ORIGINAL ARTICLE

Patterns and outcomes of zone 3 REBOA use in the management of

severe pelvic fractures: Results from the AAST Aortic Occlusion for
Resuscitation in Trauma and Acute Care Surgery database
Melike Harfouche, MD, Kenji Inaba, MD, Jeremy Cannon, MD, Mark Seamon, MD, Ernest Moore, MD,
Thomas Scalea, MD, and Joseph DuBose, MD, Baltimore, Maryland

BACKGROUND: Knowledge on practice patterns for aortic occlusion (AO) in the setting of severe pelvic fractures is limited. This study aimed to
describe clinical outcomes based on number and types of interventions after zone 3 resuscitative endovascular balloon occlusion
of the aorta (REBOA) deployment.
METHODS: A retrospective review of the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute
Care Surgery multicenter registry was performed for patients who underwent zone 3 AO from 2013 to 2020. Patients with a blunt
mechanism who survived beyond the emergency department were included. Interventions evaluated were preperitoneal pelvic packing
(PP), angioembolization (AE), and external fixation (EF) of the pelvis. Management approaches were compared against the primary
outcome of mortality. Secondary outcomes included transfusion requirements, overall complications and acute kidney injury (AKI).
RESULTS: Of 207 patients who underwent zone 3 AO, 160 (77.3%) fit the inclusion criteria. Sixty (37.5%) underwent AO alone, 50 (31.3%)
underwent a second hemostatic intervention, and 49 (30.6%) underwent a third hemostatic intervention. Overall mortality was
37.7% (n = 60). There were no differences in mortality based on any number or combination of interventions. On multivariable
regression, only EF was associated with a mortality reduction (odds ratio, 0.22; p = 0.011). Increasing number of interventions
were associated with higher transfusion and complication rates. Pelvic packing + AE was associated with increased AKI than
PP or AE alone (73.3% vs. 29.5% and 28.6%, p = 0.005), and AE was associated with increased AKI resulting in dialysis than
PP alone (17.9% vs. 6.8%, p = 0.036).
CONCLUSION: Zone 3 REBOA can be used as a standalone hemorrhage control technique and as an adjunct in the management of severe pelvic
fractures. The only additional intervention associated with a mortality reduction was EF. The benefit of increasing number of in-
terventions must be weighed against more harm. Heterogeneity in practice patterns for REBOA use in pelvic fracture management
underscores the need for an evidence base to standardize care. (J Trauma Acute Care Surg. 2021;90: 659–665. Copyright © 2021
Wolters Kluwer Health, Inc. All rights reserved.)
LEVEL OF EVIDENCE: Therapeutic, Level IV.
KEY WORDS: Pelvic fractures; REBOA; hemorrhage control.

malperfusion associated with supraceliac AO.3 Despite the po-

B alloon occlusion of the aorta to arrest bleeding from pelvic
fractures was first outlined as a technique in 1999,1 but
was not subsequently proposed as part of an integrated manage-
ment guideline for pelvic fractures until 2010.2 Although originally
described as supraceliac aortic occlusion (AO), the technique of re-
suscitative endovascular balloon occlusion of the aorta (REBOA)
as a hemostatic adjunct for pelvic fracture management has since
been modified. Inflation of the balloon in the infrarenal aorta, or
zone 3, has been shown to arrest troublesome arterial bleeding un-
til definitive hemostasis can be achieved while avoiding the organ
Submitted: August 29, 2020, Revised: November 24, 2020, Accepted: November 28,
2020, Published online: December 31, 2020.
From the R Adams Cowley Shock Trauma Center (M.H., T.S., J.D.), University of
Maryland School of Medicine, Baltimore, Maryland; Division of Trauma and
Critical Care (K.I.), University of Southern California, Los Angeles, California;
Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Depart-
ment of Surgery (J.C., M.S.), University of Pennsylvania, Philadelphia,
Pennsylvania; and Department of Surgery (E.M.), University of Colorado,
Denver Health Medical Center, Denver, Colorado
Address for reprints: Melike Harfouche, MD, R Adams Cowley Shock Trauma Center,
University of Maryland Medical Center, 22 S. Greene St, Baltimore, MD 21201;
email: mharfouche@som.umaryland.edu.
DOI: 10.1097/TA.0000000000003053
J Trauma Acute Care Surg
Volume 90, Number 4
tential benefit of this adjunct, there remains uncertainty regard-
ing appropriate next steps to achieve definitive hemostasis after
REBOA deployment.
Interventions used to promote hemorrhage control in pel-
vic fractures presently used at modern trauma centers are highly
variable because of the lack of consensus on best practices and
different resource capabilities at each institution. These include
preperitoneal pelvic packing (PP), external fixation (EF), and
angioembolization (AE). Pelvic packing with EF for pelvic frac-
ture management following REBOA inflation has been described
by the Denver Health group.4 Their management guideline for
unstable pelvic fractures emphasizes PP to be performed concur-
rently with EF, and they report mortality rates of 21% to hospital
discharge,5 lower than previous studies of a similar cohort.6 How-
ever, not all centers perform EF in conjunction with PP and may
prefer different hemostatic maneuvers such as AE. Although early
reports of AE demonstrated favorable results,7 subsequent studies
have questioned its role as a primary therapeutic intervention
when the majority of pelvic fracture bleeding is venous in na-
ture.8 Furthermore, given the critical importance of time to he-
mostasis, the delay to an interventional radiology (IR) suite
may preclude the expedient delivery of AE.9,10
659

