Resuscitative endovascular balloon occlusion of the aorta versus resuscitative thoracotomy for noncompressible torso hemorrhage: A systematic review and meta-analysis

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as a minimally invasive alternative to resuscitative thoracotomy (RT) for noncompressible torso hemorrhage. Comparative effectiveness remains uncertain. This is a systematic review and meta-analysis evaluating the effectiveness and safety of REBOA versus RT in adult trauma patients with exsanguinating hemorrhagic shock or traumatic cardiac arrest.

Methods: A systematic search of MEDLINE, PubMed, Embase, Scopus, and ClinicalTrials.gov was performed through August 2025 for comparative observational studies assessing REBOA versus RT with supraceliac aortic cross-clamping in adults (≥18 y). The primary outcome was in-hospital mortality, with stratified analyses by physiological state (shock vs. cardiac arrest) and early versus late mortality. Secondary outcomes included overall complications, neurological status, and aortic occlusion metrics.

Results: Fourteen studies comprising 9,028 patients (2,477 REBOA; 6,551 RT) were included; six studies (2,912 patients) contributed to the primary pooled analysis. REBOA was associated with significantly lower in-hospital mortality (OR: 0.17, 95% CI: 0.10-0.28; I2=53.2%; moderate-certainty evidence). The benefit was greater in hemorrhagic shock (OR: 0.18, 95% CI: 0.12-0.28) than in cardiac arrest (OR: 0.32, 95% CI: 0.15-0.69). Early mortality showed the most substantial effect (OR: 0.12, 95% CI: 0.07-0.23). REBOA improved neurological outcomes but increased complication rates (OR: 7.81, 95% CI: 3.88-15.72) and prolonged aortic occlusion duration.

Conclusions: REBOA demonstrates superior survival compared with RT in carefully selected patients with trauma, particularly those in hemorrhagic shock. Despite increased complications, current evidence supports REBOA as the preferred aortic occlusion strategy when performed by experienced teams within structured trauma systems. Further research should refine selection criteria and methods to mitigate complication risk. (J Trauma Acute Care Surg. 2026;00: 00-00.Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.).

Level of evidence: Systematic Review and Meta-Analysis, Level III.