STRATEGIES FOR CONTROLLING AORTIC HEMORRHAGE IN EXSANGUINATING ABDOMINAL TRAUMA: A SYSTEMATIC REVIEW COMPARING REBOA VERSUS RESUSCITATIVE THORACOTOMY FOR VASCULAR COMPLICATIONS, TRANSFUSION REQUIREMENTS AND RETURN OF SPONTANEOUS CIRCULATION (ROSC)
DOI:
https://doi.org/10.18623/rvd.v23.5433Palabras clave:
REBOA, Resuscitative Thoracotomy, Aortic Occlusion, Control of Hemorrhage, Complications of the Vessel, Transfusion, ROSC, Traumatic Cardiac ArrestResumen
Background: bad abdominal hemorrhage with the need for aortic occlusion is a big problem in trauma care. Resuscitative endovascular balloon occlusion of the aorta (REBOA) and resuscitative thoracotomy (RT) with aortic cross-clamping are the two main methods of controlling hemorrhage immediately, but evidence checking these two methods is conflicting. This systematic review checks REBOA to RT for vascular problems, transfusion requirement and ROSC in adult folks with exsanguinating abdominal trauma. Methods: Using the PRISMA guidelines, we searched the literature in the databases: MEdlne, Embase, Cochrane CENTRAL, Scopus and Web of Science from January 2000 to December 2024. Included studies straight compared REBOA with RT in adults with hemorrhage of the abdominal/pelvic region requiring occlusion of the aorta. Primary outcomes were vascular problems, 24 hr transfusion requirement and ROSC. Secondary outcomes were death, time to occlusion and non-vascular complications. Data were synthesized in a narrative way with quantitative presentation of individual study results. Results: Twenty-three studies with 8247 patients (REBOA: 2417; RT: 5830) were eligible. Vascular complication chances with REBOA were 4.2-19.2% among studies compared to 1.1-8.3% among studies with RT. Access site artery injury was found in 4.0% of REBOA patients compared to 1.1% with RT. Distal Limb Ischemia that Required fix occurred in 3.0% of REBOA patients compared with 1.3% with RT. Twenty-four hour transfusion requirements were consistently less with REBOA with mean PRBC transfusion reductions of 2.4 - 4.2 units across studies. ROSC rates in traumatic cardiac arrest were higher with REBOA (36 - 60%) than RT (18 - 33%). REBOA (711 minutes) and RT (48minutes) had a longer time to aortic occlusion. Mortality at hospital discharge ranged from 37 - 88% with REBOA and 45 - 93% with RT at the end of studies with high heterogeneity based on patient population. Conclusions: REBOA has benefits in regards to transfusion reduction and ROSC achievement in comparison to RT, especially in penetrating trauma and traumatic cardiac arrest. These advantages are however offset by the jump in the risk of vascular complications such as access site injuries and limb ischemia. These findings support the approach to do selective based on clinical context, mechanism of injury and institutional capabilities.
Citas
1. Abe, T., Uchida, M., Nagata, I., Saitoh, D., & Tamiya, N. (2016). Resuscitative endovascular balloon occlusion of the aorta versus aortic cross clamping among patients with critical trauma: A nationwide cohort study in Japan. Critical Care, *20*, 400.
2. Aso, S., Matsui, H., Fushimi, K., & Yasunaga, H. (2017). Resuscitative endovascular balloon occlusion of the aorta or resuscitative thoracotomy with aortic clamping for noncompressible torso hemorrhage. Journal of Trauma and Acute Care Surgery, *82*(5), 910–914.
3. Balch, J. A., Loftus, T. J., Efron, P. A., Mohr, A. M., Upchurch, G. R., Jr., & Smith, R. S. (2023). Survival and neurologic outcomes following aortic occlusion for trauma and hemorrhagic shock in a hybrid operating room. World Journal of Emergency Surgery, *18*, 21.
4. Bini, J. K., Hardman, C., Morrison, J., Scalea, T. M., Moore, L. J., Podbielski, J. M., Inaba, K., Piccinini, A., Kauvar, D. S., Cannon, J., & AAST AORTA Study Group. (2022). 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. Injury, *53*(6), 2126–2132.
