Scoping review and recommendation to establish standardized best practices for resuscitative endovascular balloon occlusion of the aorta in combat casualties: A North Atlantic Treaty Organization exploratory team report

Abstract

Abstract: Truncal hemorrhage is a major cause of combat-related mortality, with delayed surgical access likely increasing future fatalities. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a technique to temporarily control hemorrhage until surgery can be performed. Differences in management, device selection, and training among North Atlantic Treaty Organization (NATO) allies can compromise patient care during deployments. In response, NATO formed a multinational team of REBOA experts to make recommendations for future efforts to standardize care and enhance interoperability. The team held virtual meetings to assess field use, materiel solutions, training programs, and persistent problems. A scoping review was conducted to identify relevant military medicine studies, including those using preclinical combat injury models, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews framework. Contributions came from published work, gray literature, and expert input. Experts from seven countries participated, identifying 52 key studies, 47 published combat uses, and 14 unpublished cases from Ukraine. Of the multitude of available catheters, only one had recent combat use cases for prolonged partial occlusion, and none were published. Unlike other countries, the United States and the United Kingdom possessed military-specific REBOA guidelines; however, both were outdated and assumed air superiority. Training programs varied significantly, with no standardized approach across NATO. Courses differed in the instructional method, intended audience, content, competencies, and refresher frequency; none included partial REBOA. As such, the Ukrainian military was reliant on training from catheter manufacturers. Arterial access challenges continue to hinder REBOA use. There is a critical need for ongoing data collection from combat to inform best practices. Given the rapid evolution of REBOA devices, the changing landscape of war, and limited published literature on these topics, further NATO research efforts should be applied to develop uniform guidance for REBOA in combat environments.

Level of evidence: Scoping Review; Level IV.

Keywords: NATO; REBOA; aortic occlusion; combat injury; military medicine.