Is Resuscitative Endovascular Balloon Occlusion of the Aorta contraindicated in the elderly? An analysis of the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery registry

INTRODUCTION Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as a critical tool in trauma management, particularly for elderly patients. However, its application in this population is often debated because of concerns over potential complications. This study evaluates the outcomes of REBOA compared with resuscitative thoracotomy (RT) in trauma patients 65 years or older with indications for aortic occlusion. METHODS A retrospective cohort analysis was conducted using the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery registry (2013–2024), including trauma patients presented pulseless or sustained cardiac arrest in the trauma bay during evaluation. Patients were divided into REBOA and RT groups based on the aortic occlusion method selected at physician discretion. Variables analyzed included demographics, injury severity, hemorrhage control procedures, transfusion needs, and clinical outcomes. Multivariate analyses accounted for confounders, such as penetrating injuries, Injury Severity Score of >15, systolic blood pressure of <90 mm Hg, heart rate of >100 beats per minute, Glasgow Coma Scale score of <9, provider type, and the need for hemorrhage control procedures. RESULTS The study included 360 patients (RT, 162; REBOA, 198). Survival to hemorrhage control was significantly higher in the REBOA group (75.8% vs. 49.4%, p < 0.001), and overall, in-hospital mortality was lower (74.6% vs. 97.5%, p < 0.001). Major complications were similar between groups, but minor complications occurred more frequently in the REBOA cohort (34.7% vs. 6.3%, p < 0.001). Adjusted analyses revealed no differences in mortality (odds ratio [OR], 1.14; 95% confidence interval [CI], 0.34–1.79; p = 0.702) or major complications (OR, 0.87; 95% CI, 0.62–1.87; p = 0.596), while REBOA was associated with higher odds of minor complications (OR, 1.25; 95% CI, 1.01–2.29; p = 0.007). CONCLUSION Resuscitative endovascular balloon occlusion of the aorta provides comparable survival and major complication outcomes to RT in elderly trauma patients, with an increased risk of minor complications. These results suggest that REBOA is a viable alternative to RT, although further studies are needed to optimize patient selection and procedural techniques. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.