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Harfouche et al.
Amidst the general lack of consensus on the timing and
use of hemostatic techniques for severe pelvic fractures, there
is a paucity of data on the integration of REBOA within this ar-
mamentarium of options. The aim of this study is to describe the
outcomes of patients in the Aortic Occlusion for Resuscitation in
Trauma and Acute Care Surgery (AORTA) registry who have
undergone zone 3 REBOA placement with a focus on the num-
ber and types of hemostatic interventions performed for the
management of pelvic fractures.
METHODS
The AORTA registry was approved by the American As-
sociation for the Surgery of Trauma (AAST) Multicenter Trials
Committee. It is a prospectively collected, national database that
gathers data from trauma centers within the continental United
States of adult patients (≥18 years) who undergo AO in the acute
phases after injury. Data that are captured include demographics,
clinical findings, laboratory results, and Injury Severity Scores
(ISS). Specifics regarding AO timing, location, physiologic response,
and subsequent outcomes are recorded as well. All centers obtain
their own institutional review board approval prior to data collection
and registrars enter deidentified data in real time in an online data
collection portal. Each center provides the Basic Endovascular Skills
in Trauma course by the American College of Surgeons or its
equivalent prior to having providers deploy the REBOA catheter.
A retrospective review of the AORTA registry was per-
formed for all patients who underwent zone 3 AO from
November 2013 to April 2020. Patients who died in the emer-
gency department (ED) and who did not sustain a blunt mecha-
nism were excluded from the analysis. The purpose of this study
was to evaluate integration of REBOA with other hemostatic in-
terventions; as such, those who died in the ED did not satisfy the
population of interest. Within this group who survived beyond the
ED, those who underwent subsequent hemostatic intervention
FIGURE 1. Flow diagram demonstrating number and outcome of interventions performed on zone 3 REBOA patients in the AORTA
registry from November 2013 to April 2020.
660
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J Trauma Acute Care Surg
Volume 90, Number 4
beyond AO were identified. These interventions were preperitoneal
PP, pelvic AE, and EF. Patients who only underwent angiography
without AE were excluded. Patient outcomes were compared based
on the number and types of hemostatic interventions performed.
Primary outcome was in-hospital mortality. Secondary outcomes
were transfusion requirements, overall complication rate, and rates of
acute kidney injury (AKI) with or without dialysis, sepsis, acute respi-
ratory distress syndrome, and multiorgan dysfunction syndrome.
Univariate and multivariate analyses were performed using
STATAv16 SE. Continuous variables were reported as mean with
standard deviation for parametric values and median with inter-
quartile range for nonparametric values. χ2 Testing was used to
compare categorical data and analysis of variance and the Student
t test were used to compare parametric continuous data. Nonpara-
metric data were compared using the Kruskal-Wallis test. Multi-
variable logistic regression was used to test for significant
associations between multiple variables and the primary outcome
of mortality. Significance was assumed for p values <0.05.
RESULTS
A total of 207 patients were identified as having under-
gone zone 3 AO from November 2013 to April 2020. Seventeen
(8.2%) patients died in the ED prior to any additional interven-
tions and 30 (14.5%) had a penetrating or unreported mecha-
nism. Among the 160 (77.3%) patients who were in the final
study population, 60 (37.5%) did not undergo an additional in-
tervention. Fifty (31.3%) patients underwent a second hemo-
static intervention, whereas 49 (30.6%) underwent a third
hemostatic intervention. Only 1 patient received all 4 hemostatic
interventions. This is represented in Figure 1. Within the group
that underwent 2 hemostatic interventions, 17 (34%) underwent
AO + PP, 20 (40%) underwent AO + AE, and 13 (26%)
underwent AO + EF. Within the group that received three hemo-
static interventions, 27 (55.1%) underwent AO + PP + EF, 14
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J Trauma Acute Care Surg
Volume 90, Number 4 Harfouche et al.

