Zone 1 Endovascular Balloon Occlusion of the Aorta vs Resuscitative Thoracotomy for Patient Resuscitation After Severe Hemorrhagic Shock

Abstract

ImportanceAortic occlusion (AO) is a lifesaving therapy for the treatment of severe traumatic hemorrhagic shock; however, there remains controversy whether AO should be accomplished via resuscitative thoracotomy (RT) or via endovascular balloon occlusion of the aorta (REBOA) in zone 1.ObjectiveTo compare outcomes of AO via RT vs REBOA zone 1.Design, Setting, and ParticipantsThis was a comparative effectiveness research study using a multicenter registry of postinjury AO from October 2013 to September 2021. AO via REBOA zone 1 (above celiac artery) was compared with RT performed in the emergency department of facilities experienced in both procedures and documented in the prospective multicenter Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry. Propensity score matching (PSM) with exact institution matching was used, in addition to subgroup multivariate analysis to control for confounders. The study setting included the ED, where AO via RT or REBOA was performed, and participants were adult trauma patients 16 years or older.ExposuresAO via REBOA zone 1 vs RT.Main Outcomes and MeasuresThe primary outcome was survival. Secondary outcomes were ventilation-free days (VFDs), intensive care unit (ICU)–free days, discharge Glasgow Coma Scale score, and Glasgow Outcome Score (GOS).ResultsA total of 991 patients (median [IQR] age, 32 [25-48] years; 808 male individuals [81.9%]) with a median (IQR) Injury Severity Score of 29 (18-50) were included. Of the total participants, 306 (30.9%) had AO via REBOA zone 1, and 685 (69.1%) had AO via RT. PSM selected 112 comparable patients (56 pairs). REBOA zone 1 was associated with a statistically significant lower mortality compared with RT (78.6% [44] vs 92.9% [52]; P = .03). There were no significant differences in VFD greater than 0 (REBOA, 18.5% [10] vs RT, 7.1% [4]; P = .07), ICU-free days greater than 0 (REBOA, 18.2% [10] vs RT, 7.1% [4]; P = .08), or discharge GOS of 5 or more (REBOA, 7.5% [4] vs RT, 3.6% [2]; P = .38). Multivariate analysis confirmed the survival benefit of REBOA zone 1 after adjustment for significant confounders (relative risk [RR], 1.25; 95% CI, 1.15-1.36). In all subgroup analyses (cardiopulmonary resuscitation on arrival, traumatic brain injury, chest injury, pelvic injury, blunt/penetrating mechanism, systolic blood pressure ≤60 mm Hg on AO initiation), REBOA zone 1 offered an either similar or superior survival.Conclusions and RelevanceResults of this comparative effectiveness research suggest that REBOA zone 1 provided better or similar survival than RT for patients requiring AO postinjury. These findings provide the ethically necessary equipoise between these therapeutic approaches to allow the planning of a randomized controlled trial to establish the safety and effectiveness of REBOA zone 1 for AO in trauma resuscitation.

Resuscitative endovascular balloon occlusion of the aorta and resuscitative thoracotomy are associated with similar outcomes in traumatic cardiac arrest

“…Increased time to AO with REBOA compared with RT was also described in a recent study of the AORTA registry 21 . In addition, 24-hour blood product transfusion was also greater with REBOA 22 . Besides time to AO, another factor which could have contributed to the difference in transfusions is the nature of the AO itself.…”

Contemporary Adjuncts to Hemorrhage Control

“…The balloon is inflated to occlude the aorta proximal to the presumed site of bleeding in the abdomen, pelvis, or both places. Multiple studies have suggested that REBOA does not worsen outcomes and, in many institutions and settings, improves outcomes with increased institutional experience . When REBOA is used in a setting with standardized training, protocol, expertise, and experience, outcomes are improved compared with patients who do not receive REBOA .…”

Advances in trauma care to save lives from traumatic injury: A narrative review

“…Resuscitative endovascular balloon occlusion of the aorta in zone 1 was associated with a statistically lower mortality compared with resuscitative thoracotomy, including all subgroup analysis. 39 Among patients with signs of life or presenting with traumatic cardiac arrest, prehospital and in-hospital data have shown promising results for NCTH control by REBOA. 40 Resuscitative endovascular balloon occlusion of the aorta represents a less invasive technique, allows personalized aortic occlusion (regarding injuries) and uninterrupted chest compressions.…”