Practice, Practice, Practice! Effect of Resuscitative Endovascular Balloon Occlusion of the Aorta Volume on Outcomes: Data From the AAST AORTA Registry

doi:10.1016/j.jss.2020.03.027

Journal of Surgical Research

Volume 253, September 2020, Pages 18-25

https://doi.org/10.1016/j.jss.2020.03.027 Get rights and content

Abstract

Background

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an endovascular adjunct to hemorrhage control. Success relies on institutional support and focused training in arterial access. We hypothesized that hospitals with higher REBOA volumes will be more successful than low-volume hospitals at aortic occlusion with REBOA.

Methods

This is a retrospective study from the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery Registry from November 2013 to January 2018. Patients aged ≥18 y who underwent REBOA were included. Successful placement of REBOA catheters (defined as hemodynamic improvement with balloon inflation) was compared between high-volume (≥80 cases; two hospitals), mid-volume (10-20 cases; four hospitals), and low-volume (<10 cases; 14 hospitals) hospitals, adjusting for patient factors.

Results

Of 271 patients from 20 hospitals, 210 patients (77.5%) had successful REBOA placement. Most patients were male (76.0%) and sustained blunt trauma (78.1%). cardiopulmonary resuscitation (CPR) was ongoing at the time of REBOA placement in 34.5% of patients. Inpatient mortality was 67.4%, unchanged by hospital volume. Multivariable logistic regression found increased odds of successful REBOA placement at high-volume versus low-volume hospitals (odds ratio [OR], 7.50; 95% confidence interval [CI], 2.10-27.29; P = 0.002) and mid-volume versus low-volume hospitals (OR, 7.82; 95% CI, 1.52-40.31; P = 0.014) and decreased odds among patients undergoing CPR during REBOA placement (OR, 0.10; 95% CI, 0.03-0.34; P < 0.001) when adjusting for age, sex, mechanism of injury, prehospital CPR, CPR on admission, transfer status, hospital location of REBOA placement, Glasgow Coma Scale ≤ 13, and injury severity.

Conclusions

Hospitals with higher REBOA volumes were more likely to achieve hemodynamic improvement with REBOA inflation. However, mortality and complication rates were unchanged. Independent of hospital volume, ongoing CPR is associated with a decreased odds of successful REBOA placement.

Introduction

Multiple studies have evaluated the effect of hospital and procedural volume on outcomes for a variety of procedures, including emergency general surgery operations,¹ pancreaticoduodenectomies,² robotic lobectomies,³ open abdominal aortic aneurysm repair,⁴ and emergency department thoracotomy,⁵ finding improved outcomes at higher-volume hospitals.⁶ Resuscitative endovascular balloon occlusion of the aorta (REBOA) is rapidly gaining widespread use throughout the United States,7, 8, 9 and as more nuanced indications for its use are identified, it is likely to be used in large trauma centers as well as smaller, community hospitals. The effects of hospital volume of REBOA procedures on outcomes of patients undergoing REBOA are unknown.

Placing a REBOA catheter involves gaining common femoral arterial access and inserting a sheath through which the REBOA device is inserted and advanced into one of two ideal landing zones for aortic occlusion. Which zone is selected is determined by the physician's suspicion for the most likely source of hemorrhage. Once inflated, REBOA provides time-sensitive hemorrhage control while the patient proceeds to definitive treatment. Successful aortic occlusion with REBOA begins with identifying patients who may benefit, mobilizing the trauma team to perform the procedure, and getting the patient to definitive hemorrhage control. This requires coordination between trauma surgeons and emergency medicine physicians, as well as operating room and emergency department nurses and technicians.

Given these multiple institutional factors, we hypothesized that success of REBOA placement will depend on the frequency of REBOA utilization at an institution, and that successful aortic occlusion will be higher at high REBOA–volume versus low REBOA–volume hospitals.

Section snippets

Methods

This is a retrospective study of data from the American Association for the Surgery of Trauma (AAST) Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) Registry, approved by the AAST Multicenter Trials Committee. The AORTA registry is a multiinstitutional registry developed to prospectively collect data on patients undergoing aortic occlusion via open and endovascular techniques. Data were collected from November 2013 to January 2018 from collaborating hospitals in the

Results

From the AORTA registry, 308 patients were identified as having undergone REBOA during the study period. Of these, 33 patients were excluded for incomplete data regarding key variables, two were excluded because the REBOA balloon was never inflated, and two were excluded for age less than 18 y (Fig. 1).

