A Network Meta-Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta in the Treatment of Noncompressible Torso Hemorrhage: Evaluating Mortality and Acute Kidney Injury Outcomes Compared to Alternative Surgical Techniques

Abstract

Introduction: Noncompressible torso hemorrhage (NCTH) is a major cause of preventable death in both civilian and military trauma settings. It involves vascular disruptions within the thoracic cavity, major axial torso vessels, severe solid organ injuries, or pelvic ring fractures leading to hemodynamic instability resistant to direct pressure control. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a minimally invasive technique used to temporarily occlude aortic blood flow, mitigating distal hemorrhage and preserving proximal perfusion until surgical intervention. This meta-analysis compares the effectiveness of REBOA with alternative surgical techniques in managing NCTH in trauma patients.

Materials and methods: A systematic review was conducted to investigate peer-reviewed studies on the outcomes of REBOA when compared to alternative surgical techniques in the management of NCTH. Databases searched include PubMed, Embase, Ovid EBM reviews (Cochrane), CINAHL, and Web of Science. The review included cohort, case-control, or randomized trials on patients 18 years or older with NCTH, comparing REBOA with alternative surgical techniques. Data on in-hospital mortality and acute kidney injury (AKI) were extracted. Critical appraisal of the risk of bias was assessed using the Cochrane Collaboration's ROBINS-I tool. Statistical analyses were performed using R version 4.2.2.

Results: Eight studies (n = 2,197) met the inclusion criteria. Resuscitative Endovascular Balloon Occlusion of the Aorta was associated with lower mortality compared to resuscitative thoracotomy and combined REBOA/thoracotomy, but higher mortality compared to pelvic angioembolization. Partial Resuscitative Endovascular Balloon Occlusion of the Aorta (p-REBOA) showed a significant reduction in AKI compared to full REBOA. No significant differences in AKI were found between REBOA and other treatments like preperitoneal packing or open aortic occlusion.

Conclusions: Resuscitative Endovascular Balloon Occlusion of the Aorta may offer a survival advantage over resuscitative thoracotomy in NCTH management, but pelvic angioembolization may be more effective for pelvic trauma. Partial Resuscitative Endovascular Balloon Occlusion of the Aorta is associated with a lower risk of AKI compared to full REBOA. The study is limited by the small number of included studies and heterogeneity. Further research, particularly randomized controlled trials, is needed to optimize NCTH treatment protocols, especially in military settings.