5. Brede, J. R., Skulberg, A. K., Rehn, M., Thorsen, K., Klepstad, P., Tylleskär, I., Farbu, B., Dale, J., Nordseth, T., Wiseth, R., & Kurola, J. (2021). REBOARREST, resuscitative endovascular balloon occlusion of the aorta in non-traumatic out-of-hospital cardiac arrest: A study protocol for a randomised, parallel group, clinical multicentre trial. Trials, *22*, 511.
6. Brenner, M. (2024). The role of resuscitative endovascular balloon occlusion of the aorta. Surgical Clinics of North America, *104*(2), 311–323.
7. Brenner, M., Inaba, K., Aiolfi, A., DuBose, J., Fabian, T., Bee, T., Holcomb, J. B., Moore, L., Skarupa, D., Scalea, T. M., & AAST AORTA Study Group. (2018). 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. Journal of the American College of Surgeons, *226*(5), 730–740.
8. Brenner, M., Zakhary, B., Coimbra, R., Scalea, T., Moore, L., Moore, E., Cannon, J., Spalding, C., Ibrahim, J., & Dennis, B. (2024). Balloon rises above: REBOA at zone 1 may be superior to resuscitative thoracotomy. Journal of the American College of Surgeons, *238*(3), 261–271.
9. Broome, J. M., Ali, A., Simpson, J. T., Tran, S., Tatum, D., Taghavi, S., DuBose, J., Duchesne, J., & AORTA Study Group. (2022). Impact of time to emergency department resuscitative aortic occlusion after noncompressible torso hemorrhage. Shock, *58*(4), 275–279.
10. Bukur, M., Gorman, E., DiMaggio, C., Frangos, S., Morrison, J. J., Scalea, T. M., Moore, L. J., Podbielski, J., Inaba, K., Kauvar, D., & AAST AORTA Study Group. (2021). Temporal changes in REBOA utilization practices are associated with increased survival: An analysis of the AORTA registry. Shock, *55*(1), 24–32.
11. Castellini, G., Gianola, S., Biffi, A., Porcu, G., Fabbri, A., Ruggieri, M. P., Coniglio, C., Napoletano, A., Coclite, D., D'Angelo, D., Fauci, A. J., Iacorossi, L., Latina, R., Salomone, K., Gupta, S., Iannone, P., Chiara, O., & Italian National Institute of Health guideline working group on Major Trauma. (2021). Resuscitative endovascular balloon occlusion of the aorta (REBOA) in patients with major trauma and uncontrolled haemorrhagic shock: A systematic review with meta-analysis. World Journal of Emergency Surgery, *16*(1), 41.
12. Chien, C. Y., Lewis, M. R., Dilday, J., Biswas, S., Luo, Y., & Demetriades, D. (2023). Worse outcomes with resuscitative endovascular balloon occlusion of the aorta in severe pelvic fracture: A matched cohort study. American Journal of Surgery, *225*(2), 414–419.
13. Cralley, A. L., Vigneshwar, N., Moore, E. E., Dubose, J., Brenner, M. L., Sauaia, A., & AAST AORTA Study Group. (2023). Zone 1 endovascular balloon occlusion of the aorta vs resuscitative thoracotomy for patient resuscitation after severe hemorrhagic shock. JAMA Surgery, *158*(2), 140–150.
14. Dewey, M. G., Moore, E. E., Ammons, L. A., Bernhardt, I. M., Sauaia, A., & Brenner, M. L. (2025). Partial REBOA zone 1 is associated with lower mortality compared to complete REBOA zone 1 and emergency department thoracotomy: A cohort study using the AORTA registry. Transfusion, *65*(Suppl 1), S80–S97.
15. DuBose, J. J., Scalea, T. M., Brenner, M., Skiada, D., Inaba, K., Cannon, J., Moore, L., Holcomb, J., Turay, D., Arbabi, C. N., & AAST AORTA Study Group. (2016). The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: Data on contemporary utilisation and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA). Journal of Trauma and Acute Care Surgery, *81*(3), 409–419.
16. García, A. F., Manzano-Núñez, R., Orlas, C. P., Ruiz-Yucuma, J., Londoño, A., Salazar, C., Melendez, J., Sánchez, Á. I., Puyana, J. C., & Ordoñez, C. A. (2021). Association of resuscitative endovascular balloon occlusion of the aorta (REBOA) and mortality in penetrating trauma patients. European Journal of Trauma and Emergency Surgery, *47*(6), 1779–1785.
