To Ultrasound or not to Ultrasound: A REBOA Femoral Access Analysis from the ABOTrauma and AORTA Registries

IntroductionResuscitative endovascular balloon occlusion of the aorta (REBOA) is becoming a standardizedadjunct in the management of non-compressible hemorrhage. Ultrasound (US)-guided femoralaccess has been taught as the best practice for femoral artery cannulation. However, there is lackof evidence to support its use in patients in extremis with severe hemorrhage. We hypothesizethat no differences in outcome will exist between US-guided in comparison to blindpercutaneous or cutdown access methods.MethodsThis was an international, multicenter retrospective review of all patients managed with REBOAfrom the ABOTrauma Registry and the AORTA database. REBOA characteristics and outcomeswere compared among puncture access methods. Significance was set at P < 0.05.ResultsThe cohort included 523 patients, primarily male (74%), blunt injured (77%) with median age 40(27 – 58), ISS 34 (25 – 45). Percutaneous using external landmarks/palpation was the mostcommon femoral puncture method (53%) used followed by US-guided (27.9%). There was nosignificant difference in overall complication rates (37.4% vs 34.9%; P = 0.615) or mortality(47.8% vs 50.3%; P = 0.599) between percutaneous and US-guided methods; however, access bycutdown was significantly associated with emergency department (ED) mortality (P = 0.004), 24hour mortality (P = 0.002), and in-hospital mortality (P = 0.007).ConclusionsIn patients with severe hemorrhage in need of REBOA placement, the percutaneous approachusing anatomic landmarks and palpation, when compared to ultrasound-guided femoral access, was used more frequently without an increase in complications, access attempts, or mortality.Surgical cutdown was associated with highest ED, 24-hour, and in-hospital mortality. Level of Evidence: Level III; Prognostic