Systematic review to evaluate algorithms for REBOA use in trauma and identify a consensus for patient selection

Abstract

BackgroundPatient selection for resuscitative endovascular balloon occlusion of the aorta (REBOA) has evolved during the last decade. A recent multicenter collaboration to implement the newest generation REBOA balloon catheter identified variability in patient selection criteria. The aims of this systematic review were to compare recent REBOA patient selection guidelines and to identify current areas of consensus and variability.MethodsIn accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic review of clinical practice guidelines for REBOA patient selection in trauma. Published algorithms from 2015 to 2022 and institutional guidelines from a seven-center REBOA collaboration were compiled and synthesized.ResultsTen published algorithms and seven institutional guidelines on REBOA patient selection were included. Broad consensus exists on REBOA deployment for blunt and penetrating trauma patients with non-compressible torso hemorrhage refractory to blood product resuscitation. Algorithms diverge on precise systolic blood pressure triggers for early common femoral artery access and REBOA deployment, as well as the use of REBOA for traumatic arrest and chest or extremity hemorrhage control.ConclusionAlthough our convenience sample of institutional guidelines likely underestimates patient selection variability, broad consensus exists in the published literature regarding REBOA deployment for blunt and penetrating trauma patients with hypotension not responsive to resuscitation. Several areas of patient selection variability reflect individual practice environments.Level of evidenceLevel 5, systematic review.

Nomogram for predicting in-hospital mortality in trauma patients undergoing resuscitative endovascular balloon occlusion of the aorta: a retrospective multicenter study

“…Considering the inherent adverse effects and invasiveness of REBOA, our prediction model can be useful given its increased net benefit even at elevated threshold probabilities, as demonstrated by our decision curve analysis 18 . The indications for REBOA in the current study are similar to those used by other trauma centers in the US 6 . However, the appropriateness of implementing a treat-all policy for patients with SBP below 90 mmHg remains controversial.…”

“…Although a systematic review of several clinical studies by Russo et al reported promising results, more human studies are warranted 10 . Nonetheless, partial REBOA has been implemented in level 1 trauma centers across the US 6 , as well as in various level 1 trauma centers throughout South Korea. In our study, lateral compression pelvic fracture was a significant risk factor for overall mortality.…”

“…Various challenges, such as ischemic complications, also necessitate careful patient selection and technique refinement 4 . Therefore, relevant indications for REBOA remain unclear, warranting further studies 6 . Moreover, identifying risk factors for mortality and predicting its occurrence are crucial considering that REBOA is an invasive procedure and has been associated with critical complications, such as limb ischemia and acute kidney injury 4 .…”

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

“…Earlier, SBP thresholds of 60 mm Hg to 70 mm Hg in penetrating and blunt trauma patients have been proposed as cutoff for aortic occlusion. 37,38 As summarized by Maiga et al 39 most institutional algorithms for in-hospital REBOA consider a SBP threshold of <90 mm Hg as trigger. Our panel reached consensus that a SBP < 90 mm Hg without response to fluid therapy, a sign of persistent or recurrent hypotension, combined with estimated transportation times >20 minutes could trigger REBOA deployment in blunt abdominopelvic trauma and possibly in nontraumatic hemorrhage patients.…”

Resuscitative Endovascular Balloon Occlusion of the Aorta in Patients With Exsanguinating Hemorrhage

“…Moreover, the indications for REBOA for the patients in this study were vague. A systematic review designed to evaluate algorithms for use of REBOA in trauma patients and to identify a consensus for patient selection reported a SBP level of less than 80 to 90 mm Hg as a relatively consistent criterion . Even though all patients in the REBOA and standard care group met this SBP threshold of less than 80 to 90 mm Hg, only 67% of patients in the standard care alone group did, raising concerns about randomization and patient selection.…”