FIGURE 2.. Flow diagram demonstrating types and outcomes of interventions performed on zone 3 REBOA patients in the AORTA
registry from November 2013 to April 2020.

(28.6%) underwent AO + PP + AE and 8 (16.3%) underwent
AO + AE + EF. Additional interventions performed after REBOA
deployment are shown in Figure 2.
Mean age of the overall study population was 47 ± 18 years
and 72% (n = 115) were men. The most common mechanism
subtype was motor vehicle collision (n = 64, 40%) followed by
pedestrian struck (n = 49, 30.6%). When comparing patients
who underwent REBOA alone (R) to those who underwent a
second or third hemostatic intervention, there were no differ-
ences with regard to age, head or chest Abbreviated Injury Scale
(AIS) scores, systolic blood pressure (SBP) or heart rate (HR) on
admission, or cardiopulmonary resuscitation (CPR) on arrival
(Table 1). Patients who underwent two hemostatic interventions
(R + 1) had a higher abdominal AIS score (3 vs. 2, p = 0.004)
and a higher ISS (38 vs. 33 p = 0.058) when compared to
REBOA alone. Patients who underwent a third hemostatic inter-
vention (R + 2) were more likely to be men (88% vs. R = 63.3%,
2nd = 68.0%, p = 0.013) and have a higher ISS (38 vs. R = 33,
p = 0.058) and higher Glasgow Coma Scale (GCS) score (11 vs.
R = 9, 2nd = 8, p = 0.019).
Overall mortality was 37.7% (n = 60). In evaluating mor-
tality based on number of hemostatic interventions, there were
no differences between groups (Table 2). There was no differ-
ence in mean time to mortality between groups, with an average
of 6 ± 12 days to in-hospital death. Patients who underwent a
third hemostatic intervention had higher packed red blood cell
(pRBC) requirements (22.2 units vs. R = 13.1, 2nd = 17.2,
p = 0.019), higher rates of overall complications (61.2% vs.
R = 45.0%, 2nd = 36.0%, p = 0.039), AKI (49% vs.
R = 16.7%, 2nd = 20.0%, p < 0.001), and acute renal failure re-
quiring dialysis (18.4% vs. R = 5.0%, 2nd = 8.0%, p = 0.006).
With regard to access site complications, there were 10 total
cases of lower-extremity ischemia (6.3%), from which 7 were
in the REBOA+2 group (p = 0.005). Two patients who

TABLE 1. Clinical Characteristics of Zone 3 REBOA Patients Who Underwent REBOA Only Versus 1 or 2 Additional Pelvic Interventions
Total (N = 159) REBOA Only (n = 60) REBOA +1 (n = 50) REBOA +2 (n = 49) p
Age, y 47 ± 18 46 ± 20 49 ± 18 45 ± 18 0.62
Sex, n (%) 0.013
Male 115 (72.3) 38 (63.3) 34 (68.0) 43 (87.8)
Female 44 (27.7) 22 (36.7) 16 (32.0) 6 (12.2)
ISS 36 ± 13 33 ± 15 38 ± 14 38 ± 11 0.058
Body region AIS score*
Head 3 (4) 3 (4) 2 (4) 3 (4) 0.26
Chest 3 (2) 3 (2) 3 (2) 3 (1) 0.99
Abdomen 3 (2) 2 (2) 3 (1) 3 (2) 0.004
SBP** 86 ± 41 81 ± 42 89 ± 39 90 ± 42 0.50
HR** 108 ± 37 108 ± 38 108 ± 33 109 ± 42 0.99
GCS score** 9±5 8±5 8±5 11 ± 5 0.019
CPR on arrival, n (%) 12 (7.5) 3 (5.0) 6 (12.0) 3 (6.1) 0.37
Duration of AO, min* 47.5 (70.5) 35 (52) 67 (98) 62 (73) 0.11
*Median (interquartile range).
**On admission.