17. Harfouche, M. N., Bugaev, N., Como, J. J., Fraser, D. R., McNickle, A. G., Golani, G., Johnson, B. P., Hojman, H., Abdel-Aziz, H., Sawhney, J. S., Cullinane, D. C., Lorch, S., Haut, E. R., Fox, N., Magder, L. S., & Kasotakis, G. (2025). Resuscitative endovascular balloon occlusion of the aorta in surgical and trauma patients: A systematic review, meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma. Trauma Surgery & Acute Care Open, *10*(1), e001730.
18. Harfouche, M. N., Madurska, M. J., Elansary, N., Abdou, H., Lang, E., DuBose, J. J., Kundi, R., Feliciano, D. V., Scalea, T. M., & Morrison, J. J. (2022). Resuscitative endovascular balloon occlusion of the aorta associated with improved survival in hemorrhagic shock. PLoS One, *17*(4), e0265778.
19. Inoue, J., Shiraishi, A., Yoshiyuki, A., Haruta, K., Matsui, H., & Otomo, Y. (2016). Resuscitative endovascular balloon occlusion of the aorta might be dangerous in patients with severe torso trauma: A propensity score analysis. Journal of Trauma and Acute Care Surgery, *80*(4), 559–566.
20. Jansen, J. O., Hudson, J., Cochran, C., MacLennan, G., Lendrum, R., Sadek, S., Gillies, K., Cotton, S., Kennedy, C., Boyers, D., & UK-REBOA Trial Investigators. (2023). Emergency department resuscitative endovascular balloon occlusion of the aorta in trauma patients with exsanguinating hemorrhage: The UK-REBOA randomized clinical trial. JAMA, *330*(19), 1862–1871.
21. Joseph, B., Zeeshan, M., Sakran, J. V., Hamidi, M., Kulvatunyou, N., Khan, M., O'Keeffe, T., & Rhee, P. (2019). Nationwide analysis of resuscitative endovascular balloon occlusion of the aorta in civilian trauma. JAMA Surgery, *154*(6), 500–508.
22. Khalid, S., Khatri, M., Siddiqui, M. S., & Ahmed, J. (2022). Resuscitative endovascular balloon occlusion of aorta versus aortic cross-clamping by thoracotomy for noncompressible torso hemorrhage: A meta-analysis. Journal of Surgical Research, *270*, 252–260.
23. Koh, E. Y., Fox, E. E., Wade, C. E., Scalea, T. M., Fox, C. J., Moore, E. E., Morse, B. C., Inaba, K., Bulger, E. M., & Meyer, D. E. (2023). Resuscitative endovascular balloon occlusion of the aorta and resuscitative thoracotomy are associated with similar outcomes in traumatic cardiac arrest. Journal of Trauma and Acute Care Surgery, *95*(6), 912–917.
24. Matsumoto, S., Funabiki, T., Hayashida, K., Yamazaki, M., Ebihara, T., & Moriya, T. (2020). Effectiveness and usage trends of hemorrhage control interventions in patients with pelvic fracture in shock. World Journal of Surgery, *44*(7), 2229–2236.
25. Matsumoto, S., Hayashida, K., Akashi, T., Jung, K., Sekine, K., Funabiki, T., & Moriya, T. (2019). Resuscitative endovascular balloon occlusion of the aorta (REBOA) for severe torso trauma in Japan: A descriptive study. World Journal of Surgery, *43*(7), 1700–1707.
26. Mikdad, S., van Erp, I. A. M., Moheb, M. E., Fawley, J., Saillant, N., King, D. R., Kaafarani, H. M. A., Velmahos, G., & Mendoza, A. E. (2020). Pre-peritoneal pelvic packing for early hemorrhage control reduces mortality compared to resuscitative endovascular balloon occlusion of the aorta in severe blunt pelvic trauma patients: A nationwide analysis. Injury, *51*(8), 1834–1839.
27. Moore, L. J., Brenner, M., Kozar, R. A., Pasley, J., Wade, C. E., Baraniuk, M. S., Scalea, T., & Holcomb, J. B. (2015). Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage. Journal of Trauma and Acute Care Surgery, *79*(4), 523–530.
28. Morrison, J. J., Ross, J. D., Houston, R., Watson, J. D. B., Sokol, K. K., & Rasmussen, T. E. (2014). Use of resuscitative endovascular balloon occlusion of the aorta in a highly lethal model of noncompressible torso hemorrhage. Shock, *41*(2), 130–137.
