52 in 52 – #17: REBOA for Proximal Aortic Control in Patients with Severe Hemorrhage and Arrest
- Oct 27th, 2022
- Christiaan van Nispen
- categories:
Welcome back to the “52 in 52” series. This collection of posts features recently published must-know articles. Our seventeenth post looks at using REBOA for proximal aortic control in patients with severe hemorrhage and arrest.
Author: Christiaan van Nispen, MD (Emergency Medicine Physician Resident, San Antonio, TX) and Brannon Inman (Chief Resident, Emergency Medicine Physician, San Antonio, TX) // Reviewed by: Alex Koyfman, MD (@EMHighAK); Brit Long, MD (@long_brit)
Use of Resuscitative Endovascular Balloon Occlusion of the Aorta for Proximal Aortic Control in Patients with Severe Hemorrhage and Arrest1
Question:
In patients with severe hemorrhage and arrest, is resuscitative endovascular balloon occlusion of the aorta (REBOA) a feasible option for proximal aortic control?
Design: Single-center, prospective, observational cohort feasibility study
PICO
Population:
- Prospectively enrolled all patients who received REBOA for severe traumatic hemorrhage, traumatic arrest, and non-traumatic hemorrhage
- Intra-abdominal hemorrhage was presumed with positive or equivocal results from FAST (Focused Assessment with Sonography for Trauma).
- Exclusion criteria
- Ruptured abdominal aortic aneurysms
- Major intrathoracic injury was excluded using chest radiography and ultrasonography
- Data collection from 2013 to 2017 at one center in Baltimore, Maryland
Intervention:
- Placement of REBOA balloon
- Procedure performed by acute care or vascular surgeons
- For hemorrhage below the diaphragm or if the patient is a traumatic arrest REBOA was placed in the distal thoracic aorta (zone 1)
- For hemorrhage at or below the level of the pelvis REBOA was placed in the distal abdominal aorta (zone 3)
- Initially, a 260-cm stiff guidewire, 12F catheter sheath, and 32-mm compliant balloon were used
- In the final 11 months of the study, the ER-REBOA (a Food and Drug Administration-approved, wire-free device) was used exclusively
Control:
- No control group in the study
- The manuscript alludes to resuscitative thoracotomy with aortic cross-clamping as the alternative standard of care
- This manuscript uses historical literature for outcomes of resuscitative thoracotomy as a loose comparator
Outcome:
- Technical success (placement of aortic balloon in the desired location, as above) achieved in 83% of patients
- Mean systolic blood pressure improved by 63.4 mm Hg after aortic occlusion in severe traumatic hemorrhage and by 55.9 mm Hg in traumatic arrest (no data provided for SBP improvement in pelvic hemorrhage)
- Mean duration of aortic occlusion was 53 minutes; only one patient survived after aortic occlusion lasting longer than one hour
- 56% mortality rate observed in those with severe traumatic hemorrhage and/or traumatic arrest who underwent REBOA, but specifically in the severe traumatic hemorrhage group was 41%
Take Aways:
- Mortality in patients suffering severe hemorrhage or traumatic arrest treated with REBOA appears improved compared to estimates from other studies regarding to mortality in similar patients treated with resuscitative thoracotomy.2
- Many of the REBOAs were placed via direct cut-down, a method not commonly used by emergency physicians in the age of ultrasound.
- Clinicians performing the procedure in this study were acute care or vascular surgeons; no emergency physicians took part in the performance of these procedures.
- The study does not directly compare REBOA to alternative treatments therefore it is technically not possible to imply superiority or noninferiority.
- It would have been helpful to see more data regarding relevant outcomes beyond in-hospital mortality, including complications.
My Take:
- REBOA may be a viable temporizing option for severe subdiaphragmatic hemorrhage.
- Though not studied here, thoracotomy seems the preferable option if severe thoracic hemorrhage and/or cardiac tamponade are considered. These patients were excluded from the study.
- Studies contrasting mortality outcomes for REBOA versus thoracotomy with aortic cross-clamping for subdiaphragmatic hemorrhage are needed to make more declarative comparisons (one of the authors in this study was the first author on an additional study comparing the two, but used a less-than-ideal marker of “total duration of interruptions of cardiac compressions” as the outcome of interest rather than mortality or other patient-centered outcomes).3
References:
- Brenner M, Teeter W, Hoehn M, et al. Use of Resuscitative Endovascular Balloon Occlusion of the Aorta for Proximal Aortic Control in Patients with Severe Hemorrhage and Arrest. JAMA Surg. 2018;153(2):130-135. Doi: 10.1001/jamasurg.2017.3549
- Boddaert G, Hornez E, De Lesquen H, et al. Resuscitation thoracotomy. J Visc Surg. 2017;154 Suppl 1:S34-S41. Doi: 10.1016/j,jviscsurg.2017.07.003
- Teeter W, Romagnoli A, Wasicek P, et al. Resuscitative Endovascular Balloon Occlusion of the Aorta Improves Cardiac Compression Fraction Versus Resuscitative Thoracotomy in Patients in Traumatic Arrest. Ann Emerg Med. 2018;72(4):354-360. Doi: 10.1016/j.annemergmed.2018.02.020