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 J Trauma Acute Care Surg
Harfouche et al. Volume 90, Number 4

TABLE 2. Clinical Outcomes of Study Population Divided Into REBOA Alone Versus 1 or 2 Additional Pelvic Interventions
Total (N = 159) REBOA (n = 60) REBOA +1 (n = 50) REBOA +2 (n = 49) p
Mortality 60 (37.7) 24 (40.0) 21 (42.0) 15 (30.6) 0.49
Hospital day mortality 6.0 ± 11.8 6.8 ± 9.7 5.9 ± 15.3 5.1 ± 9.6 0.91
pRBC requirements 17.2 ± 16.6 13.1 ± 9.9 17.2 ± 16.5 22.2 ± 21.5 0.019
Overall complications* 75 (47.2) 27 (45.0) 18 (36.0) 30 (61.2) 0.039
AKI 44 (27.7) 10 (16.7) 10 (20.0) 24 (49.0) <0.001
Dialysis 16 (10.1) 3 (5.0) 4 (8.0) 9 (18.4) 0.006
Sepsis/septic shock 18 (11.3) 7 (11.7) 6 (12.0) 5 (10.2) 0.96
ALI/ARDS 28 (17.6) 13 (21.7) 7 (14.0) 8 (16.3) 0.55
MODS 22 (13.8) 7 (11.7) 6 (12.0) 9 (18.4) 0.54
Extremity ischemia 9 (5.7) 2 (3.3) 0 (0) 7 (14.3) 0.005
*Includes AKI +/− dialysis, sepsis, ARDS, MODS, pneumonia, MI, and stroke.
ALI, acute lung injury; ARDS, acute respiratory distress syndrome; MODS, multiple organ dysfunction syndrome.

developed ischemia required amputation. There were 3 cases of
pseudoaneurysm formation and 2 cases of distal embolism, with
no difference between groups. Most of the devices used were
ER-REBOA catheters (n = 112, 76.5%), followed by CODA
catheters (n = 33, 22.3%). No association was found between de-
vice type and extremity ischemia.
A separate evaluation of outcomes based on type and
combination of interventions demonstrated no association with
mortality with regard to those who underwent PP alone, AE
alone, and PP + AE, stratified into all-comers, with EF, and
without EF (Table 3). Patients who underwent PP + AE had
higher pRBC requirements, overall complication rates, and rates

TABLE 3. Outcomes in Zone 3 REBOA Patients With Specific Additional Management Modalities
All-Comers
Pelvic Packing (n = 44) AE (n = 28) PP + AE (n = 15) p
Mortality 17 (38.6) 9 (32.1) 7 (46.7) 0.64
pRBC requirements 19.6 ± 14.1 17.1 ± 19.2 35.5 ± 32 0.012
Overall complications 20 (45.5) 12 (42.9) 13 (86.7) 0.012
AKI 13 (29.5) 8 (28.6) 11 (73.3) 0.005
Dialysis 3 (6.8) 5 (17.9) 4 (26.7) 0.036
Sepsis/septic shock 5 (11.4) 2 (7.1) 3 (20.0) 0.45
ALI/ARDS 6 (13.6) 5 (17.9) 3 (20.0) 0.81
MODS 5 (11.4) 4 (14.3) 5 (33.3) 0.13
With EF
Pelvic Packing (n = 27) AE (n = 8) PP + AE (n = 1) p
Mortality 6 (22.2) 2 (25.0) 0 (0) 0.85
pRBC requirements 17.0 ± 13.9 20.6 ± 13.7 70.0 0.003
Overall complications 14 (51.9) 4 (50.0) 1 (100) 0.63
AKI 10 (37.0) 4 (50.0) 1 (100) 0.39
Dialysis 3 (11.1) 3 (37.5) 1 (100) 0.13
Sepsis/septic shock 3 (11.1) 0 (0) 1 (100) 0.011
ALI/ARDS 5 (18.5) 0 (0) 0 (0) 0.38
MODS 3 (11.1) 1 (12.5) 0 (0) 0.93
Without EF
Pelvic Packing (n = 17) AE (n = 20) PP + AE (n = 14) p
Mortality 11 (64.7) 7 (35.0) 7 (50.0) 0.20
pRBC requirements 23.8 ± 13.8 15.9 ± 20.9 33.1 ± 31.7 0.10
Overall complications 6 (35.3) 8 (40.0) 12 (85.7) 0.009
AKI 3 (17.6) 4 (20.0) 10 (71.4) 0.002
Dialysis 0 (0) 2 (10.0) 3 (21.4) 0.027
Sepsis/Septic Shock 2 (11.8) 2 (10.0) 2 (14.3) 0.92
ALI/ARDS 1 (5.9) 5 (25.0) 3 (21.4) 0.29
MODS 2 (11.8) 3 (15.0) 5 (35.7) 0.10