29. Nahmias, J., Byerly, S., Stein, D., Haut, E. R., Smith, J. W., Gelbard, R., Ziesmann, M., Boltz, M., Zarzaur, B., Biffl, W. L., & AAST PROOVI Study Group. (2022). A core outcome set for resuscitative endovascular balloon occlusion of the aorta: A consensus based approach using a modified Delphi method. Journal of Trauma and Acute Care Surgery, *92*(1), 144–151.
30. Norii, T., Crandall, C., & Terasaka, Y. (2015). Survival of severe blunt trauma patients treated with resuscitative endovascular balloon occlusion of the aorta compared with propensity score-adjusted untreated patients. Journal of Trauma and Acute Care Surgery, *78*(4), 721–728.
31. Ordoñez, C. A., Rodríguez, F., Orlas, C. P., Parra, M. W., Caicedo, Y., Guzmán, M., Serna, J. J., Salcedo, A., Zogg, C. K., Herrera-Escobar, J. P., & García, A. F. (2020). The critical threshold value of systolic blood pressure for aortic occlusion in trauma patients in profound hemorrhagic shock. Journal of Trauma and Acute Care Surgery, *89*(6), 1107–1113.
32. Romagnoli, A., Teeter, W., Pasley, J., Hu, P., Hoehn, M., Stein, D., Scalea, T., & Brenner, M. (2017). Time to aortic occlusion: It's all about access. Journal of Trauma and Acute Care Surgery, *83*(6), 1161–1164.
33.Shaw, J., & Brenner, M. (2023). Resuscitative balloon occlusion of the aorta in the modern era: Expanding indications, optimal techniques, unresolved issues and current results. Seminars in Vascular Surgery, *36*(2), 250–257.
34. Shaw, J., & Brenner, M. (2025). Resuscitative endovascular balloon occlusion of the aorta: What you need to know. Journal of Trauma and Acute Care Surgery, *98*(6), 831–839.
35. Teeter, W., Romagnoli, A., Wasicek, P., Hu, P., Yang, S., Stein, D., Scalea, T., & Brenner, M. (2018a). Resuscitative endovascular balloon occlusion of the aorta improves cardiac compression fraction versus resuscitative thoracotomy in patients in traumatic arrest. Annals of Emergency Medicine, *72*(4), 354–360.
36. Teeter, W. A., Bradley, M. J., Romagnoli, A., Hu, P., Li, Y., Stein, D. M., Scalea, T. M., & Brenner, M. (2018b). Treatment effect or effective treatment? Cardiac compression fraction and end-tidal carbon dioxide are higher in patients resuscitative endovascular balloon occlusion of the aorta compared with resuscitative thoracotomy and open-chest cardiac massage. The American Surgeon, *84*(10), 1691–1695.
37. White, J. M., Cannon, J. W., Stannard, A., Markov, N. P., Spencer, J. R., & Rasmussen, T. E. (2011). Endovascular balloon occlusion of the aorta is superior to resuscitative thoracotomy with aortic clamping in a porcine model of hemorrhagic shock. Surgery, *150*(3), 400–409.
38. Yamamoto, R., Cestero, R. F., Suzuki, M., Funabiki, T., & Sasaki, J. (2019). Resuscitative endovascular balloon occlusion of the aorta (REBOA) is associated with improved survival in severely injured patients: A propensity score matching analysis. American Journal of Surgery, *218*(6), 1162–1168.
39. Yamamoto, R., Suzuki, M., Funabiki, T., Nishida, Y., Maeshima, K., & Sasaki, J. (2020). Resuscitative endovascular balloon occlusion of the aorta and traumatic out-of-hospital cardiac arrest: A nationwide study. Journal of the American College of Emergency Physicians Open, *1*(4), 624–632.
Descargas
Publicado
Cómo citar
Número
Sección
Licencia
I (we) submit this article which is original and unpublished, of my (our) own authorship, to the evaluation of the Veredas do Direito Journal, and agree that the related copyrights will become exclusive property of the Journal, being prohibited any partial or total copy in any other part or other printed or online communication vehicle dissociated from the Veredas do Direito Journal, without the necessary and prior authorization that should be requested in writing to Editor in Chief. I (we) also declare that there is no conflict of interest between the articles theme, the author (s) and enterprises, institutions or individuals.
I (we) recognize that the Veredas do Direito Journal is licensed under a CREATIVE COMMONS LICENSE.
Licença Creative Commons Attribution 3.0
