Editor's Choice – Systematic Review and Meta-Analysis of Lower Extremity Vascular Complications after Arterial Access for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): An Inevitable Concern?

Foley, Megan Power; Walsh, Stewart R.; Doolan, Nathalie; Vulliamy, Paul; McMonagle, Morgan; Aylwin, Christopher

doi:10.1016/j.ejvs.2023.02.007

Cited by 8 publications

(6 citation statements)

References 63 publications

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“…In a recent analysis of 418 patients from the AORTA registry who survived more than 48 hours, the incidence of arterial access related ischemic complications was 8.6%, 7 with this increase likely explained in part by controlling for survivorship bias. In the most recent meta-analysis of REBOA for exsanguinating hemorrhage, similar overall results were obtained, with an incidence of vascular complications of 8.6%, with no difference in complication rates related to sheath size nor insertion technique 46 . However, this meta-analysis looked at all exsanguinating hemorrhage, not just traumatic, and identified that traumatic hemorrhage was associated with higher vascular access complication rates (12.3 vs. 10.1%) 46 …”

Section: Discussionmentioning

confidence: 60%

“…In the most recent meta-analysis of REBOA for exsanguinating hemorrhage, similar overall results were obtained, with an incidence of vascular complications of 8.6%, with no difference in complication rates related to sheath size nor insertion technique. 46 However, this meta-analysis looked at all exsanguinating hemorrhage, not just traumatic, and identified that traumatic hemorrhage was associated with higher vascular access complication rates (12.3 vs. 10.1%). 46 Contrary to recent evidence, our initial subgroup analysis by sheath size found no significant difference in the incidence of vascular access complications when comparing 7 Fr to larger sheath sizes.…”

Section: Discussionmentioning

confidence: 99%

“…46 However, this meta-analysis looked at all exsanguinating hemorrhage, not just traumatic, and identified that traumatic hemorrhage was associated with higher vascular access complication rates (12.3 vs. 10.1%). 46 Contrary to recent evidence, our initial subgroup analysis by sheath size found no significant difference in the incidence of vascular access complications when comparing 7 Fr to larger sheath sizes. Single and multicenter series have reported decreased incidence of these complications with 7-Fr devices.…”

Section: Discussionmentioning

confidence: 99%

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Vascular access complications associated with resuscitative endovascular balloon occlusion of the aorta in adult trauma patients: A systematic review and meta-analysis

Shum-Tim

Bichara-Allard

Hopkins

et al. 2023

J Trauma Acute Care Surg

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Background Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is gaining popularity worldwide for managing hypotensive trauma patients. Vascular access complications related to REBOA placement have been reported, with some cases resulting in permanent morbidity. We aim to capitalize on the increase in literature to further describe and estimate the incidence of REBOA-associated vascular access complications in adult trauma patients. Method We searched Medline, EMBASE, Scopus and CINAHL for studies reporting vascular access complications of REBOA in adult trauma patients from inception to Oct 14, 2021. Studies reporting data from adult trauma patients who underwent REBOA insertion were eligible. Exclusion criteria included patients aged 15 and younger, non-trauma patients, non-REBOA use, non-vascular access complications and patient duplication. Study data was abstracted using the PRISMA checklist and verified independently by three reviewers. Metanalysis of proportions was performed using a random effects model with Freeman-Turkey double-arcsine transformation. Post-hoc meta-regression by year of publication, sheath-size, and geographic region was also performed. The incidence of vascular access complications from REBOA insertion was the primary outcome of interest. Subgroup analysis was performed by degree of bias, sheath size, technique of vascular access, provider specialty, geographical region, and publication year. Results 24 articles were included in the systematic review and the meta-analysis, for a total of 675 trauma patients who underwent REBOA insertion. The incidence of vascular access complications was 8% (95% CI [5%-13%]). In post-hoc meta-regression adjusting for year of publication and geographic region, the use of a smaller (7-Fr) sheath was associated with a decreased incidence of vascular access complications (OR 0.87 95CI [0.75-0.99], p = 0.046, R2 = 35%, I2 = 48%). Conclusion This study provides a benchmark for quality of care in terms of vascular access complications related to REBOA insertion in adult trauma patients. Smaller sheath size may be associated with a decrease in vascular access complications. Level of Evidence III Study type: Systematic Review and Meta-Analysis

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Section: Discussionmentioning

confidence: 60%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Vascular access complications associated with resuscitative endovascular balloon occlusion of the aorta in adult trauma patients: A systematic review and meta-analysis

