Zone 1 REBOA aortic occlusion effective alternative to resuscitative thoracotomy after severe hemorrhagic shock: JAMA

The study's findings, published in JAMA Surgery, provide the ethically needed equipoise between these treatment approaches to allow the planning of an RCT (randomized controlled trial) to establish the effectiveness and safety of zone 1 REBOA for aortic occlusion in trauma resuscitation.

Aortic occlusion is a lifesaving treatment for severe traumatic hemorrhagic shock; however, there is confusion regarding whether AO should be done via resuscitative thoracotomy or endovascular balloon occlusion of the aorta in zone 1.

Alexis L. Cralley from the University of Colorado, Denver, and colleagues aimed to compare outcomes of AO via RT vs REBOA zone 1 while addressing the question, "is REBOA zone 1 a safe and effective alternative to resuscitative thoracotomy in the resuscitation of patients with severe traumatic hemorrhagic shock?"

For the study, the researchers used a multicenter registry of postinjury AO from 2013 to 2021. Aortic occlusion via zone 1 REBOA (above celiac artery) was compared with resuscitative thoracotomy performed in the emergency department of facilities experienced in both procedures and documented in the AORTA (Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery) registry. They used PSM (propensity score matching) and multivariate subgroup analysis to control for confounders. The study was set in an emergency department where AO was performed via RT or REBOA, and participants were adult trauma patients aged 16 years and above.

Survival in these patients was assessed (primary outcome). Secondary outcomes included ICU-free days, discharge Glasgow Coma Scale score, ventilation-free days (VFDs), and Glasgow Outcome Score (GOS).

The study led to the following findings:

• A total of 991 patients (median age, 32 years; 81.9% were males) with a median (IQR) Injury Severity Score of 29 were included.
• Of the participants, 30.9% had AO via REBOA zone 1, and 69.1% had AO via RT. PSM selected 112 (56 pairs) comparable patients.
• REBOA zone 1 was associated with a statistically significant lower mortality compared with RT (78.6% vs 92.9%).
• There were no significant differences in VFD greater than 0 (REBOA, 18.5% vs RT, 7.1%), ICU-free days more important than 0 (REBOA, 18.2% vs RT, 7.1%), or discharge GOS of 5 or more (REBOA, 7.5% vs RT, 3.6%).
• Multivariate analysis confirmed the survival benefit of REBOA zone 1 after adjustment for significant confounders (relative risk [RR], 1.25).
• 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 either similar or superior survival.

"Our findings suggest that REBOA zone 1 aortic occlusion is a safe and effective alternative to resuscitative thoracotomy," the authors conclude.

Reference:

Cralley AL, Vigneshwar N, Moore EE, et al. Zone 1 Endovascular Balloon Occlusion of the Aorta vs Resuscitative Thoracotomy for Patient Resuscitation After Severe Hemorrhagic Shock. JAMA Surg. Published online December 21, 2022. doi:10.1001/jamasurg.2022.6393