The Majority of Major Amputations After Resuscitative Endovascular Balloon Occlusion of the Aorta Are Associated With Preadmission Trauma

Abstract

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potentially lifesaving intervention. However, recent reports of associations with limb loss and mortality have called its safety into question. We aimed to evaluate patient and hospital characteristics associated with major amputation and inpatient mortality in patients undergoing REBOA for major trauma. The National Trauma Data Bank (2015-2017) was queried for patients who presented to trauma centers and were treated with REBOA. We included REBOAs performed on hospital day 1 in patients who survived at least 6 hours from presentation. Univariable and multivariable analyses were performed to evaluate associations with major amputation and in-hospital mortality. A total of 316 patients underwent REBOA and survived in the acute period after presentation. Overall, mean age was 45 ± 20 years, and the majority were men (73%) and white (56%). Most patients presented to level I trauma centers (72%) after blunt injuries (79%) with an average Injury Severity Score of 31 ± 15. In 15 patients (5%), there were 18 major amputations, 7 above knee (39%) and 11 below knee (61%). Eleven of the amputations (61%) were either traumatic amputations (73%) or mangled limbs requiring amputation within 24 hours (27%). Of the remaining amputations, 71% were associated with ipsilateral vascular or orthopedic lower extremity (LE) injuries of serious to severe Abbreviated Injury Scale. Comparison of patients with and without major amputations revealed no significant differences in patients’ demographics or chronic comorbidities or hospital characteristics. Patients undergoing major amputation were more likely to present with LE vascular injuries (33% vs 9%; P = .01) and LE Abbreviated Injury Scale severe vascular injuries (6.7% vs 1.3%; P = .01). They more frequently received open peripheral vascular interventions (40% vs 10%; P = .002) and developed compartment syndrome (13% vs 2%; P = .04) during hospitalization. There were 110 deaths (35%). On multivariable analysis, prehospital cardiac arrest (odds ratio [OR], 8.47; 95% confidence interval [CI], 1.47-48.66; P = .02), penetrating vs blunt trauma (OR, 5.5; 95% CI, 1.05-28.82; P = .04), increased age (OR, 1.06; 95% CI, 1.03-1.1; P < .001), increased Injury Severity Score (OR, 1.05; 95% CI, 1-1.1; P = .03), and decreased total Glasgow Coma Scale score (OR, 0.85; 95% CI, 0.76-0.95; P = .005) were associated with increased mortality. The majority of major amputations in patients undergoing REBOA are trauma related from injuries sustained before admission. Injury type and severity as well as initial hemodynamic derangements are associated with mortality after REBOA. Despite concerns about limb complications of REBOAs, baseline injuries appear to be the primary cause of limb loss, but further prospective analysis is needed.