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REBOA or Thoracotomy – Which Is Better?

January 12, 2024

Written by Michael Stocker

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Traumatic cardiac arrest patients receiving either resuscitative endovascular balloon occlusion of the aorta (REBOA) or resuscitative thoracotomy (RT) experienced similar outcomes, though time to successful occlusion of the aorta took significantly longer with REBOA. The limiter? Common femoral artery (CFA) access.

Rock, paper, scissors, balloon, forceps
This study analyzed a subset of patients from the ETHC observational study which evaluated noncompressible torso trauma at six US level 1 trauma centers from 2017 to 2018. The ETHC inclusion criteria – 15+ years old with truncal hemorrhage below the diaphragm requiring emergent intervention (n=454) – were narrowed to those experiencing traumatic arrest with CPR in which REBOA or RT was pursued prior to ROSC (n=72, 26 REBOA, 46 RT). While there were notable differences between groups, overall injury severity scores were comparable and the researchers utilized inverse probability weighting analysis to adjust for variability. Ultimately, outcomes (in-hospital mortality, hospital days, total blood products, favorable discharges) were not significantly different. However, time from decision to successful aortic occlusion was significantly longer for the REBOA group (7 vs 4 minutes, p=0.001). 6 (23%) of REBOA patients did not achieve successful occlusion with REBOA primarily due to unsuccessful CFA access in 4 of 6 (67%). Keep in mind, this is a secondary analysis of a small subset of patients from an observational study of data from last decade and as such should be considered with the appropriate caution.

How will this change my practice?
Taken on its own, this is not practice-changing study. That said, I see it as somewhat favorable for REBOA use in traumatic arrest. If the primary drawback of REBOA is difficulty with CFA access leading to delays, perhaps one answer is to move for earlier access in patients who seem to be moving toward arrest. At the very least, this reiterates a take-home point from our JF of the UK-REBOA trial: mastery of time-critical CFA access logically precedes any chance REBOA has of unseating RT as the procedure of choice.

Source
Resuscitative endovascular balloon occlusion of the aorta and resuscitative thoracotomy are associated with similar outcomes in traumatic cardiac arrest. J Trauma Acute Care Surg. 2023 Dec 1;95(6):912-917. doi: 10.1097/TA.0000000000004094. Epub 2023 Jun 29.