Outcomes Associated With Aortic Balloon Occlusion Time in Patients With Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta.

ABSTRACT

INTRODUCTION: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has the potential to cause clinically relevant systemic ischemic burden with long durations of aortic occlusion (AO). We aimed to examine the association between balloon occlusion time and clinical complications and mortality outcomes in patients undergoing zone 1 REBOA. METHODS: A retrospective cohort analysis of American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acuteregistry patients with Zone 1 REBOA between 2013 and 2022 was performed. Patients with cardiopulmonary resuscitation on arrival or who did not survive past the emergency department were excluded. Total AO times were categorized as follows <15 min, 15-30 min, 31-60 min, and >60 min. Clinical and procedural variables and in-hospital outcomes were compared across groups using bivariate and multivariate regression analyses. RESULTS: There were 327 cases meeting inclusion criteria (n = 51 < 15 min, 83 15-30 min, 98 31-60 min, and 95 > 60 min, respectively). AO >60 min had higher admission lactate (8 ± 6; P = 0.004) compared to all other time groups, but injury severity score, heart rate, and systolic blood pressure were similar. Group average times from admission to definitive hemorrhage control ranged from 82 to 103 min and were similar across groups (85 min in AO >60 group). Longer AO times were associated with greater red blood cell, fresh frozen plasma transfusions (P < 0.001), and vasopressor use (P = 0.001). Mortality was greatest in the >60 min group (73%) versus the <15 min, 15-30 min, and 31-60 min groups (53%, 43%, and 45%, P < 0.001). With adjustment for injury severity score, systolic blood pressure, and lactate, AO >60 min had greater mortality (OR 3.7, 95% CI 1.6-9.4; P < 0.001) than other AO duration groups. Among 153 survivors, AO >60 min had a higher rate of multiple organ failure (15.4%) compared to the other AO durations (0%, 0%, and 4%, P = 0.02). There were no differences in amputation rates (0.7%) or spinal cord ischemia (1.4%). acute kidney injury was seen in 41% of >60 min versus 21%, 27%, and 33%, P = 0.42. CONCLUSIONS: Though greater preocclusion physiologic injury may have been present, REBOA-induced ischemic insult was correlated with poor patient outcomes, specifically, REBOA inflation time >60 min had higher rates of mortality and multiple organ failure. Minimizing AO duration should be prioritized, and AO should not delay achieving definitive hemostasis. Partial REBOA may be a solution to extend safe AO time and deserves further study.