Resuscitative Endovascular Balloon Occlusion of the Aorta vs Pre-Peritoneal Packing in Patients with Pelvic Fracture

Abstract

Pelvic hemorrhage is potentially lethal despite homeostatic interventions such as pre-peritoneal packing (PP), resuscitative endovascular balloon occlusion of the aorta (REBOA), surgery, and/or angioembolization. REBOA may be used as an alternative/adjunct to PP for temporizing bleeding in patients with pelvic fractures. Our study aimed to compare the outcomes of REBOA and/or PP, as temporizing measures, in blunt pelvic fracture patients. We hypothesized that REBOA is associated with worsened outcomes. We performed a 2017 review of the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) and identified trauma patients with blunt pelvic fractures who underwent REBOA placement and/or PP before laparotomy and/or angioembolization. Propensity score matching was performed, adjusting for demographics, vitals, mechanism of injury, ISS, each body region-AIS, and pelvic fracture type. Outcomes were complication rates and mortality. A total of 156 patients (PP: 52; REBOA: 52; REBOA+PP: 52) were matched and included. Mean age was 43 ± 18 years, Injury Severity Score (ISS) was 28 (range 17-32), and 74% were males. Overall mortality was 42%. The 24-hour mortality (25% vs 14% vs 35%; p= 0.042), in-hospital mortality (44% vs 29% vs 54%; p= 0.034), and 4-hour pRBC units transfused (15 [9-23] vs 10 [4-19] vs 16 [9-27]; p= 0.017) were lower in the REBOA group. The REBOA group had faster times to both laparotomy (p= 0.040) and/or angioembolization (p= 0.012). There was no difference between the groups in acute kidney injury, lower limb amputations, or hospital and ICU length of stay among survivors. REBOA is a less invasive procedure compared with PP and is associated with improved outcomes. Further clinical trials are needed to define the optimal patient who will benefit from REBOA.