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J Trauma Acute Care Surg
Volume 90, Number 4 Harfouche et al.

with severe pelvic fractures from blunt trauma. This study illus-
TABLE 4. Multivariable Regression Model of Odds of Mortality
trates the nationwide integration of REBOA into pelvic fracture
Following Zone 3 REBOA for Pelvic Hemorrhage
management by describing mortality and complication rates
OR CI p based on the number and type of intervention performed. The
Age >50 years 3.75 1.49–9.44 0.005 findings of this study indicate that trauma centers use REBOA
Male sex 1.06 0.39–2.91 0.905 as both a stand-alone technique and with additional techniques,
ISS > 30 5.56 1.71–18.12 0.004 such as AE, PP, and EF, to control pelvic fracture-related hemor-
Body region AIS score ≥ 3 rhage. The increasing number of interventions was associated
Head 2.32 0.78–6.92 0.132 with higher complication rates. No combination of interventions
Chest 0.86 0.27–2.72 0.794 was found to be superior, and only EF was associated with a sig-
Abdomen 0.24 0.08–0.73 0.012 nificant mortality benefit when controlling for multiple variables.
SBP < 80 0.61 0.24–1.56 0.298 The mortality rate in this study population (37.7%) is sim-
HR > 120 1.06 0.42–2.69 0.900 ilar to the 32% mortality reported in the AAST retrospective
GCS score < 8 5.10 1.97–13.2 0.001 study reviewing 1,339 patients with pelvic fractures, among
CPR in progress 9.75 1.28–74.3 0.028 which 178 had hemodynamic instability.6 However, their data
Thoracotomy 6.29 0.64–61.8 0.114 spanning 2013 to 2015 reported a mean ISS of 28, with four pa-
Laparotomy 4.14 1.44–11.9 0.008 tients arriving in cardiac arrest and only five undergoing
Preperitoneal pelvic packing 0.75 0.27–2.14 0.596 REBOA placement. In contrast, this study reviews 160 patients
Pelvic AE 1.02 0.37–2.84 0.963 who survived REBOA placement beyond the ED with a mean ISS
Pelvic EF 0.22 0.07–0.70 0.011 of 36, among which 12 arrived in cardiac arrest. The larger sample
size and lower mortality rate in our study support the growing role
R2 = 0.365.
CI, confidence interval. of zone 3 REBOA among hypotensive pelvic fracture patients and
suggest the potential for greater mortality reduction when used
as stand-alone intervention or as a bridge to definitive hemostasis.
of AKI with or without dialysis when compared with those who
The use of additional hemostatic interventions after zone
underwent PP or AE alone. Patients who underwent AE alone
3 REBOA deployment in this study was common, with most pa-
had higher rates of AKI, resulting in dialysis than those who
tients undergoing some combination of pelvic packing,
underwent PP alone (17.9% vs. 6.8%, p = 0.036). Patients un-
angioembolization or EF. No combination of procedures with
dergoing AE did not undergo AE of any other body region. Uni-
REBOA appeared to be superior to REBOA alone in terms of
variate analysis of patients undergoing PP alone demonstrated
survival. This could be explained by the REBOA-only patients
6.7 times higher odds of mortality than if undergoing PP + EF
having a lower injury severity rather than the lack of benefit of
(p = 0.005). There was no difference in mortality on univariate
