Outcomes and management approaches of resuscitative endovascular balloon occlusion of the aorta based on the income of countries.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) could provide a survival benefit to severely injured patients as it may improve their initial ability to survive the hemorrhagic shock. Although the evidence supporting the use of REBOA is not conclusive, its use has expanded worldwide. We aim to compare the management approaches and clinical outcomes of trauma patients treated with REBOA according to the countries' income based on the World Bank Country and Lending Groups. METHODS: We used data from the AORTA (USA) and the ABOTrauma (multinational) registries. Patients were stratified into two groups: (1) high-income countries (HICs) and (2) low-to-middle income countries (LMICs). Propensity score matching extracted 1:1 matched pairs of subjects who were from an LMIC or a HIC based on age, gender, the presence of pupillary response on admission, impeding hypotension (SBP ≤ 80), trauma mechanism, ISS, the necessity of CPR on arrival, the location of REBOA insertion (emergency room or operating room) and the amount of PRBCs transfused in the first 24 h. Logistic regression (LR) was used to examine the association of LMICs and mortality. RESULTS: A total of 817 trauma patients from 14 countries were included. Blind percutaneous approach and surgical cutdown were the preferred means of femoral cannulation in HICs and LIMCs, respectively. Patients from LMICs had a significantly higher occurrence of MODS and respiratory failure. LR showed no differences in mortality for LMICs when compared to HICs; neither in the non-matched cohort (OR = 0.63; 95% CI: 0.36­1.09; p = 0.1) nor in the matched cohort (OR = 1.45; 95% CI: 0.63­3,33; p = 0.3). CONCLUSION: There is considerable variation in the management practices of REBOA and the outcomes associated with this intervention between HICs and LMICs. Although we found significant differences in multiorgan and respiratory failure rates, there were no differences in the risk-adjusted odds of mortality between the groups analyzed. Trauma surgeons practicing REBOA around the world should joint efforts to standardize the practice of this endovascular technology worldwide.

Safety and efficacy of radial access in trauma in 65 trauma endovascular cases.

OBJECTIVE: Endovascular techniques in trauma surgery are becoming increasingly important in patient management, with procedures such as pelvic and splenic angioembolization becoming the standard of care for certain injuries. Traditionally, such interventions are performed via femoral access, although the morbidity of this approach is not insignificant (3%-10%). Transradial access (TRA) is an attractive alternative, pioneered by cardiologists, with low rates of access site complications in patients undergoing coronary intervention. Recently, this technology has extended to other interventions. The aim of this study was to present the initial experience of a radial program in a busy trauma center, with specific regard to safety and complications. METHODS: The medical records of trauma patients undergoing endovascular procedures via TRA between March 2018 and December 2018 were queried for procedural and postoperative data. Demography and injury characteristics were presented for the overall cohort, followed by a comparison of procedural data and complications between laterality. Continuous variables were compared using a two-tailed t-test and categorical variables were compared using a χ2 test. RESULTS: Over a 9-month period, 65 patients underwent 81 interventions via TRA, most commonly solid organ or pelvic angiography/embolization. Radial artery access was achieved in all patients, with procedural success achieved in all but two patients (n = 63 [96.9%]) who had hypoplastic radial artery anatomy, who underwent ulnar access. The overall technique-related complication rate was 1.5% with no difference observed between laterality (n = 1; P = .523). One patient with an admission Glasgow Coma Score of 3 and coagulopathy developed radial artery thrombosis after pelvic angiography via right TRA. Mortality was seen in seven patients (10.8%) owing to hemorrhagic shock (n = 3 [42.8%]) or multiorgan failure (n = 4 [57.1%]). There were no cases of postprocedural access site bleeding, hematoma, pseudoaneurysm, vascular injury, intraoperative arrhythmia or cerebrovascular accident, arteriovenous fistula formation, or infection. CONCLUSIONS: TRA is a feasible and low-risk alternative for endovascular intervention in the trauma patient. It yields good technical success with low morbidity. Although larger studies are needed to establish the full efficacy of TRA at the multi-institutional level, this single-institution study demonstrates the legitimacy of an alternative means for endovascular intervention in the trauma patient.

Could resuscitative endovascular balloon occlusion of the aorta improve survival among severely injured patients with post-intubation hypotension?

Current literature shows the association of post-intubation hypotension and increased odds of mortality in critically ill non-trauma and trauma populations. However, there is a lack of research on potential interventions that can prevent or ameliorate the consequences of endotracheal intubation and thus improve the prognosis of trauma patients with post-intubation hypotension. This review paper hypothesizes that the deployment of REBOA among trauma patients with PIH, by its physiologic effects, will reduce the odds of mortality in this population. The objective of this paper is to review the current literature on REBOA and post-intubation hypotension, and, furthermore, to provide a rational hypothesis on the potential role of REBOA in severely injured patients with post-intubation hypotension.