Zone 1 Endovascular Balloon Occlusion of the Aorta vs Resuscitative Thoracotomy for Patient Resuscitation After Severe Hemorrhagic Shock
Authors: Cralley Alexis L. , Vigneshwar Navin , Moore Ernest E. , Dubose Joseph , Brenner Megan L. , Sauaia Angela ,   AAST AORTA Study Group, Haan James , Lightwine Kelly , Bukur Marko , Yanoff Matthew , Rizzo Julie , Beasy Alexander , Chung Kevin , Bloom Matthew , Ward Jeannette G. , Lachant Joseph , Poulin Nathaniel , Parsikia Afshin , Sauaia Angela , Moore Ernest , Colling Kristin , Kirkpatrick Andrew W. , Ball Chad G. , Xiao Zhengwen , Mercado Michelle , Rados Alma , Richardson Chad , Lumbard Derek , Nygard Rachel , Moore Forrest , Turay David , Luo-Owen Xian , Piccinini Alice , Inaba Kenji , Moore Laura J. , Lee Seong , Solomon Rachele , Farhat Joseph , Gibson Jesse , Teperman Sheldon , Spalding M. Chance , Wolff Timothy W. , Ibrahim Joseph , Safcsak Karen Safcsak , Duchesne Juan , Tatum Danielle , Rauschendorfer Catherine , Baggenstoss Valorie L. , Fortuna Gerry , Pinson Greg , Madayag Robert M. , Benitez Alyha , Skubic Jeffrey , Betancourt-Garcia Monica M. ​ , Dauer Elizabeth , Roden-Foreman Jacob , Furuta Sho Furuta , Ng Karen , Hayashi Michael , Galante Joseph , Doucet Jay , Constantini Todd , Brenner Megan , Browder Timothy , Aarabi Shahram , Skarupa David , Mull Jennifer A. , Diaz Zuniga Yohan , Kundi Rishi , Scalea Thomas M. , Teeter William , Cannon Jeremy , Seamon Mark , Mathew Sarah , Daley Brian , Rasnake Niki Rasnake , Bollig Reagan , Bulger Eileen , Tran Nam T. , Dennis Bradley , Knight Jennifer , Cornell Nicole , Bini John K. , Matsuura John , Pringle Joshua , Nolan Kailey , Herzing Karen 
Published: December 2022

Importance

Aortic occlusion (AO) is a lifesaving therapy for the treatment of severe traumatic hemorrhagic shock; however, there remains controversy whether AO should be accomplished via resuscitative thoracotomy (RT) or via endovascular balloon occlusion of the aorta (REBOA) in zone 1.

Objective

To compare outcomes of AO via RT vs REBOA zone 1.

Design, Setting, and Participants

This was a comparative effectiveness research study using a multicenter registry of postinjury AO from October 2013 to September 2021. AO via REBOA zone 1 (above celiac artery) was compared with RT performed in the emergency department of facilities experienced in both procedures and documented in the prospective multicenter Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry. Propensity score matching (PSM) with exact institution matching was used, in addition to subgroup multivariate analysis to control for confounders. The study setting included the ED, where AO via RT or REBOA was performed, and participants were adult trauma patients 16 years or older.

Exposures

AO via REBOA zone 1 vs RT.

Main Outcomes and Measures

The primary outcome was survival. Secondary outcomes were ventilation-free days (VFDs), intensive care unit (ICU)–free days, discharge Glasgow Coma Scale score, and Glasgow Outcome Score (GOS).

Results

A total of 991 patients (median [IQR] age, 32 [25-48] years; 808 male individuals [81.9%]) with a median (IQR) Injury Severity Score of 29 (18-50) were included. Of the total participants, 306 (30.9%) had AO via REBOA zone 1, and 685 (69.1%) had AO via RT. PSM selected 112 comparable patients (56 pairs). REBOA zone 1 was associated with a statistically significant lower mortality compared with RT (78.6% [44] vs 92.9% [52]; P = .03). There were no significant differences in VFD greater than 0 (REBOA, 18.5% [10] vs RT, 7.1% [4]; P = .07), ICU-free days greater than 0 (REBOA, 18.2% [10] vs RT, 7.1% [4]; P = .08), or discharge GOS of 5 or more (REBOA, 7.5% [4] vs RT, 3.6% [2]; P = .38). Multivariate analysis confirmed the survival benefit of REBOA zone 1 after adjustment for significant confounders (relative risk [RR], 1.25; 95% CI, 1.15-1.36). 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 an either similar or superior survival.

Conclusions and Relevance

Results of this comparative effectiveness research suggest that REBOA zone 1 provided better or similar survival than RT for patients requiring AO postinjury. These findings provide the ethically necessary equipoise between these therapeutic approaches to allow the planning of a randomized controlled trial to establish the safety and effectiveness of REBOA zone 1 for AO in trauma resuscitation.