Perioperative Outcomes and Safety of Resuscitative Endovascular Balloon Occlusion of the Aorta in Ruptured Abdominal Aortic Aneurysm Repair: A Propensity-Matched Cohort Study

OBJECTIVE: To compare perioperative outcomes between resuscitative endovascular balloon occlusion of the aorta (REBOA) and non-REBOA management in ruptured abdominal aortic aneurysm (rAAA) repair, and to perform an exploratory comparison of REBOA outcomes between open surgical repair (OSR) and endovascular aortic repair (EVAR). METHODS: A retrospective analysis was conducted of 107 consecutive rAAA patients (2013-2022), stratified by surgical approach (OSR vs EVAR) and REBOA utilization. Propensity score matching (1:2) was performed based on preoperative shock, comorbidities, and aneurysm morphology, yielding 22 REBOA and 44 non-REBOA patients. Outcomes were compared statistically. RESULTS: Resuscitative endovascular balloon occlusion of the aorta was utilized in 22 patients (10/45 [22.2%] OSR and 12/62 [19.4%] EVAR), with a 100% technical success rate. One Clavien-Dindo grade I access site hematoma occurred (4.5%). No instances of aortic injury, distal embolization, limb ischemia, or balloon failure were observed. After matching, 30-day mortality did not differ significantly (13.6% vs 22.7%, p=0.555). Resuscitative endovascular balloon occlusion of the aorta was associated with a significantly reduced rate of major adverse cardiovascular event (MACE) (4.5% vs 20.5%, p=0.043) and a higher intraoperative diastolic blood pressure (BP) (mean difference+6.7 mm Hg, p=0.031). Blood loss, intensive care unit stay length, and costs were comparable between groups. Long-term survival was similar (log-rank p=0.375). In an exploratory analysis, outcomes between REBOA-OSR (n=10) and REBOA-EVAR (n=12) subgroups showed no significant differences in mortality or MACE, although this analysis was underpowered. CONCLUSIONS: Resuscitative endovascular balloon occlusion of the aorta demonstrated high technical success and an excellent safety profile in rAAA repair. Its use was associated with improved intraoperative hemodynamic stability (higher diastolic BP) and a reduced rate of MACE, although it did not significantly impact mortality or survival. Larger, prospective trials are warranted to confirm the observed reduction in MACE. The comparative outcomes of REBOA in OSR versus EVAR settings remain inconclusive due to the limited sample size.Clinical ImpactThis study demonstrates that resuscitative endovascular balloon occlusion of the aorta (REBOA) in ruptured abdominal aortic aneurysm (rAAA) repair is safe and feasible, and is associated with improved intraoperative hemodynamics and reduced major adverse cardiovascular events. For clinicians, these findings support its use for unstable rAAA patients, particularly those with refractory shock or challenging anatomy. Resuscitative endovascular balloon occlusion of the aorta may serve as both a resuscitative and a cardioprotective strategy by augmenting coronary perfusion. The innovation lies in validating its contemporary safety and proposing a mechanism for cardiac benefits, potentially changing risk-benefit assessments in emergency aortic surgery.