A total of 271 patients who met the inclusion criteria from 20 hospitals were included in this study (Table 1). The median age was 50 (range, 18-91; mean, 43) y. Most patients (n = 206, 76.0%)

Discussion

This multiinstitutional registry study is the first to look at hospital REBOA volume as it relates to successful aortic occlusion with REBOA as determined by resultant improvement in the patient's hemodynamic status. Using data collected from twenty hospitals placing REBOA catheters around the country, we found that odds of successful REBOA placement were increased at high and mid REBOA–volume hospitals compared with low REBOA–volume hospitals. In addition, odds of successful REBOA placement

Conclusion

Hospitals with high REBOA volumes were more likely to achieve hemodynamic improvement with REBOA inflation. However, mortality and complication rates were unchanged. Independent of hospital REBOA volume, ongoing CPR is, at the time of REBOA placement, associated with a decreased likelihood of successful REBOA placement.

Acknowledgment

The project described was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through grant number UL1 TR001860 provided for the author C.M.T. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Authors' contributions: C.M.T., J.J.D., and J.M.G. contributed to study conception and design. C.M.T., M.B., T.M.S., K.I., J.C., M.S., M.C.S., C.J.F., E.E.M., J.J.D., and J.M.G.

References (21)

A. Mehta et al.
Effect of surgeon and hospital volume on emergency general surgery outcomes
J Am Coll Surg
(2017)
D.J. Kagedan et al.
The impact of increasing hospital volume on 90-day postoperative outcomes following pancreaticoduodenectomy
J Gastrointest Surg
(2017)
L.N. Tchouta et al.
Hospital volume and outcomes of robot-assisted lobectomies
Chest
(2017)
S.L. Zettervall et al.
The effect of surgeon and hospital volume on mortality after open and endovascular repair of abdominal aortic aneurysms
J Vasc Surg
(2017)
L.J. Moore et al.
Resuscitative endovascular balloon occlusion of the aorta for control of noncompressible truncal hemorrhage in the abdomen and pelvis
Am J Surg
(2016)
C.F. Mackenzie et al.
Using an individual procedure score before and after the advanced surgical skills exposure for trauma course training to benchmark a hemorrhage-control performance metric
J Surg Educ
(2015)
Z. Qasim et al.
Successful interprofessional approach to development of a resuscitative endovascular balloon occlusion of the aorta program at a community trauma center
J Emerg Med
(2018)
M. Brenner 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)
R.P. Dumas et al.
The epidemiology of emergency department thoracotomy in a statewide trauma system: does center volume matter?
J Trauma Acute Care Surg
(2018)
J.D. Birkmeyer et al.
Surgeon volume and operative mortality in the United States
N Engl J Med
(2003)

There are more references available in the full text version of this article.

Cited by (24)