additional interventions. The use of REBOA alone in 37.5%
analysis of patients undergoing AE alone versus AE + EF. Multivar-
of the study population suggests that it may function as a
iable logistic regression demonstrated that significant contributors to
stand-alone intervention by temporarily eliminating flow to bleed-
mortality were: older than 50 years (odds ratio [OR], 3.8; p = 0.005),
ing arterial branch vessels that subsequently thrombose.
ISS greater than 30 (OR, 5.6; p = 0.004), GCS score less than 8 (OR,
When controlling for pretreatment variables that might in-
5.1; p = 0.001), laparotomy (OR, 4.14; p = 0.008), and CPR in
fluence the outcome of mortality, such as ISS and arrival in car-
progress (OR, 9.8; p = 0.028). Of the three interventions, only EF
diac arrest, the only hemostatic intervention associated with a
was independently associated with a decrease in mortality follow-
mortality reduction after zone 3 REBOA was EF. Patients who
ing zone 3 REBOA utilization (OR, 0.22; p = 0.011) (Table 4).
underwent EF in this setting were 4.5 times less likely to die than
A subgroup analysis excluding patients who underwent
those who did not undergo EF. This underscores the critical im-
CPR on arrival demonstrated similar findings. There was no dif-
portance of pelvic stabilization as a method of hemostasis in he-
ference in mortality based on number and types of interventions
modynamically unstable patients with pelvic fractures and as a
performed, aside from pelvic fixation. On the multivariable re-
necessary adjunct to pelvic packing. These findings are in agree-
gression model, EF was associated with 3.3 times decreased
ment with previous published studies emphasizing the impor-
odds of mortality (OR, 0.30; p = 0.041). More complications
tance of early pelvic stabilization to reduce pelvic volume and
were associated with an increasing number of interventions.
control venous bleeding.11
A separate table (Table 5) is included in the Appendix
Preperitoneal pelvic packing was the most common proce-
comparing the excluded patients who underwent AO and ex-
dure after REBOA deployment, followed by EF and AE. The lower
pired in the ED to the overall study population and the
rates of AE in this study population suggest that most patients were
REBOA-only patients who were ultimately included in the
being managed in an operative suite rather than in an Interventional
study. Excluded patients had significantly higher ISS, lower
Radiology (IR) suite or a hybrid operating room (hybrid-OR). This
SBP, HR, and GCS, and higher percentage of patients arriving
could be due to several factors, namely greater comfort with one
in cardiac arrest than either comparator group.
technique over another, other indications for operative explora-
tion, or lack of availability of an IR suite or a hybrid-OR. The de-
DISCUSSION lay in time to hemostasis for IR intervention is a deterrent to AE
in many centers that do not have access to a hybrid-OR.12
This is the largest and most comprehensive study to date Increasing number and combination of interventions af-
of utilization of zone 3 REBOA in the management of patients ter zone 3 REBOA deployment were associated with greater

