{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,9,27]],"date-time":"2025-09-27T05:10:18Z","timestamp":1758949818561,"version":"3.44.0"},"reference-count":26,"publisher":"MDPI AG","issue":"10","license":[{"start":{"date-parts":[[2025,9,25]],"date-time":"2025-09-25T00:00:00Z","timestamp":1758758400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.mdpi.com"],"crossmark-restriction":true},"short-container-title":["Bioengineering"],"abstract":"<jats:p>Background: The use of resuscitative endovascular balloon occlusion of the aorta (REBOA) for control of noncompressible torso hemorrhage remains controversial. We aimed to utilize a novel and transparent\/interpretable artificial intelligence (AI) method called Optimal Policy Trees (OPTs) to improve the appropriate use and decrease the misuse of REBOA in hemodynamically unstable blunt trauma patients. Methods: We trained and then validated OPTs that \u201cprescribe\u201d REBOA in a 50:50 split on all hemorrhagic shock blunt trauma patients in the 2010\u20132019 ACS-TQIP database based on rates of survival. Hemorrhagic shock was defined as a systolic blood pressure \u226490 on arrival or a transfusion requirement of \u22654 units of blood in the first 4 h of presentation. The expected 24 h mortality rate following OPT prescription was compared to the observed 24 h mortality rate in patients who were or were not treated with REBOA. Results: Out of 4.5 million patients, 100,615 were included, and 803 underwent REBOA. REBOA patients had a higher rate of pelvic fracture, femur fracture, hemothorax, pneumothorax, and thoracic aorta injury (p &lt; 0.001). The 24 h mortality rate for the REBOA vs. non-REBOA group was 47% vs. 21%, respectively (p &lt; 0.001). OPTs resulted in an 18% reduction in 24 h mortality for REBOA and a 0.8% reduction in non-REBOA patients. We specifically divert the misuse of REBOA by recommending against REBOA in cases where it leads to worse outcomes. Conclusions: This proof-of-concept study shows that interpretable AI models can improve mortality in unstable blunt trauma patients by optimizing the use and decreasing the misuse of REBOA. To date, these models have been used to predict outcomes, but their groundbreaking use will be in prescribing interventions and changing outcomes.<\/jats:p>","DOI":"10.3390\/bioengineering12101025","type":"journal-article","created":{"date-parts":[[2025,9,26]],"date-time":"2025-09-26T06:02:52Z","timestamp":1758866572000},"page":"1025","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Can Artificial Intelligence Improve the Appropriate Use and Decrease the Misuse of REBOA?"],"prefix":"10.3390","volume":"12","author":[{"given":"Mary","family":"Bokenkamp","sequence":"first","affiliation":[{"name":"Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA 02114, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8409-7222","authenticated-orcid":false,"given":"Yu","family":"Ma","sequence":"additional","affiliation":[{"name":"Operations Research Center, Massachusetts Institute of Technology, Cambridge, MA 02142, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ander","family":"Dorken-Gallastegi","sequence":"additional","affiliation":[{"name":"Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA 02114, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jefferson A.","family":"Proa\u00f1o-Zamudio","sequence":"additional","affiliation":[{"name":"Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA 02114, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Anthony","family":"Gebran","sequence":"additional","affiliation":[{"name":"Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA 02114, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"George C.","family":"Velmahos","sequence":"additional","affiliation":[{"name":"Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA 02114, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Dimitris","family":"Bertsimas","sequence":"additional","affiliation":[{"name":"Operations Research Center, Massachusetts Institute of Technology, Cambridge, MA 02142, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Haytham M. A.","family":"Kaafarani","sequence":"additional","affiliation":[{"name":"Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA 02114, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,9,25]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"559","DOI":"10.1097\/TA.0000000000000968","article-title":"Resuscitative endovascular balloon occlusion of the aorta might be dangerous in patients with severe torso trauma: A propensity score analysis","volume":"80","author":"Inoue","year":"2016","journal-title":"J. Trauma Acute Care Surg."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"500","DOI":"10.1001\/jamasurg.2019.0096","article-title":"Nationwide Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta in Civilian Trauma","volume":"154","author":"Joseph","year":"2019","journal-title":"JAMA Surg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1162","DOI":"10.1016\/j.amjsurg.2019.09.007","article-title":"Resuscitative endovascular balloon occlusion of the aorta (REBOA) is associated with improved survival in severely injured patients: A propensity score matching analysis","volume":"218","author":"Yamamoto","year":"2019","journal-title":"Am. J. Surg."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"62","DOI":"10.1186\/s13049-020-00757-2","article-title":"Resuscitative endovascular balloon occlusion of the aorta may contribute to improved survival","volume":"28","author":"Aoki","year":"2020","journal-title":"Scand. J. Trauma Resusc. Emerg. Med."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1779","DOI":"10.1007\/s00068-020-01370-9","article-title":"Association of resuscitative endovascular balloon occlusion of the aorta (REBOA) and mortality in penetrating trauma patients","volume":"47","author":"Orlas","year":"2021","journal-title":"Eur. J. Trauma Emerg. Surg."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"130","DOI":"10.1001\/jamasurg.2017.3549","article-title":"Use of Resuscitative Endovascular Balloon Occlusion of the Aorta for Proximal Aortic Control in Patients with Severe Hemorrhage and Arrest","volume":"153","author":"Brenner","year":"2018","journal-title":"JAMA Surg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"409","DOI":"10.1097\/TA.0000000000001079","article-title":"The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: Data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA)","volume":"81","author":"DuBose","year":"2016","journal-title":"J. Trauma Acute Care Surg."