Partial occlusion, conversion from thoracotomy, undelayed but shorter occlusion: Resuscitative endovascular balloon occlusion of the aorta strategy in Japan

Introduction Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a viable alternative to resuscitative thoracotomy (RT) in refractory hemorrhagic patients. We evaluated REBOA strategies using Japanese multi-institutional data. Patients and methods The DIRECT-IABO investigators registered trauma patients requiring REBOA from 18 hospitals. Patients' characteristics, outcomes, and time in initial treatment were collected and analyzed. Results From August 2011 to December 2015, 106 trauma patients were analyzed. The majority of patients were men (67%) (median BMI of 22 kg/m 2, 96% blunt injured). REBOA occurred in the field (1.9%, all survived >30 days), emergency department (75%), angiography suite (17%), and operating room (1.9%). Initial deployment was at zone I in 93% and partial occlusion in 70% of cases. RT and REBOA were combined in 30 patients (RT+REBOA group) who showed significantly higher injury severity score (44 vs. 36, P=0.001) and chest abbreviated injury scale (4 vs. 3; P<0.001) than the REBOA-alone group (n=76). Frequent cardiopulmonary resuscitation (73%), longer prothrombin time-international normalised ratio, lower pH, and higher lactate were observed in the RT+REBOA. Among 24 h nonsurvivors (n=30) of the REBOA alone, preocclusion systolic blood pressure was lower (43 vs. 72 mmHg; P=0.002), indicating impending cardiac arrest, and duration of occlusion was longer (60 vs. 31 min; P=0.010). In the RT+REBOA (n=30), six survived beyond 24 h, three beyond 30 days, and achieved survival discharge. Conclusion Partial occlusion was performed in 70% of patients. Undelayed deployment of REBOA without presenting impending cardiac arrest with shorter balloon occlusion (<30 min at zone I with partial occlusion) might be related to successful hemodynamic stabilization and improved survival. Further evaluation should be performed prospectively.