Propensity Score Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta: Zone-1 Versus Zone-3 Resuscitative Endovascular Balloon Occlusion of the Aorta Odds of Mortality
2024, Journal of Surgical Research
There are two zones for the placement of a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in trauma patients: above the mesenteric vessels (Zone-1) or below the renal arteries (Zone-3). Zone-1 REBOA diverts blood away from the visceral organs which leads to a systemic inflammatory response and reperfusion injury. We hypothesized that patients undergoing Zone-1 REBOA placement had a higher odds of mortality.
The 2017-2019 Trauma Quality Improvement Program database was queried for patients undergoing either Zone-1 or Zone-3 REBOA. We excluded all patients with prehospital cardiac arrest. We compared Zone-1 versus Zone-3 REBOA using a 1:2 propensity-score model, matching for age, mechanism, sex, hypotension, tachycardia, blunt solid organ injury grade, pelvic fracture, and injuries to the aorta, iliac artery, iliac vein, and inferior vena cava.
We matched 130 Zone-1 REBOA patients to 260 Zone-3 REBOA patients. There were no statistically significant differences in the matched variables (P > 0.05). Compared to Zone-3 REBOA, patients with Zone-1 REBOA who survived ≥48 h had similar rates of acute kidney injury (18.6% versus 10.9%, P = 0.19). Zone-1 REBOA patients had a higher mortality rate (71.4% versus 48.8%, P = 0.002) and mortality odds ratio (OR) (OR 1.85, OR 1.18-2.89, P = 0.007). Zone-1 REBOA remained associated with a higher odds of mortality after controlling for traumatic brain injury and injury severity score (OR 1.86, OR 1.18-2.92, P = 0.007).
Compared to Zone-3, using a REBOA in Zone-1 is associated with higher odds of mortality. The use of REBOA Zone-1 deployment should be done with caution.
International registry on aortic balloon occlusion in major trauma: Partial inflation does not improve outcomes in abdominal trauma
2024, Surgeon
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a method for temporary hemorrhage control used in haemodynamically unwell patients with severe bleeding. In haemodynamically unwell abdominal trauma patients, laparotomy remains the initial procedure of choice. Using REBOA in patients as a bridge to laparotomy is a novel option whose feasibility and efficacy remain unclear. We aimed to assess the clinical outcome in patients with abdominal injury who underwent both REBOA placement and laparotomy.
This is a retrospective study, including trauma patients with an isolated abdominal injury who underwent both REBOA placement and laparotomy, during the period 2011–2019. All data were collected via the Aortic Balloon Occlusion Trauma Registry database.
One hundred and three patients were included in this study. The main mechanism of trauma was blunt injury (62.1%) and the median injury severity score (ISS) was 33 (14–74). Renal failure and multi-organ dysfunction syndrome (MODS) occurred in 15.5% and 35% of patients, respectively. Overall, 30-day mortality was 50.5%. Post balloon inflation systolic blood pressure (SBP) >80 mmHg was associated with lower 24-h mortality (p = 0.007). No differences in mortality were found among patients who underwent partial occlusion vs. total occlusion of the aorta.
Our results support the feasibility of REBOA use in patients with isolated abdominal injury, with survival rates similar to previous reports for haemodynamically unstable abdominal trauma patients. Post-balloon inflation SBP >80 mmHg was associated with a significant reduction in 24-h mortality rates, but not 30-day mortality. Total aortic occlusion was not associated with increased mortality, MODS, and complication rates compared with partial occlusion.
Learning insertion of a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) catheter: Is clinical experience necessary? A prospective trial
2023, Injury
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emerging and potentially life-saving procedure, necessitating qualified operators in an increasing number of centres. The procedure shares technical elements with other vascular access procedures using the Seldinger technique, which is mastered by doctors not only in endovascular specialties but also in trauma surgery, emergency medicine, and anaesthesiology. We hypothesised that doctors mastering the Seldinger technique (experienced anaesthesiologist) would learn the technical aspects of REBOA with limited training and remain technically superior to doctors unfamiliar with the Seldinger technique (novice residents) given similar training.
This was a prospective trial of an educational intervention. Three groups of doctors were enroled: novice residents, experienced anaesthesiologists, and endovascular experts. The novices and the anaesthesiologists completed 2.5 h of simulation-based REBOA training. Their skills were tested before and 8–12 weeks after training using a standardised simulated scenario. The endovascular experts, constituting a reference group, were equivalently tested. All performances were video recorded and rated by three blinded experts using a validated assessment tool for REBOA (REBOA-RATE). Performances were compared between groups and with a previously published pass/fail cutoff.
Sixteen novices, 13 board-certified specialists in anaesthesiology, and 13 endovascular experts participated. Before training, the anaesthesiologists outperformed the novices by 30 percentage points of the maximum REBOA-RATE score (56% (SD 14.0) vs 26% (SD 17%), p<0.01). After training, there was no difference in skills between the two groups (78% (SD 11%) vs 78 (SD 14%), p = 0.93). Neither group reached the endovascular experts' skill level (89% (SD 7%), p<0.05).
For doctors mastering the Seldinger technique, there was an initial inter-procedural transfer of skills advantage when performing REBOA. However, after identical simulation-based training, novices performed equally well to anaesthesiologists, indicating that vascular access experience is not a prerequisite to learning the technical aspects of REBOA. Both groups would need more training to reach technical proficiency.
Inflate and pack! Pelvic packing combined with REBOA deployment prevents hemorrhage related deaths in unstable pelvic fractures
2022, Injury
Citation Excerpt :
Inherent in the adoption was the surrounding elements of 1) support for definitive hemorrhage control and damage control resuscitation, 2) limitation of the duration of aortic occlusion time and resulting ischemia, 3) structured implementation of the technique by trained surgeons, and 4) the ability to manage complications. There is the clear recognition that a robust training and credentialing process followed by quality review and sustained volume is critical to programmatic success [24–27]. In our clearly defined patient population, patients with profound shock despite red cell transfusion due to pelvic fracture-related hemorrhage, use of REBOA appears to reduce mortality.