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"e000715","DOI":"10.1136\/tsaco-2021-000715","article-title":"Resuscitative endovascular balloon occlusion of the aorta (REBOA) may be superior to resuscitative thoracotomy (RT) in patients with traumatic brain injury (TBI)","volume":"7","author":"Brenner","year":"2022","journal-title":"Trauma Surg. Acute Care Open"},{"key":"ref_9","first-page":"65","article-title":"Use of an intra-aortic balloon catheter tamponade for controlling intra-abdominal hemorrhage in man","volume":"36","author":"Hughes","year":"1954","journal-title":"Surgery"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"e000154","DOI":"10.1136\/tsaco-2017-000154","article-title":"Joint statement from the American College of Surgeons Committee on Trauma (ACS COT) and the American College of Emergency Physicians (ACEP) regarding the clinical use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)","volume":"3","author":"Brenner","year":"2018","journal-title":"Trauma Surg. Acute Care Open"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"e000376","DOI":"10.1136\/tsaco-2019-000376","article-title":"Clinical use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in civilian trauma systems in the USA, 2019: A joint statement from the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, the National Association of Emergency Medical Services Physicians and the National Association of Emergency Medical Technicians","volume":"4","author":"Bulger","year":"2019","journal-title":"Trauma Surg. Acute Care Open"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"748","DOI":"10.1097\/TA.0000000000003438","article-title":"A Western Trauma Association critical decisions algorithm: Resuscitative endovascular balloon occlusion of the aorta","volume":"92","author":"Inaba","year":"2022","journal-title":"J. Trauma Acute Care Surg."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"574","DOI":"10.1097\/SLA.0000000000002956","article-title":"Surgical Risk Is Not Linear: Derivation and Validation of a Novel, User-friendly, and Machine-learning-based Predictive OpTimal Trees in Emergency Surgery Risk (POTTER) Calculator","volume":"268","author":"Bertsimas","year":"2018","journal-title":"Ann. Surg."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"93","DOI":"10.1097\/TA.0000000000003158","article-title":"Trauma outcome predictor: An artificial intelligence interactive smartphone tool to predict outcomes in trauma patients","volume":"91","author":"Maurer","year":"2021","journal-title":"J. Trauma Acute Care Surg."},{"key":"ref_15","first-page":"164","article-title":"Optimal prescriptive trees","volume":"1","author":"Bertsimas","year":"2019","journal-title":"Inf. J. Optim."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"2741","DOI":"10.1007\/s10994-022-06128-5","article-title":"Optimal policy trees","volume":"111","author":"Amram","year":"2022","journal-title":"Mach. Learn."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"761","DOI":"10.1093\/aje\/kwq439","article-title":"Doubly robust estimation of causal effects","volume":"173","author":"Funk","year":"2011","journal-title":"Am. J. Epidemiol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1228","DOI":"10.1080\/01621459.2017.1319839","article-title":"Estimation and inference of heterogeneous treatment effects using random forests","volume":"113","author":"Wager","year":"2018","journal-title":"J. Am. Stat. Assoc."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"6100","DOI":"10.1109\/JBHI.2023.3314632","article-title":"MEGA: Machine Learning-Enhanced Graph Analytics for Infodemic Risk Management","volume":"27","author":"Hang","year":"2023","journal-title":"IEEE J. Biomed. Health Inform."},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Shang, J., Ma, T., Xiao, C., and Sun, J. (2019, January 10\u201316). Pre-training of Graph Augmented Transformers for Medication Recommendation. Proceedings of the 28th International Joint Conference on Artificial Intelligence (IJCAI), Macau, China.","DOI":"10.24963\/ijcai.2019\/825"},{"key":"ref_21","first-page":"606","article-title":"Learning the Graphical Structure of Electronic Health Records with Graph Convolutional Transformer","volume":"34","author":"Choi","year":"2020","journal-title":"Proc. AAAI Conf. Artif. Intell."},{"key":"ref_22","first-page":"1","article-title":"From predictive methods to missing data imputation: An optimization approach","volume":"18","author":"Bertsimas","year":"2018","journal-title":"J. Mach. Learn. Res."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"e520","DOI":"10.1097\/SLA.0000000000004055","article-title":"Prospective Observational Evaluation of the ER-REBOA Catheter at 6 U.S. Trauma Centers","volume":"275","author":"Moore","year":"2022","journal-title":"Ann. Surg."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1161","DOI":"10.1097\/TA.0000000000001665","article-title":"Time to aortic occlusion: It\u2019s all about access","volume":"83","author":"Romagnoli","year":"2017","journal-title":"J. Trauma Acute Care Surg."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"A1","DOI":"10.1016\/j.jss.2021.01.046","article-title":"Artificial Intelligence, Machine Learning, and Surgical Science: Reality Versus Hype","volume":"264","author":"Ward","year":"2021","journal-title":"J. Surg. Res."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"e738","DOI":"10.1097\/SLA.0000000000005396","article-title":"Machine Learning Reimagined: The Promise of Interpretability to Combat Bias","volume":"275","author":"Maurer","year":"2022","journal-title":"Ann. Surg."}],"container-title":["Bioengineering"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2306-5354\/12\/10\/1025\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,9,27]],"date-time":"2025-09-27T04:34:34Z","timestamp":1758947674000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2306-5354\/12\/10\/1025"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,9,25]]},"references-count":26,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2025,10]]}},"alternative-id":["bioengineering12101025"],"URL":"https:\/\/doi.org\/10.3390\/bioengineering12101025","relation":{},"ISSN":["2306-5354"],"issn-type":[{"type":"electronic","value":"2306-5354"}],"subject":[],"published":{"date-parts":[[2025,9,25]]}}}