title: Resuscitative endovascular balloon occlusion of the aorta versus aortic cross clamping among patients with critical trauma: a nationwide cohort study in Japan.
abstract: BACKGROUND
  Measures of aortic occlusion (AO) for resuscitation in patients with severe torso trauma remain controversial. Our aim was to characterize the current use of resuscitative endovascular balloon occlusion of the aorta (REBOA) and resuscitative open aortic cross-clamping (ACC), and to evaluate whether REBOA should be an alternative method to resuscitative open ACC.
  
  
  METHODS
  This study was a retrospective cohort study between 2004 and 2013 from a nationwide trauma registry in Japan. Participants were selected who underwent either REBOA or ACC. Their characteristics, interventions, and outcomes were analyzed to compare REBOA and ACC directly. The primary outcome was in-hospital mortality and the secondary outcome was mortality in the emergency department. Logistic regression analysis was performed to compare the outcomes between REBOA and ACC with adjustment for severity; 1:1 propensity score matching was also performed.
  
  
  RESULTS
  Of the 159,157 trauma patients, 903 were eligible based on the selection criteria. Overall, 405/607 patients (67%) who had REBOA died compared to 210/233 patients (90%) who had ACC. Patients with REBOA had higher revised trauma score (RTS) (mean ± SD, 5.2 ± 2.0 vs. 4.2 ± 2.2; P < 0.001) but higher Injury Severity Score (ISS) (median (interquartile); 34 (25) vs. 34 (20); P < 0.001), and higher probability of survival (0.43 ± 0.36 vs. 0.27 ± 0.30; P < 0.001) compared to those with ACC. REBOA had an odds ratio (OR) for in-hospital mortality of 0.309 (95% confidence interval (CI) = 0.190-0.502) adjusting for trauma and injury severity score using a logistic regression model (n = 903). Similar associations were observed adjusting for RTS (OR = 0.224; 95% CI = 0.129-0.700) or adjusting for ISS (OR, 0.188; 95% CI, 0.116 to 0.303). In the propensity score-matched cohort (n = 304), REBOA was associated with lower mortality compared to ACC (OR, 0.261; 95% CI, 0.130 to 0.523). Patients with REBOA had less severe chest complications than those with ACC (Abbreviated Injury Scale thorax, 3.8 ± 0.8 vs. 4.2 ± 0.8; P < 0.001), although physiological severity and backgrounds were similar in this population.
  
  
  CONCLUSIONS
  Patients who underwent AO had a high mortality. REBOA might be a favorable alternative method to resuscitative ACC for severe torso trauma although some indication bias could still remain. Further studies are needed to elucidate optimal indications.
authors.affiliation: Department of Health Services Research, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, 305-8577, Japan. abetoshi111@gmail.com.|Department of Emergency Medicine, Tsukuba Medical Center Hospital, 1-3-1, Amakubo, Tsukuba, 305-8558, Japan. abetoshi111@gmail.com.
authors.forename: Toshikazu
authors.initials: T
authors.lastname: Abe
authors.affiliation: Department of Health Services Research, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, 305-8577, Japan.
authors.forename: Masatoshi
authors.initials: M
authors.lastname: Uchida
authors.affiliation: Department of Health Services Research, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, 305-8577, Japan.
authors.forename: Isao
authors.initials: I
authors.lastname: Nagata
authors.affiliation: Department of Traumatology and Emergency Medicine, National Defense Medical College, 3-2, Namiki, Tokorozawa, Saitama, 359-8513, Japan.
authors.forename: Daizoh
authors.initials: D
authors.lastname: Saitoh
authors.affiliation: Department of Health Services Research, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, 305-8577, Japan.
authors.forename: Nanako
authors.initials: N
authors.lastname: Tamiya
mesh_terms: D000328:Adult; D000368:Aged; D001011:Aorta / Q000601:surgery*; D021721:Balloon Occlusion / Q000592:standards*; D015331:Cohort Studies; D003250:Constriction; D057510:Endovascular Procedures / Q000379:methods; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D007564:Japan; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D057216:Propensity Score; D012042:Registries / Q000706:statistics & numerical data; D012151:Resuscitation / Q000379:methods*; D012189:Retrospective Studies; D016019:Survival Analysis; D013898:Thoracic Injuries / Q000601:surgery / Q000628:therapy; D014947:Wounds and Injuries / Q000601:surgery / Q000628:therapy