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. 2025 Mar 28;10(1):e001730.
doi: 10.1136/tsaco-2024-001730. eCollection 2025.

Resuscitative Endovascular Balloon Occlusion of the Aorta in surgical and trauma patients: a systematic review, meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma

Melike N Harfouche  1 , Nikolay Bugaev  2 , John J Como  3 , Douglas R Fraser  4 , Allison G McNickle  5 , Guy Golani  6 , Benjamin P Johnson  2 , Horacio Hojman  2 , Hiba Abdel-Aziz  7 , Jaswin S Sawhney  8 , Daniel C Cullinane  8 , Steven Lorch  9 , Elliott R Haut  10 , Nicole Fox  11 , Laurence S Magder  12 , George Kasotakis  13
Affiliations

Resuscitative Endovascular Balloon Occlusion of the Aorta in surgical and trauma patients: a systematic review, meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma

Melike N Harfouche et al. Trauma Surg Acute Care Open. .

Abstract

Background: The role of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the management of patients with subdiaphragmatic bleeding, as well as its utility in traumatic cardiac arrest (TCA), is unknown.

Methods: A working group from the Eastern Association for the Surgery of Trauma (EAST) applied the Grading of Recommendations Assessment, Development and Evaluation methodology (GRADE) to perform a systematic review and meta-analysis, assess the level of evidence, and create recommendations pertaining to the use of REBOA in the management of trauma or non-trauma patients, as well as those in TCA (1946 to 2024).

Results: Thirty-one studies were included in the meta-analysis. In unstable trauma patients with subdiaphragmatic bleeding, there was no significant difference in mortality among patients who were treated with REBOA vs no REBOA [OR 0.86, 95% CI 0.37, 2.04]. Subgroup analysis for individuals with pelvic fractures demonstrated higher mortality for REBOA vs no REBOA [OR=2.15, CI 1.35, 3.42]. In patients with TCA, pooled analysis demonstrated decreased mortality with REBOA vs resuscitative thoracotomy (OR 0.32, 95% CI 0.15, 0.69). Compared with no REBOA, prophylactic placement of REBOA prior to cesarean section in placenta accreta syndrome (PAS) had lower intra-operative blood loss [-1.06 L, CI -1.57 to -0.56] and red blood cell transfusion [-2.44 units, CI -4.27 to -0.62]. Overall, the level of evidence was assessed by the working group as very low.

Conclusion: Considering the risks associated with its use and lack of discernible benefit, the committee conditionally recommends against the use of REBOA in trauma patients who are hemodynamically unstable due to suspected subdiaphragmatic hemorrhage. Further research is needed to identify specific subpopulations who may benefit. For individuals with TCA due to suspected subdiaphragmatic bleeding and for prophylactic placement in PAS, the committee conditionally recommends for the use of REBOA.

Level of evidence: IV.

Keywords: Emergency Treatment; Shock, Hemorrhagic; guideline; resuscitation.

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Conflict of interest statement

None declared.

Figures

Figure 1
Figure 1. PRISMA diagram demonstrating process of study identification. PRISMA, Preferred Reporting Items for Systematic reviews and Meta-Analyses.
Figure 2
Figure 2. Results of meta-analysis for PICO 1. M-H, Mantel-Haenszel; PICO, Population, Intervention, Comparison, Outcomes; REBOA, resuscitative endovascular balloon occlusion of the aorta; RCT, Randomized Controlled Trial; CI, confidence interval; IV, inverse variance; SD, standard deviation.
Figure 3
Figure 3. Results of meta-analysis for PICO 2. M-H, Mantel-Haenszel; PICO, Population, Intervention, Comparison, Outcomes; REBOA, resuscitative endovascular balloon occlusion of the aorta; CI, confidence interval; IV, inverse variance; SD, standard deviation.
Figure 4
Figure 4. Results of meta-analysis for PICO 3. M-H, Mantel-Haenszel; PICO, Population, Intervention, Comparison, Outcomes; REBOA, resuscitative endovascular balloon occlusion of the aorta; CI, confidence interval; IV, inverse variance; SD, standard deviation; RT, resuscitative thoracotomy.
Figure 5
Figure 5. Results of meta-analysis for PICO 4. M-H, Mantel-Haenszel; PICO, Population, Intervention, Comparison, Outcomes; REBOA, resuscitative endovascular balloon occlusion of the aorta; CI, confidence interval; IV, inverse variance; SD, standard deviation; RT, resuscitative thoracotomy.
Figure 6
Figure 6. Results of meta-analysis for PICO 6. PICO, Population, Intervention, Comparison, Outcomes; REBOA, resuscitative endovascular balloon occlusion of the aorta; CI, confidence interval; IV, inverse variance; SD, standard deviation.
See this image and copyright information in PMC

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