Resuscitative endovascular balloon occlusion of the aorta (REBOA) is associated with improved survival in severely injured patients: A propensity score matching analysis
Introduction
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a technique for temporary control of arterial hemorrhage which maintains cerebral and coronary perfusion while improving hemodynamic stability in trauma victims.1, 2, 3, 4 This relatively less invasive method has developed to broad applications including traumatic arrest,5 subdiaphragmatic hemorrhage,6 combat casualties,7,8 and prehospital management9,10 since the first report in 1954.11 While various investigators have challenged the optimal situation where REBOA can be applied as an effective treatment,1,3,5,12, 13, 14 recent literature suggests that REBOA may be indicated as an alternative to cross-clamping the proximal aorta via resuscitative thoracotomy (RT), or an adjunct for life-threatening hemorrhage below the diaphragm.1,15
Despite the improvement of technology and increasing popularity in REBOA,2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14,16 there is considerable debate regarding improved clinical outcomes for severely injured patients managed by REBOA.1, 2, 3,12,17,18 An analysis in 2015 using the American Association for the Surgery of Trauma (AAST) Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery (AORTA) database revealed no difference in survival between REBOA and RT groups,12 and other database analyses demonstrated that REBOA treatment was associated with higher in-hospital mortality compared with patients treated without REBOA.17,18 Although a more recent study using the AAST AORTA database found a survival benefit of REBOA compared with RT in hypotensive patients not requiring cardiopulmonary resuscitation (CPR), these results may not be universally applicable since the majority of REBOA cases enrolled in the study were treated at only two institutions.1
Furthermore, given that REBOA provides only temporary hemostasis and definitive therapy always needs to follow, some limitations should be considered in determining the optimal study design that can validate the efficacy of REBOA. First, comparing REBOA with cross-clamping the aorta through RT is not ideal since definitive hemostasis can be achieved with simultaneous procedures, such as cardiorrhaphy, aortorrhaphy, and pulmonary resection in patients with RT, but not with REBOA. Second, in retrospective or observational studies, the clinical outcome of death after trauma might be significantly modified by factors other than REBOA, including physiological signs, severity of injuries, procedures for definitive hemostasis, and even the fact that the REBOA catheter can be placed prior to other surgical procedures. Third, although some studies may support the superiority of REBOA over RT, the possibility that equal or better outcomes could be obtained without REBOA or RT must be considered and not all studies evaluate this possibility.
Accordingly, in an effort to verify the efficacy of REBOA on severely injured patients, we examined outcomes in patients treated with REBOA compared with those treated without REBOA, using propensity score matching analysis that offered the most reliable method in a retrospective study for reducing the effects of confounding factors. We hypothesized that REBOA would improve in-hospital survival in trauma victims, applied in conjunction with other standard trauma resuscitation and hemostasis procedures.
Section snippets
Study design and setting
We conducted a retrospective cohort study using data from the Japan Trauma Data Bank (JTDB). The JTDB was established as a Japanese nationwide trauma registry in 2003 and has been maintained by the Japanese Association for the Surgery of Trauma and the Japanese Association for Acute Medicine, in which more than 200 major hospitals including tertiary care centers participate currently. Data were collected prospectively and entered by treating physicians or volunteer registrars designated by each
Results
After the screening process, a total of 88,701 trauma patients who presented to collaborating hospitals during the study period were identified and included in the study. Among them, 417 (0.5%) patients underwent REBOA treatment in conjunction with other standard resuscitation. Six thousand three hundred and thirty patients were excluded due to missing or unknown survival data. The patient flow diagram is summarized in Fig. 1.
A total of 82,371 patients were eligible for this study, among whom
Discussion
In this study, we used propensity score matching to show that REBOA was independently associated with improved in-hospital survival in trauma patients. To the best of our knowledge, this is the first study to have reported this relationship using robust statistical methods on a large nationwide trauma database. Notably, the observed relationship was consistent in the survival at 28 days, and a significantly low hazard ratio of death from REBOA was detected among patients who survived the first
Conclusions
In severely injured trauma patients, REBOA use was associated with improved survival to discharge as well as at 28 days after injury. The use of REBOA should therefore be considered in conjunction with trauma resuscitation during the management of severely injured trauma patients.
Funding
This study was supported in part by a research grant on traffic accident from the General Insurance Association of Japan.
Data statement
The data of this study are available from the Japanese Association for Trauma Surgery and the Japanese Association for Acute Medicine, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the Japanese Association for Trauma Surgery and the Japanese Association for Acute Medicine.
Conflicts of interest
The authors have no conflict of interest to report.
References (28)
- et al.
Resuscitative endovascular balloon occlusion of the aorta and resuscitative thoracotomy in select patients with hemorrhagic shock: early results from the American association for the surgery of trauma's aortic occlusion in resuscitation for trauma and Acute care surgery registry
J Am Coll Surg
(2018) - et al.
Resuscitative endovascular balloon occlusion of the aorta: implementation and preliminary results at an academic level I trauma center
J Am Coll Surg
(2018) - et al.
Impact of self-inflicted injury on nontherapeutic laparotomy in patients with abdominal stab wounds
Injury
(2018) - et al.
Endovascular balloon occlusion of the aorta is superior to resuscitative thoracotomy with aortic clamping in a porcine model of hemorrhagic shock
Surgery
(2011) - et al.
A systematic review and meta-analysis of the use of resuscitative endovascular balloon occlusion of the aorta in the management of major exsanguination
Eur J Trauma Emerg Surg
(2018) - et al.
Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock
J Trauma
(2011) - et al.
Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage
J Trauma Acute Care Surg
(2015) - 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) - et al.
REBOA at Role 2 Afloat: resuscitative endovascular balloon occlusion of the aorta as a bridge to damage control surgery in the military maritime setting
J R Army Med Corps
(2018) - et al.
Recent advances in austere combat surgery: use of aortic balloon occlusion as well as blood challenges by special operations medical forces in recent combat operations
J Trauma Acute Care Surg
(2018)