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 J Trauma Acute Care Surg
Harfouche et al. Volume 90, Number 4

complication rates and transfusion requirements. This could compounding this issue is the lack of clear guidelines from ma-
have been due to greater injury severity in these patients with on- jor trauma societies. The latest Eastern Association for the Sur-
going hemorrhage requiring additional interventions and com- gery of Trauma (EAST) guidelines are from 2011 and do not
plications associated with large volume blood loss. However, mention REBOA,15 whereas Western Trauma guidelines from
increasing number of interventions may also be associated with 2016 include it as an option alongside preperitoneal packing and
greater harm and little additional benefit. EF.16 The paucity of data regarding outcomes in hemodynamically
Patients who underwent PP + AE had the highest overall unstable patients with pelvic fractures who undergo REBOA place-
complication and AKI rates than those who underwent either in- ment adds greater complexity to decision-making. A recent survey
tervention alone. Patients who underwent AE alone had higher of trauma medical directors from 36 Level I trauma centers reported
rates of AKI resulting in dialysis than those who underwent PP that less than half have incorporated REBOA into their pelvic frac-
alone. These findings suggest that the potential benefit of AE ture clinical guidelines.17 The top contributing institutions to this
in the setting of pelvic hemorrhage must be weighed carefully study include REBOA as a suggestion in their pelvic fracture prac-
against the increased risk of renal insult. tice management guidelines rather than a mandatory step in their
This study is largely descriptive in nature and some limi- algorithm. As the use of REBOA grows, it is essential to determine
tations must be noted. It does not include several variables that how it can best be integrated into pelvic fracture management.
may further describe severity of illness such as pelvic fracture
subtype or cause of death. These variables could add greater va-
lidity to the comparison of different interventions. The lack of CONCLUSION
several pretreatment variables as well as the small sample size
of this study limit the conclusions that can be drawn from the This is the largest study to date from trauma centers within
comparisons across groups, both for the number of interventions the United States that describes the outcome and management of
performed and for types and combinations of interventions. The patients who have undergone zone 3 REBOA deployment for
results of the multivariable regression should be interpreted with the management of severe pelvic fractures. This study confirms
caution due to the small sample size and regression coefficient that mortality and morbidity from this injury pattern remains
which indicates there are several confounders the model does high, but that REBOA is being used successfully as both a
not account for. The purpose of this study was to describe how standalone hemorrhage control technique and as an adjunct in
centers integrate REBOA into pelvic fracture management, conjunction with other hemostatic techniques. The benefit of in-
and not to test the benefit of one intervention over another. A fu- creasing number of interventions must be weighed against addi-
ture study that standardizes pretreatment variables across groups tional harm. The integration of REBOA in severe pelvic fracture
would more appropriately address the mortality benefit for each management alongside the myriad of additional hemostatic in-
intervention or combination thereof. Given institutional tenden- terventions must be studied in a concerted fashion to fill the cru-
cies to perform certain interventions more frequently than cial need for an evidence base to standardize care.
others, the relationship between intervention type and outcome
might have been influenced by center practice and experience.
Furthermore, the AORTA registry does not capture all trauma APPENDIX
centers nationwide, but only those that are part of the AAST pro-
spective trial which may bias the results toward centers with
more REBOA experience. Critically, the AORTA registry only TABLE 5. Characteristics of ED Deaths Compared to
captures patients who have received AO to control hemorrhage. REBOA-Only Patients in Study Population and Overall Study
As such, the use of this data set does not afford comparison to subsets Population
of patients who went directly to some combination of EF, PP or AE Study
without antecedent AO. The purpose of this study was not to deter- ED Deaths REBOA-Only Population
mine when to use REBOA in the setting of pelvic fractures, and no (n = 17) (n = 60) p (n = 160) p
conclusions on this question can be drawn from the data presented. Age, y 40 ± 17 46 ± 20 0.30 47 ± 18 0.21
Future studies must evaluate the benefits of each pelvic Sex, n (%) 0.14 0.37
fracture management intervention with and without AO. A re- Male 14 (82.3) 38 (63.3) 115 (72.3)
cent publication comparing zone 3 REBOA to PP in the setting Female 3 (17.6) 22 (36.7) 44 (27.7)
of severe pelvic fractures found worse outcomes in the REBOA ISS 46 ± 19 33 ± 15 0.003 36 ± 13 0.005
group.13 As seen in our study, current practice patterns involve Body region AIS score*
the use of the two techniques in cohort rather than as exclusive Head 4 (3) 3 (4) 0.42 3 (4) 0.13
interventions. To determine the benefit of AO, study design Chest 3 (1) 3 (2) 0.24 3 (2) 0.17
must consider actual clinical practice which involves the combi- Abdomen 3 (2) 2 (2) 0.17 3 (2) 0.70
nation of several interventions for pelvic hemorrhage control. SBP** 48 ± 57 81 ± 42.3 0.010 86 ± 41 <0.001
This study affirms the wide variability across institutions HR** 58 ± 55 108 ± 38 <0.001 108 ± 37 <0.001
regarding the use of hemostatic adjuncts for the management GCS score** 3±1 8±5 <0.001 9±5 <0.001
of severe pelvic fractures and the need for guidance on the best CPR on arrival n (%) 7 (41.2) 3 (5.0) <0.001 12 (7.5) <0.001
approach.14 The order, combination, and specific indications
for each technique often differ from one trauma center to the *Median (interquartile range).
**On admission.
next based on local capabilities and practice patterns. Further

664 © 2021 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

J Trauma Acute Care Surg
Volume 90, Number 4
AUTHORSHIP
M.H. contributed to the literature search, data analysis, data interpreta-
tion, writing, and critical revision. J.D. contributed to literature search,
study design, data collection, data analysis, data interpretation, and criti-
cal revisions. K.I., M.S., and J.C. contributed to literature search, study de-
sign and data collection. E.M. contributed to the study design, data
collection, data interpretation, and critical revisions. T.S. contributed to
study design, data collection, and critical revisions.
DISCLOSURE
The authors declare no funding and no conflicts of interest.
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