Impact of resuscitative endovascular balloon occlusion of the aorta (REBOA) in traumatic abdominal and pelvic exsanguination: a systematic review and meta-analysis

Abstract

Purpose: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) represents a minimally invasive technique of aortic occlusion (AO). It has been demonstrated to be safe and effective with appropriate training in traumatic hemorrhage with hemodynamic instability; however, its indications are still debated. The aim of this systematic review and meta-analysis is to assess the impact of REBOA on mortality in torso trauma patient with severe non-compressible hemorrhage compared to other temporizing hemostatic techniques.

Study design: The primary outcome is represented by 24-h, and in-hospital mortality. Secondary outcomes are post-procedural hemodynamic improvement (systolic blood pressure-SBP), mean injury severity score (ISS) differences, treatment-related morbidity, transfusional requirements and identification of prognostic factors.

Results: A significant survival benefit at 24 h (RR 0.46; 95% CI 0.27-0.79; I²: 55%; p = 0.005) was highlighted in patients undergoing REBOA. Regarding in-hospital mortality (RR 0.99; 95% CI 0.75-1.32; I²: 73%; p = 0.98) no differences in risk of death were noticed. A hemodynamic improvement-although not significant-was highlighted, with 55.8 mmHg post-AO SBP mean difference between REBOA and control groups. A significantly lower mean number of packed Red Blood Cells (pRBCs) was noticed for REBOA patients (mean difference: - 3.02; 95% CI - 5.79 to - 0.25; p = 0.033). Nevertheless, an increased risk of post-procedural complications (RR 1.66; 95% CI 0.39-7.14; p = 0.496) was noticed in the REBOA group.

Conclusions: REBOA may represent a valid tool in the initial treatment of multiple sites subdiaphragmatic hemorrhage with refractory hemodynamic instability. However, due to several important limitations of the present study, our findings should be interpreted with caution.

Level of evidence: Level III according to ELIS (SR/MA with up to two negative criteria).

Keywords: Aortic cross-clamping; Extraperitoneal pelvic packing; Meta-analysis; REBOA; Traumatic torso hemorrhage.