Non-traumatic hemorrhage is controlled with REBOA in acute phase then mortality increases gradually by non-hemorrhagic causes: DIRECT-IABO registry in Japan
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is now a feasible and less invasive resuscitation procedure. This study aimed to compare the clinical course of trauma and non-trauma patients undergoing REBOA.
Patient demographics, etiology, bleeding sites, hemodynamic response, length of critical care, and cause of death were recorded. Characteristics and outcomes were compared between non-trauma and trauma patients. Kaplan–Meier survival analysis was then conducted.
Between August 2011 and December 2015, 142 (36 non-trauma; 106 trauma) cases were analyzed. Non-traumatic etiologies included gastrointestinal bleeding, obstetrics and gynecology-derived events, visceral aneurysm, abdominal aortic aneurysm, and post-abdominal surgery. The abdomen was a common bleeding site (69%), followed by the pelvis or extra-pelvic retroperitoneum. None of the non-trauma patients had multiple bleeding sites, whereas 45% of trauma patients did (P < 0.001). No non-trauma patients required resuscitative thoracotomy compared with 28% of the trauma patients (P < 0.001). Non-trauma patients presented a lower 24-h mortality than trauma patients (19 vs. 51%, P = 0.001). The non-trauma cases demonstrated a gradual but prolonged increased mortality, whereas survival in trauma cases rapidly declined (P = 0.009) with similar hospital mortality (68 vs. 64%). Non-trauma patients who survived for 24 h had 0 ventilator-free days and 0 ICU-free days vs. a median of 19 and 12, respectively, for trauma patients (P = 0.33 and 0.39, respectively). Non-hemorrhagic death was more common in non-trauma vs. trauma patients (83 vs. 33%, P < 0.001).
Non-traumatic hemorrhagic shock often resulted from a single bleeding site, and resulted in better 24-h survival than traumatic hemorrhage among Japanese patients who underwent REBOA. However, hospital mortality increased steadily in non-trauma patients affected by non-hemorrhagic causes after a longer period of critical care.
KeywordsResuscitative endovascular occlusion of the aorta (REBOA) Trauma Non-trauma Critical care Hemorrhagic shock
We thank all the members and investigators of DIRECT-IABO. Osaka City University Hospital (Naohiro Hagawa MD); Ohta Nishinouchi Hospital (Tokiya Ishida MD); National Hospital Organization Osaka National Hospital (Kenichiro Ishida MD); Nippon Medical School Musashikosugi Hospital (Eiji Yamamura MD); Ehime University Hospital (Kensuke Umakoshi MD); Saga University Hospital (Kosuke Chiris Yamada MD); Tokyobay Urayasu-Ichikawa Medical Center (Yosuke Homma MD); Osaka University Hospital (Tomoya Hirose MD); Kouseiren Takaoka Hospital (Mahiro Fujii MD); Asahi General Hospital (Chikao Ito MD); Teikyo University Hospital (Takahiro Yamamoto MD); Saiseikai Yokohamashi Tobu Hospital (Tomohiko Orita MD); St. Marianna University Hospital (Junichi Matsumoto MD); Senshu Trauma and Critical Care Medical Center (Koji Idoguchi MD); Hachinohe City Hospital (Yuri Kon MD); Chiba University Hospital (Keisuke Tomita MD); Yokohama Rosai Hospital (Takafumi Shinjo MD); Toho University Omori Medical Center (Yukitoshi Toyoda MD).
YM contributed to study conception and design, analysis and interpretation of data, statistical analysis, and drafting of the manuscript. JM, KI, HK, and TF contributed to the critical revision of the manuscript for important intellectual content and provided intellectual input to the research and manuscript. TI, YK, KT, KI, TH, and KU contributed to data acquisition and provided intellectual input to the research and manuscript. All authors read and approved the manuscript.
Compliance with ethical standards
Conflict of interest
Yosuke Matsumura is a member of clinical advisory board member of Tokai Medical Products. None of the other authors have any conflicts of interest to declare.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
All participating hospitals obtained individual local Institutional Review Board approval prior to registration of patient data. Individual consent was waived to register the observational data and was approved by the JAST Ethical Committee.
- 6.Brenner ML, Moore LJ, DuBose JJ, Tyson GH, McNutt MK, Albarado RP, et al. A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation. J Trauma Acute Care Surg. 2013;75(3):506–11. doi: 10.1097/TA.0b013e31829e5416.CrossRefPubMedGoogle Scholar
- 9.Moore LJ, Brenner M, Kozar RA, Pasley J, Wade CE, Baraniuk MS, et al. Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage. J Trauma Acute Care Surg. 2015;79(4):523–32. doi: 10.1097/TA.0000000000000809.CrossRefPubMedGoogle Scholar
- 14.Mayer D, Aeschbacher S, Pfammatter T, Veith FJ, Norgren L, Magnuson A, et al. Complete replacement of open repair for ruptured abdominal aortic aneurysms by endovascular aneurysm repair: a two-center 14-year experience. Ann Surg. 2012;256(5):688–95. doi: 10.1097/SLA.0b013e318271cebd (discussion 95–6).CrossRefPubMedGoogle Scholar
- 17.Matsumura Y, Matsumoto J, Kondo H, Idoguchi K, Funabiki T, investigators D-I. Partial occlusion, conversion from thoracotomy, undelayed but shorter occlusion: resuscitative endovascular balloon occlusion of the aorta strategy in Japan. Eur J Emerg Med. 2017;. doi: 10.1097/MEJ.0000000000000466.PubMedGoogle Scholar
- 19.Morrison JJ, DuBose JJ, Reva VA, Matsumoto J, Matsumura Y, Falkenberg M, et al. Top Stent. http://www.jevtmcom/top-stent/. 2017.
- 20.DuBose JJ, Scalea TM, Brenner M, Skiada D, Inaba K, Cannon J, et al. The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA). J Trauma Acute Care Surg. 2016;81(3):409–19. doi: 10.1097/TA.0000000000001079.CrossRefPubMedGoogle Scholar
- 21.Ogura T, Lefor AT, Nakano M, Izawa Y, Morita H. Nonoperative management of hemodynamically unstable abdominal trauma patients with angioembolization and resuscitative endovascular balloon occlusion of the aorta. J Trauma Acute Care Surg. 2015;78(1):132–5. doi: 10.1097/TA.0000000000000473.CrossRefPubMedGoogle Scholar