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is advocated for hemorrhage control in pelvic fracture patients in shock. We evaluated REBOA in patients undergoing preperitoneal pelvic packing (PPP) for pelvic fracture-related hemorrhage.
Retrospective, single-institution study of unstable pelvic fractures (hemodynamic instability despite 2 units of red blood cells (RBCs) and fracture identified on x-ray). Management included the placement of a Zone III REBOA in the emergency department (ED) for systolic blood pressure <80 mmHg. All PPP patients were included and analyzed for injury characteristics, transfusion requirements, outcomes and complications. Additionally, patients who received REBOA (REBOA+) were compared to those that did not (REBOA-).
During the study period (January 2015 - January 2019), 652 pelvic fracture patients were admitted; 78 consecutive patients underwent PPP. Median RBCs at PPP completion compared to 24 h post-packing were 11 versus 3 units (p<0.05). Median time to operation was 45 min. After PPP, 7 (9%) patients underwent angioembolization. Mortality was 14%. No mortalities were due to ongoing pelvic fracture hemorrhage or physiologic exhaustion; all were a withdrawal of life sustaining support, most commonly due to neurologic insults (TBI/fat emboli = 6, stroke/spinal cord injury = 3). REBOA+ patients (n = 31) had a significantly higher injury severity score (45 vs 38, p<0.01) and higher heart rate (130 vs 118 beats per minute, p = 0.04) than REBOA-. The systolic blood pressure, base deficit, and number of RBCs transfused in the ED, and time spent in the ED were similar between groups. REBOA+ had a higher median transfusion of RBCs at PPP completion (11 units vs 5 units, p<0.01) but similar RBC transfusion in the 24 h after PPP (2 vs 1 units, p = 0.27). Mortality, pelvic infection, and ICU length of stay was not different between these cohorts.
PPP with REBOA was utilized in more severely injured patients with greater physiologic derangements. Although REBOA patients required greater transfusion requirements, there were no deaths due to acute pelvic hemorrhage. This suggests the combination of REBOA with PPP provides life-saving hemorrhage control in otherwise devastating injuries.
Survival benefit for pelvic trauma patients undergoing Resuscitative Endovascular Balloon Occlusion of the Aorta: Results of the AAST Aortic Occlusion for Resuscitation in Trauma Acute Care Surgery (AORTA) Registry
2022, Injury
Citation Excerpt :
AKI requiring dialysis was not different between open AO and REBOA patients. The AORTA database has proven its value in numerous studies of non-compressible truncal hemorrhage [7,9-14]. Contributions to the development of best practices using this dataset encompass procedural variables, comparison of outcomes between open and endovascular occlusion, and development of patient selection criteria.
Aortic occlusion (AO) to facilitate the acute resuscitation of trauma and acute care surgery patients in shock remains a controversial topic. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is an increasingly deployed method of AO. We hypothesized that in patients with non-compressible hemorrhage below the aortic bifurcation, the use of REBOA instead of open AO may be associated with a survival benefit.
From the AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry, we identified 1494 patients requiring AO from 45 Level I and 4 Level II trauma centers. Presentation, intervention, and outcome variables were analyzed to compare REBOA vs open AO in patients with non-compressible hemorrhage below the aortic bifurcation.
From December 2014 to January 2019, 217 patients with Zone 3 REBOA or Open AO who required pelvic packing, pelvic fixation or pelvic angio-embolization were identified. Of these, 109 AO patients had injuries isolated to below the aortic bifurcation (REBOA, 84; open AO, 25). Patients with intra-abdominal or thoracic sources of bleeding, above deployment Zone 3 were excluded. Overall mortality was lower in the REBOA group (35.% vs 80%, p <.001). Excluding patients who arrived with CPR in progress, the REBOA group had lower mortality (33.33% vs. 68.75%, p = 0.012). Of the survivors, systemic complications were not significantly different between groups. In the REBOA group, 16 patients had complications secondary to vascular access. Intensive care lengths of stay and ventilator days were both significantly shorter in REBOA patients who survived to discharge.
This study compared outcomes for patients with hemorrhage below the aortic bifurcation treated with REBOA to those treated with open AO. Survival was significantly higher in REBOA patients compared to open AO patients, while complications in survivors were not different. Given the higher survival in REBOA patients, we conclude that REBOA should be used for patients with hemorrhagic shock secondary to pelvic trauma instead of open AO.
Therapeutic
Controversies in Surgery: Trauma
2021, Surgical Clinics of North America
Citation Excerpt :
Perhaps, the largest pitfall to REBOA use is the learning curve for both individual practitioners and centers and the necessity for high volume to have relative success. Familiarity with the device, appropriate patient selection, and shorter time to complete aortic occlusion are all proposed reasons as to the relative success in facilities that use REBOA more frequently.14–16 Emergency department thoracotomy (EDT) is the epitome of a potentially life-saving procedure, yet the decision to perform this procedure must be made quickly and also carries the immense possibility of being futile.

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: This abstract was presented as a quickshot presentation at the 2020 Academic Surgical Congress.

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Shock/Sepsis/Trauma/Critical CarePractice, Practice, Practice! Effect of Resuscitative Endovascular Balloon Occlusion of the Aorta Volume on Outcomes: Data From the AAST AORTA Registry

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Conclusion

Acknowledgment

J Am Coll Surg

J Gastrointest Surg

Chest

J Vasc Surg

Am J Surg

J Surg Educ

J Emerg Med

J Am Coll Surg

The epidemiology of emergency department thoracotomy in a statewide trauma system: does center volume matter?

J Trauma Acute Care Surg

Surgeon volume and operative mortality in the United States

N Engl J Med

Shock/Sepsis/Trauma/Critical Care
Practice, Practice, Practice! Effect of Resuscitative Endovascular Balloon Occlusion of the Aorta Volume on Outcomes: Data From the AAST AORTA Registry