are profoundly injured and physiologically devastated. Tranexamic acid was associated with a higher rate of distal embolism in those who received REBOA, regardless of access sheath size. For patients receiving TXA, REBOA placement should be accompanied by strict protocols for immediate diagnosis and treatment of thrombotic complications.

Resuscitative balloon occlusion of the aorta in the modern era: Expanding indications, optimal techniques, unresolved issues, and current results

Resuscitative endovascular balloon occlusion of the aorta has been used by trauma surgeons at the bedside for more than a decade in civilian and military settings. Translational and clinical research suggests it is superior to resuscitative thoracotomy for select patients. Clinical research suggests outcomes are superior in patients who received resuscitative balloon occlusion of the aorta compared with those who did not. Technology has advanced considerably in the past several years, leading to the improved safety profile and wider adoption of resuscitative balloon occlusion of the aorta. In addition to trauma patients, resuscitative balloon occlusion of the aorta has been rapidly implemented for patient with nontraumatic hemorrhage.

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition

BACKGROUND

Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation.

RESULTS

This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury.

CONCLUSION

A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.

Endovascular Balloon Occlusion of the Inferior Vena Cava in Trauma: A Single-Center Case Series

Injury to the inferior vena cava (IVC) can produce bleeding that is difficult to control. Endovascular balloon occlusion provides rapid vascular control without extensive dissection and may be useful in large venous injuries, especially in the juxtarenal IVC. We describe the procedural steps, technical considerations, and clinical scenarios for using the Bridge occlusion balloon (Philips) in IVC trauma. We present a single-center case series of 5 patients in which endovascular balloon occlusion of the IVC was used for hemorrhage control. All 5 patients were men (median age 35, range 22 to 42 years). They all sustained penetrating injuries-4 gunshot wounds and 1 stab wound. Median presenting Shock Index was 0.7 (range 0.5 to 1.5). Median initial lactate was 5.4 mmol/L (range 4.6 to 6.9 mmol/L). There were 2 suprarenal IVC injuries, 2 juxtarenal injuries, and 3 infrarenal injuries. Four patients underwent primary repair of their injury, and one underwent IVC ligation. Four patients had intraoperative Resuscitative Endovascular Balloon Occlusion of the Aorta for inflow control and afterload support. The median number of total blood products transfused during the initial operation was 37 units (range 16 to 77 units). Four patients underwent damage control operations, and one patient had a single definitive operation. Four of the 5 patients (80%) survived to discharge with the lone mortality being due to other injuries. Endovascular balloon occlusion serves as a valuable adjunct in the management of IVC injury and demonstrates the potential of hybrid open-endovascular operative techniques in abdominal vascular trauma.

Zone 1 Endovascular Balloon Occlusion of the Aorta vs Resuscitative Thoracotomy for Patient Resuscitation After Severe Hemorrhagic Shock

Importance

Aortic occlusion (AO) is a lifesaving therapy for the treatment of severe traumatic hemorrhagic shock; however, there remains controversy whether AO should be accomplished via resuscitative thoracotomy (RT) or via endovascular balloon occlusion of the aorta (REBOA) in zone 1.

Objective

To compare outcomes of AO via RT vs REBOA zone 1.

Design, Setting, and Participants

This was a comparative effectiveness research study using a multicenter registry of postinjury AO from October 2013 to September 2021. AO via REBOA zone 1 (above celiac artery) was compared with RT performed in the emergency department of facilities experienced in both procedures and documented in the prospective multicenter Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry. Propensity score matching (PSM) with exact institution matching was used, in addition to subgroup multivariate analysis to control for confounders. The study setting included the ED, where AO via RT or REBOA was performed, and participants were adult trauma patients 16 years or older.

Exposures

AO via REBOA zone 1 vs RT.

Main Outcomes and Measures

The primary outcome was survival. Secondary outcomes were ventilation-free days (VFDs), intensive care unit (ICU)-free days, discharge Glasgow Coma Scale score, and Glasgow Outcome Score (GOS).

Results

A total of 991 patients (median [IQR] age, 32 [25-48] years; 808 male individuals [81.9%]) with a median (IQR) Injury Severity Score of 29 (18-50) were included. Of the total participants, 306 (30.9%) had AO via REBOA zone 1, and 685 (69.1%) had AO via RT. PSM selected 112 comparable patients (56 pairs). REBOA zone 1 was associated with a statistically significant lower mortality compared with RT (78.6% [44] vs 92.9% [52]; P = .03). There were no significant differences in VFD greater than 0 (REBOA, 18.5% [10] vs RT, 7.1% [4]; P = .07), ICU-free days greater than 0 (REBOA, 18.2% [10] vs RT, 7.1% [4]; P = .08), or discharge GOS of 5 or more (REBOA, 7.5% [4] vs RT, 3.6% [2]; P = .38). Multivariate analysis confirmed the survival benefit of REBOA zone 1 after adjustment for significant confounders (relative risk [RR], 1.25; 95% CI, 1.15-1.36). In all subgroup analyses (cardiopulmonary resuscitation on arrival, traumatic brain injury, chest injury, pelvic injury, blunt/penetrating mechanism, systolic blood pressure ≤60 mm Hg on AO initiation), REBOA zone 1 offered an either similar or superior survival.

Conclusions and Relevance

Results of this comparative effectiveness research suggest that REBOA zone 1 provided better or similar survival than RT for patients requiring AO postinjury. These findings provide the ethically necessary equipoise between these therapeutic approaches to allow the planning of a randomized controlled trial to establish the safety and effectiveness of REBOA zone 1 for AO in trauma resuscitation.