In the Vascular Trauma Controversies session at this year’s Charing Cross (CX) International Symposium (23–25 April, London, UK), one of the highlights was seen early on in proceedings, with a debate on whether there is a role for resuscitative endovascular balloon occlusion of the aorta (REBOA) after the UK-REBOA trial. With Nigel Tai (Royal London Hospital, London, UK) arguing for the use of REBOA and Tim Stansfield (Leeds Teaching Hospitals NHS Trust, Leeds, UK) putting forward a case for moving away from it, the debate had the audience split nearly down the middle; poll results showed 58% of attendees voting against the use of REBOA, with 42% voting for it, which moderator of the session Ross Davenport (Barts Health NHS Trust, London, UK) highlighted was not decisively in favour of either option.
Presenting his case in favour of REBOA first, Tai’s argument was based primarily on the ongoing requirement to address poor outcomes in sub-diaphragmatic traumatic haemorrhage, the evidence that REBOA can lead to rapid improvements in physiology and the benefit and lessons from high volume trauma centres from the USA. Whilst praising the need for and pragmatic design of the UK-REBOA study, “one that I was proud to participate in”, there were “several features of the study that, to my mind mean that we must caution against overzealous application of the study message to all settings.” He argued that, due to extended pre-hospital and pre-surgery times, difficulty in technical application of REBOA and an insufficient per-centre case load, the results of the UK-REBOA trial may instead reflect the reality of attempting to introduce a novel technology in a system that is not optimised for the care of major haemorrhage.
Tai added that he thinks where REBOA is targeted in a more proscriptive manner the picture is different. There is a “message to be gleaned” from two analyses, both of which are propensity-matched cohort studies conducted on the same Japanese trauma registry. “Where observational registry propensity-matched studies use a more comprehensive matching protocol and stricter calibration criteria there is a signal of survival advantage” he states. “Similarly, where REBOA is deployed in high-volume single centre settings such as Baltimore, the advantages can be evidenced.”
Conversely, Stansfield’s stance was that the most relevant element to this question should be framed as “would you advocate placing a REBOA resuscitation pack in your local trauma centre”. He argued that, should a major trauma centre have REBOA bags placed in them “someone will use it,” but they are not likely to “hit the sweet spot of REBOA usage, whatever that might be”. He instead suggested that they might be more likely to cause harm.
Stansfield also disputed Tai’s use of evidence to support the use of REBOA. “As we have heard, animal studies have demonstrated REBOA provides preferential pressure values to the coronary and carotid territories. However, balloon inflation comes at a cost of ischaemia reperfusion. Further, it shouldn’t be difficult to spot those that may benefit from REBOA, but in sick trauma patients, trauma mimics continue to surprise even experienced clinicians.”
One question that was posed to both presenters that did elicit a small amount of agreement, albeit with some caveats, was whether there was a role for the use of REBOA outside of hospitals and major trauma centres. As the first to respond, Tai stated: “My instinct is yes, […] but with a lot of preconditions. For instance, we run the Defence Medical Services training courses for REBOA, and we currently only teach one indication, which is essentially that if you have a patient who is occupying the single operating table in your far-forward surgical tent, and you receive another casualty who is bleeding, then you can use REBOA to bridge that patient to surgery.”
Stansfield’s response was also along a similar vein; he stated that, although he is not a pre-hospital doctor, he feels that the people that use REBOA pre-hospital are “exceptionally well trained at diagnosing haemorrhage”. However, he did urge caution, saying: “I think we’ve just got to be careful. If we say there is a role for REBOA, it has to have some very, very strong caveats to it in terms of patient selection and training.”