Shum-Tim

Bichara-Allard

Hopkins

et al. 2023

J Trauma Acute Care Surg

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“…54 In two systematic reviews specified on prehospital REBOA, Caicedo and Chan et al 10,14,15,55,56 observed diverging rates ranging from 90% success rates to failure rates of 32% accompanied with 77% (10/13) complication rates including thrombosis, superficial femoral artery cannulation and dissection with four patients requiring limb amputation. In two systematic reviews, Shum-Tim et al 57 and Foley et al 58 independently reported vascular access complication rates of respectively 8% (24 articles including 675 patients) and 8.6% (28 articles with 887 patients). 57,58 Similarly, a retrospective cohort study by Laverty et al 59 on the AAST AORTA registry found arterial access-related limb ischemia complications occurring in 8.6% (36/418) of 48-hour REBOA survivors.…”

Section: Discussionmentioning

confidence: 99%

Consensus on resuscitative endovascular balloon occlusion of the aorta in civilian (prehospital) trauma care: A Delphi study

van de Voort,

Kessel,

Borger van der Burg

et al. 2024

J Trauma Acute Care Surg

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Background REBOA could prevent lethal exsanguination and support cardiopulmonary resuscitation. In pre-hospital trauma and medical emergency settings, a small population with high mortality rates could potentially benefit from early REBOA deployment. However, its use in these situations remains highly disputed. Since publication of the first Delphi study on REBOA, in which consensus was not reached on all addressed topics, new literature has emerged. Aim of this study was to establish consensus on the use and implementation of REBOA in civilian pre-hospital settings for non-compressible truncal hemorrhage and out-of-hospital cardiac arrest as well as for various in-hospital settings. Methods A Delphi study consisting of three rounds of questionnaires was conducted based on a review of recent literature. REBOA-experts with different medical specialties, backgrounds and work environments were invited for the international panel. Consensus was reached when a minimum of 75% of panelists responded to a question and at least 75% (positive) or less than 25% (negative) of these respondents agreed on the questioned subject. Results Panel members reached consensus on potential (contra-)indications, physiological thresholds for patient selection, the use of ultrasound and practical, and technical aspects for early femoral artery access and pre-hospital REBOA. Conclusion The international expert panel agreed that REBOA can be used in civilian pre-hospital settings for temporary control of non-compressible truncal hemorrhage, provided that personnel are properly trained and protocols are established. For pre-hospital REBOA and early femoral artery access, consensus was reached on (contra-) indications, physiological thresholds and practical aspects. The panel recommends the initiation of a randomized clinical trial investigating the use of pre-hospital REBOA for non-compressible truncal hemorrhage. Level of evidence Delphi study (original research, care management), level 5

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“…Experience tells us there are a group of patients who survive with expeditious transfer to hospital, haemostatic resuscitation, and rapid access to definitive treatment [51]. Such patients may not benefit and potentially suffer harm from REBOA [52,53 ▪▪ ]. Additionally, there are a significant group of patients who despite current standard care, will continue to die in the immediate post injury phase, or succumb to cardiogenic shock and Multiple Organ Dysfunction Syndrome in the first 3–72 h due to the effects of early myocardial and cerebral hypoperfusion and massive transfusion [54].…”

Section: Progressmentioning

confidence: 99%

Revisiting the promise, practice and progress of resuscitative endovascular balloon occlusion of the aorta

Marsden,

Lendrum,

Davenport

2023

Current Opinion in Critical Care

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Purpose of review The use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) to temporarily control bleeding and improve central perfusion in critically injured trauma patients remains a controversial topic. In the last decade, select trauma services around the world have gained experience with REBOA. We discuss the recent observational data together with the initial results of the first randomized control trial and provide a view on the next steps for REBOA in trauma resuscitation. Recent findings While the observational data continue to be conflicting, the first randomized control trial signals that in the UK, in-hospital REBOA is associated with harm. Likely a result of delays to haemorrhage control, views are again split on whether to abandon complex interventions in bleeding trauma patients and to only prioritize transfer to the operating room or to push REBOA earlier into the post injury phase, recognizing that some patients will not survive without intervention. Summary Better understanding of cardiac shock physiology provides a new lens in which to evaluate REBOA through. Patient selection remains a huge challenge. Invasive blood pressure monitoring, combined with machine learning aided decision support may assist clinicians and their patients in the future. The use of REBOA should not delay definitive haemorrhage control in those patients without impending cardiac arrest.

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Editor's Choice – Systematic Review and Meta-Analysis of Lower Extremity Vascular Complications after Arterial Access for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): An Inevitable Concern?

Cited by 8 publications

References 63 publications

Vascular access complications associated with resuscitative endovascular balloon occlusion of the aorta in adult trauma patients: A systematic review and meta-analysis

Vascular access complications associated with resuscitative endovascular balloon occlusion of the aorta in adult trauma patients: A systematic review and meta-analysis

Consensus on resuscitative endovascular balloon occlusion of the aorta in civilian (prehospital) trauma care: A Delphi study

Revisiting the promise, practice and progress of resuscitative endovascular balloon occlusion of the aorta

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