Prehospital resuscitative endovascular balloon occlusion of the aorta (REBOA) in patients with major trauma and cardiac arrest: a systematic review.
OBJECTIVES Resuscitative endovascular balloon occlusion of the aorta (REBOA) provides temporary hemorrhage control and optimizes perfusion to vital organs. Despite increasing use in civilian and combat prehospital settings, there is limited consensus on its application or effectiveness. Research has shown mixed effects on mid- to long-term survival, and the inherently high mortality risk among patients receiving REBOA complicates the interpretation of literature. This systematic review consolidates evidence on REBOA use in prehospital and transport medicine settings. METHODS We conducted a systematic review of multiple databases to identify studies describing REBOA use in the prehospital or transport medicine setting. Two independent reviewers screened against inclusion and exclusion criteria. The risk of bias was assessed via the ROBINS-I tool. The primary outcomes were feasibility of REBOA and survival rates. Secondary outcomes included complications and other relevant safety outcomes. Owing to anticipated heterogeneity, a narrative synthesis was conducted. RESULTS The search yielded 1,211 articles, 31 registered trials, and 151 conference abstracts, of which 14 case studies, two prospective cohort studies, one retrospective chart review, one clinical trial, and four registered trials met the inclusion criteria. The included studies were of critical to serious risk of bias due to inherent methodological limitations. When attempted, prehospital REBOA was successfully deployed in 29/38 (76%) of civilian trauma cases, 76/90 (84%) of civilian nontraumatic cardiac arrest cases, and 2/2 (100%) of combat trauma cases. All out-of-hospital cardiac arrest (OHCA) studies reported significant elevation of blood pressure or EtCO2 following REBOA, although survival rates and complications varied widely. When reported, survival to hospital discharge was 44% (14/32) in civilian trauma cases, 4% (1/25) in civilian OHCA cases, and 88% (7/8) in civilian interfacility transport cases. No survival data were available for REBOA in combat cases. Survival rates were correlated with patient selection criteria and the nature of injuries. CONCLUSIONS The current evidence for REBOA use in the prehospital and transport medicine settings is limited by the small number of cases in most existing studies, the lack of control groups in all but one study, and limited reporting of patient-focused outcomes.