Abstract
Despite the success of prehospital resuscitative endovascular balloon occlusion of the aorta (REBOA) in combat and civilian settings, the prevalence of complications and the lack of conclusive evidence has led to uncertainty and controversy. Therefore, this systematic review aimed to evaluate the role of prehospital REBOA for hemorrhage control in trauma populations. We systematically searched Cochrane, Ovid MEDLINE, EMBASE and Google Scholar for all relevant studies that investigated the efficacy of prehospital REBOA on trauma patients with massive hemorrhage. Primary outcome was evaluated by blood pressure elevation and secondary outcome was measured by 30-day mortality and complications. Our search identified 546 studies, but only six studies met the inclusion and exclusion criteria. Included studies were low to moderate quality due to limitations within the studies. However, all of the studies reported significant elevation of blood pressure and survival, demonstrating the potential benefits of REBOA. For example, the 30-day mortality rate reduced significantly after REBOA, but studies lacked long-term outcome assessments across the continuum of care. Due to the heterogeneity of the results, a meta-analysis was not possible. We conclude that prehospital REBOA is a feasible and effective resuscitative adjunct for shock patients with lethal non-compressible torso hemorrhage. However, due to the unclear causes of complications and the lack of high quality and homogeneous data, the effects of prehospital REBOA were not truly reflected and comparison between groups was not feasible. Thus, further high-quality studies are required to attest the causality between prehospital REBOA and outcomes.
Highlights
After de-duplication, 533 studies were left for screening. Their titles and abstracts were examined for eligibility and were marked as 1, 2, 3, 4 and 5, which represented irrelevant studies, prehospital resuscitative endovascular balloon occlusion of the aorta (REBOA) on animals, in-hospital REBOA on humans, prehospital REBOA on cadaver models and prehospital REBOA on humans, respectively
The incidence of prehospital cardiac arrest and bleeding-related mortality was significantly lower in prehospital REBOA patients (50% vs. 0%, p = 0.031) (67% vs. 0%, p = 0.007) [26]
Despite the secondary outcome measurements such as 30-day mortality only being available in two civilian studies [21,26], the results suggested REBOA patients were more likely to survive, with a lower mortality rate of 38% compared to that of 67% for non-REBOA patients [26]
Summary
More than one-fourth of these deaths were preventable, occurring before arrival at hospitals or definitive care In both civilian and military settings, non-compressible torso hemorrhage (NCTH) represented the largest proportion of mortalities [1–4]. A large-scale study of the US Trauma registry postulated that the increase in prehospital time or the torso injury severity results in significantly higher mortality, where the first peak of death was identified in the first 30 min after significant torso trauma [2]. REBOA is a minimally invasive method that involves percutaneous insertion of a balloon catheter into the femoral artery and occlusion of the descending thoracic aorta (Zone I) or distal abdominal aorta (Zone III), depending on the indication This aims to temporarily arrest the arterial inflow, restore circulating blood volume and preserve brain perfusion for patients with severe exsanguination [7].
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