Research Original Investigation REBOA for Proximal Aortic Control in Severe Hemorrhage and Arrest Invited Commentary Early Adoption of Resuscitative Endovascular Balloon Occlusion of the Aorta The Beginning of a Journey Joseph M. Galante, MD New ideas rely on innovators and early adopters to advance clear indications for its use, resuscitative thoracotomy is easier into mainstream practice. Brenner and colleagues at the R. Ad- and more practical, and there is only anecdotal evidence of its efficacy. Brenner et al ams Cowley Shock Trauma Center at the University of Mary- have shown the different scenarios in land are true early adopters. which REBOA can be applied. Algorithms with indications for Building on the innovation REBOA have been published by the US Military as a clinical 2 3 4 Related article page 130 of Hughes from the 1950s, practice guideline. Biffl et al published an algorithm for Brenner et al have applied REBOA use in exsanguinating hemorrhage. There needs to resuscitative endovascular balloon occlusion of the aorta be a concerted effort to clearly define when and in whom (REBOA) to the trauma and acute care surgery settings. Their REBOA should be used. Regarding comparison with thora- results are remarkable, but represent only the experience of cotomy, Moore et al compared REBOA with thoracotomy dur- early adopters at a single institution. ing an 18-month period, and, like Brenner, showed that the 2 In this issue of JAMA Surgery, Brenner et al show that procedures are comparable. Yes, these are not randomized REBOA offers a means of hemorrhage control in severe trau- clinical trials, but if perfect data were needed for a change in matic hemorrhage and is an alternative to resuscitative tho- practice, very little in trauma care would ever advance or racotomy in traumatic arrest. In addition, REBOA is de- change. A review of trauma literature from the past 5 years re- scribed for hemorrhage control in the setting of acute care veals very few randomized clinical trials. Owing to a lack of surgery of nontraumatic hemorrhage. funding and complex regulations related to patient consent, The American College of Surgeons Committee on Trauma much of trauma care is driven by surgeons’ experiences and has recognized the potential of REBOA. The Basic Endovas- retrospective studies. cular Skills in Trauma course, which began in 2016, gives gen- A Chinese proverb says, “A journey of a thousand miles be- eral surgeons the skill set required to quickly and safely place gins with a single step.” Brenner and colleagues are several a REBOA. The development and release of the Basic Endovas- steps into the journey, and their experience with REBOA gives cular Skills in Trauma course, along with the article by Brenner us insight into the future of trauma care if the technology et al, are 2 steps toward broader adoption of REBOA. can be widely adopted. This adoption would be hastened by Unfortunately, as with all new technologies, there are skep- improving trauma funding to prove to the skeptics, through tics. Those who are skeptical of REBOA argue that there are no well-designed trials, that this technology benefits patients. ARTICLE INFORMATION REFERENCES hemorrhagic shock. http://www.usaisr.amedd .army.mil/cpgs/REBOA_for_Hemorrhagic_Shock Author Affiliations: Division of Trauma, Acute Care 1. Brenner M, Teeter W, Hoehn M, et al. Use of _16Jun2014.pdf. Published June 16, 2014. Accessed Surgery, Surgical Critical Care, University of resuscitative endovascular balloon occlusion of the July 14, 2017. California, Davis, Sacramento; Department of aorta for proximal aortic control in patients with Surgery, University of California, Davis, Sacramento. severe hemorrhage and arrest [published online 4. Biffl WL, Fox CJ, Moore EE. The role of REBOA in September 27, 2017]. JAMA Surg. doi:10.1001 the control of exsanguinating torso hemorrhage. Corresponding Author: Joseph M. Galante, MD, /jamasurg.2017.3549 J Trauma Acute Care Surg. 2015;78(5):1054-1058. Department of Surgery, University of California, Davis, 2315 Stockton Blvd, Sacramento, CA 95817 2. Hughes CW. Use of an intra-aortic balloon 5. Moore LJ, Brenner M, Kozar RA, et al. (firstname.lastname@example.org). catheter tamponade for controlling intra-abdominal Implementation of resuscitative endovascular hemorrhage in man. Surgery. 1954;36(1):65-68. balloon occlusion of the aorta as an alternative to Published Online: September 27, 2017. resuscitative thoracotomy for noncompressible doi:10.1001/jamasurg.2017.3552 3. US Army. Joint theater trauma system clinical truncal hemorrhage. J Trauma Acute Care Surg. practice guideline: resuscitative endovascular Conflict of Interest Disclosures: None reported. 2015;79(4):523-530. balloon occlusion of the aorta (REBOA) for 136 JAMA Surgery February 2018 Volume 153, Number 2 (Reprinted) jamasurgery.com © 2017 American Medical Association. All rights reserved.
JAMA Surgery – American Medical Association
Published: Feb 27, 2018
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