Outcomes and management approaches of resuscitative endovascular balloon occlusion of the aorta based on the income of countries
Authors: Manzano-Nunez Ramiro , McGreevy David , Orlas Claudia P. , García Alberto F. , Hörer Tal M. , DuBose Joseph , Ordoñez Carlos A. ,   on behalf of the AAST-AORTA Investigators and the ABOTrauma Registry Group, Morrison Jonny , Scalea Thomas M. , Moore Laura J. , Podbielski Jeanette M. , Holcomb John B. , Inaba Kenji , Piccinini Alice , Kauvar David S. , Baggenstoss Valorie L. , Rauschendorfer Catherine , Cannon Jeremey , Seamon Mark , Dumas Ryan , Vella Mike , Guzman Jessica , Spalding Chance , Wolff Timothy W. , Fox Chuck , Moore Ernest , Turay David , Arbabi Cassra N. , Luo-Owen Xian , Skarupa David , Mull Jennifer A. , Gonzalez Joannis Baez , Ibrahim Joseph , Safcsak Karen , Gordy Stephanie , Long Michael , Kirkpatrick Andrew W. , Ball Chad G. , Xiao Zhengwen , Dauer Elizabeth , Knight Jennifer , Cornell Nicole , Moore Forrest Dell , Bloom Matthew , Tran Nam T. , Bulger Eileen , Ward Jeannette G. , Bini John K. , Matsuura John , Pringle Joshua , Herzing Karen , Nolan Kailey , Poulin Nathaniel , Teeter William , Nygaard Rachel , Richardson Chad , Skaja Joseph , Lombard Derek , Bollig Reagan , Daley Brian , Rasnake Niki , Bukur Marko , Warnack Elizabeth , Farhat Joseph , Madayag Robert M. , Bourg Pamela , Ramstedt Anna , Sadeghi Mitra , Nilsson Kristofer F. , Larzon Thomas , Pirouzram Artai , Toivola Asko , Maszkowski Mariusz , Bersztel Adam , Skoog Per , Idoguchi Koji , Kon Yuri , Ishida Tokiya , Matsumura Yosuke , Matsumoto Junichi , Reva Viktor , Caragounis Eva-Corina , Falkenberg Mårten , Handolin Lauri , Oosthuizen George , Szarka Endre , Manchev Vassil , Wannatoop Tongporn , Chang Sung W. , Kessel Boris , Hebron Dan , Shaked Gad , Bala Miklosh , Coccolini Federico , Ansaloni Luca , Hibert-Carius Peter , Moe Michelle , Vrancken Suzanne Maria 
Published: October 2020

Abstract
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: 0.36‑1.09; p = 0.1) nor in the matched cohort (OR = 1.45; 95% CI: 0.63‑3,33; 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.