Resuscitative endovascular balloon occlusion of the aorta (REBOA) first gained attention as a tool of last resort for salvaging injured patients in extremis. But according to data from the American Association for the Surgery of Trauma, the way trauma teams use REBOA has evolved rapidly in the last few years.
The finding is based on an analysis of the AAST’s Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) Study. Leaders of the study found that between 2014 and 2018, utilization of REBOA increased significantly. They also found that during the study period, surgeons began deploying REBOA much earlier in the decompensation pathway.
According to M. Chance Spalding, DO, PhD, FACS, trauma surgeon at Grant Medical Center in Columbus, Ohio, the study points to significant changes in practice pattern and patient selection.
“When we first started using REBOA, it was largely as a last-ditch effort and as a replacement for thoracotomy,” said Dr. Spalding, a coauthor of the study. “Now, for patients at heightened risk for bleeding, we are starting to use REBOA earlier instead of waiting to the last minute.”
Growing comfort with endovascular tools
The AORTA analysis was presented in January 2020 at the EAST Annual Scientific Assembly. The study looked at nearly 1,500 patients who underwent aortic occlusion (by either REBOA or an open procedure) between 2014 and 2018.
Study: “Getting Better With Time? A Temporal Analysis of the AORTA Registry”
To read the full abstract, download 2020 EAST Abstracts: Quick Shots and scroll to page 5.
During this 5-year period, the use of REBOA increased significantly each year. At the same time, REBOA odds of mortality declined 23% per year while the complication rate remained unchanged at 4.5%.
The study’s most important finding highlights a key change in practice pattern. At the start of the study, patient systolic blood pressure at initiation of REBOA was an average of 52.2 mmHg. At the end of the study period, patient SBP at REBOA initiation had increased to 65 mmHg.
“At the beginning of the study period, we were using REBOA on patients who were in full arrest — patients with no pulse who were essentially dead,” said Dr. Spalding. “At the end of the period, we see that surgeons are choosing to use REBOA in less ill individuals and using it more as a resuscitative tool to control bleeding. I think that speaks to the comfort many surgeons now have with this procedure.”
Different mindset, simpler technology
Marko Bukur, MD, FACS, trauma medical director at NYU Langone Bellevue Hospital in New York City, agrees that the increase in REBOA survival is likely due to changes in patient selection. He believes this change has been driven by a shift in thinking.
“For many people, the mindset has changed,” said Dr. Bukur, a coauthor of the study. “They have gone from looking at REBOA as a last resort for salvaging patients in hemorrhagic shock to thinking about how they could potentially implement REBOA earlier.”
This shift is reflected in evolving protocols, algorithms and patient pathways. NYU Langone Bellevue started its REBOA program three years ago with an indication for major pelvic fractures that did not respond to conventional methods of resuscitation. Recently, the REBOA indications were expanded to hemorrhagic shock inside the abdomen. The center’s protocol also includes early femoral access.
“Once you have access to the artery, which is often the rate-limiting step, you can upsize to the 7 French sheath relatively quickly,” Dr. Bukur said. “A lot of these patients end up needing an A-line anyway — this is just doing it in the trauma bay. And with catheters that small, it’s unlikely you will cause major trauma to the artery if you don’t end up using REBOA.”
Dr. Bukur believes that improvements in technology have contributed to the shift in REBOA utilization patterns. “The 7 French catheter has made a big difference, because it eliminates having to do sequential dilations, and it is also more landmark-friendly for identifying your target zone,” he said.
Dr. Bukur said that simpler technology has helped make many physicians less hesitant to utilize REBOA. “More trauma surgeons are recognizing that at the end of the day, using this device is the same skill set as putting in either a central venous catheter or an A-line.”
Better training, more teamwork
According to Joseph DuBose, MD, FACS, trauma surgeon at the R Adams Cowley Shock Trauma Center in Baltimore, the growing use of REBOA is also being driven by better education.
“Clearly we’re doing a better job through programs such as the BEST course at training more acute care surgeons in the utilization of this technology,” said Dr. DuBose, a coauthor of the study. “And we have also noticed that leading REBOA centers emphasize widespread training for all members of the healthcare team, at least in terms of familiarity with the device and potential complications.”
Dr. DuBose believes that a team-based approach to resuscitation is a key to successful REBOA utilization. “I think we get far better results when everyone on the team knows what the device is, knows its potential and also understands its limitations.”
Identifying patients who will not likely benefit from REBOA is important, and Dr. DuBose believes the AORTA data and other recent studies are beginning to yield useful parameters.
“I think the data is showing that some patients are clearly so far down the decompensation ‘rabbit hole’ that they will not be able to be salvaged,” said Dr. DuBose, who is also primary investigator of the AORTA study.
“However, excluding those patients will improve our ability to look at the successes with REBOA,” he said. “We’re going to have improved understanding of not just the who, but the when, and to some degree the how we utilize REBOA.”
Dr. DuBose said that novel uses of REBOA could reduce the risks associated with the procedure. “There are now some new approaches such as partial REBOA and intermittent REBOA — along with a number of new devices and technologies that are not yet to market — that have the potential to mitigate the risk of reperfusion injury and balance the benefits of REBOA versus its risks.”
Defining optimal patient selection
Dr. DuBose believes that going forward, REBOA research needs to define optimal patient selection and optimal practice with the device itself. The key is to continue collaborative efforts to gather data on the utilization of endovascular tools in trauma.
“We are still very early in the story of REBOA for trauma care, and I think we are learning a lot at a very rapid pace,” Dr. DuBose said. “There are a lot of voices that are trying to come together to define optimal patient selection, and all those voices have an important role to play.”