Best of EAST 2023 #2: REBOA In Cardiac Arrest

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) remains one of the shiny new trauma toys. Yet, with nearly a decade of human study, we are still struggling to define the right patients to benefit from it.

A group of REBOA superfans sought to perform a secondary analysis of a research database from the US Department of Defense of patients at six Level I centers in the US. It contained outcomes of patients in hemorrhagic shock due to non-compressible bleeding below the diaphragm. The authors analyzed the subset of patients who presented in cardiac arrest and underwent either REBOA or resuscitative thoracotomy (RT).

Here are the factoids:

  • There were 454 patients in the database, and 72 underwent either REBOA or RT
  • REBOA patients were significantly older (46 vs. 35 years) and were more commonly victims of blunt injury (81% vs. 46%)
  • AIS for abdomen was lower in the REBOA group, but AIS head and chest were the same
  • Times from arrival to aortic occlusion and to procedure completion were significantly longer in the REBOA group
  • REBOA patients received more red cells and plasma in the ED, but 24-hour transfusions were the same
  • Mortality was the same between REBOA and RT, and did not change even after some statistical magic

The authors concluded that REBOA was not associated with a survival or transfusion advantage in patients already in arrest.

Bottom line: I was amazed to see a negative result from a group who tend to be avid REBOA cheerleaders. And although the abstract conforms to my own bias about REBOA, there are several things to consider here. 

First, the sample size is very small. A total of 72 patients from the database fit the cardiac arrest on arrival criterion. There is also no information on prehospital arrest duration for the patients.  The dead tend to stay dead despite just about any intervention.

Here are my questions for the presenter and authors:

  • Have you performed a power analysis to determine how many patients were needed to show real differences between the groups? Were you getting close with the 72, or a lot more needed?
  • Also, you did not break down how many of the 72 patients were in the REBOA vs RT groups. Please provide those numbers.
  • Were you able to determine how long the patients had been in arrest before arrival? This could definitely influence survival rates.
  • Did you analyze the subset of survivors in each group? You noted that times to procedure start and completion were longer with REBOA. Did the survivors get to aortic occlusion sooner? Could you identify any subjective factors that seemed associated with their survival?

I wouldn’t get too depressed yet about the efficacy of REBOA in these patients. This study just tells us that REBOA is not a miracle cure for cardiac arrest, but we can still continue to learn more about this device and which patients it is best suited for.



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